Resuscitate but not Intubate? Partial Codes in Pediatrics.

The use of partial code status in pediatric medicine presents clinicians with unique ethical challenges. The clinical vignette describes the presentation of a pulseless infant with a limited life expectancy. The infant's parents instruct the emergency medicine providers to resuscitate but not to intubate. In an emergency, without a clear understanding of parents' goals, complying with their request risks an ineffective resuscitation. The first commentary focuses on parental grief and how, in certain circumstances, a partial code best serves their needs. Its authors argue that providers are sometimes obligated to endure moral distress. The second commentary focuses on the healthcare team's moral distress and highlights the implications of a relational ethics framework for the case. The commentators emphasize the importance of honest communication and pain management. The final commentary explores the systems-level and how the design of hospital code status orders may contribute to requests for partial codes. They argue systems should discourage partial codes and prohibit resuscitation without intubation.

A Novel Web-Based and Mobile Application to Measure Real-Time Moral Distress: An Initial Pilot and Feasibility Study.

PROBLEM DEFINITION: Moral distress (MoD) is a vital clinical indicator linked to clinician burnout and provider concerns about declining patient care quality. Yet it is not routinely assessed. Earlier, real-time recognition may better target interventions aimed at alleviating MoD and thereby increase provider well-being and improve patient care quality. INITIAL APPROACH AND TESTING: Combining two validated MoD instruments (the Moral Distress Thermometer [MDT] and the Measure of Moral Distress for Healthcare Professionals [MMD-HP]), the authors developed a novel mobile and Web-based application environment to measure and report levels MoD and their associated causes. This app was tested for basic feasibility and acceptability in two groups: graduate nursing students and practicing critical care nurses. RESULTS: The MDT app appears feasible and acceptable for future use. All participants (n = 34) indicated the MDT app was satisfying to use, and 91.2% (n = 31) indicated the app was "very appropriate" for measuring MoD. In addition, 84.2% (n =16) of practicing nurses indicated the app fit either "somewhat well" (47.4%, n = 9) or "very well" (36.8%, n = 7) into their typical workday, and 68.4% (n = 13) said they were either "extremely likely" or "somewhat likely" to use the app daily in clinical practice. KEY INSIGHTS AND NEXT STEPS: Education about moral distress and its associated causes proved important to the MDT app's success. It is ready for future validity and reliability testing, as well as examining usability beyond nursing, longitudinal data monitoring, and possible leveraging to pre- and postintervention evaluation studies.

Scoping review: Positive and negative impact of technology on clinicians.

BACKGROUND: Unnecessary electronic health record (EHRs) documentation burden and usability issues have negatively impacted clinician well-being (e.g., burnout and moral distress). PURPOSE: This scoping review was conducted by members from three expert panels of the American Academy of Nurses to generate consensus on the evidence of both positive and negative impact of EHRs on clinicians. METHODS: The scoping review was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews guidelines. RESULTS: The scoping review captured 1,886 publications screened against title and abstract 1,431 excluded, examined 448 in a full-text review, excluded 347 with 101 studies informing the final review. DISCUSSION: Findings suggest few studies that have explored the positive impact of EHRs and more studies that have explored the clinician's satisfaction and work burden. Significant gaps were identified in associating distress to use of EHRs and minimal studies on EHRs' impact on nurses. CONCLUSION: Examined the evidence of HIT's positive and negative impacts on clinician's practice, clinicians work environment, and if psychological impact differed among clinicians.

A Closer Look at Feticide and Moral Distress.

Moral distress arises when healthcare providers recognize that a professional ethical obligation cannot be met due to constraints beyond their perceived or actual control. In this commentary, I expand a bit on the meaning and implications of moral distress identified among Israeli maternal-fetal medicine (MFM) physicians who participate in feticide. I examine briefly how exploring unmet professional obligations (for example, preventing harm), identifying who is burdened by the decisions of others, and drawing attention to what is owed to the woman, fetus, and physician may illuminate relevant ethical issues not currently considered in the calculus of late-term abortion decisions. Ultimately, the goal is not to mitigate MFM physicians' moral distress, but to adequately address the problems that create it.

The Nurse Manager's Experience of Moral Distress.

The purpose of this study was to describe the moral distress experiences of nurse managers. Moral distress has been studied among direct patient care providers including nurses and physicians. The moral distress experience among nurse managers is less understood. We conducted a qualitative descriptive study with 19 nurse managers from 5 healthcare institutions in Virginia. Interview data were analyzed using a directed content analysis, as the structural components of the moral distress phenomenon are already known. Participants suffered moral distress when they were unable to achieve or maintain effective unit function and felt caught in the middle between their units' and employees' needs and organizational directives. System-level causes of moral distress are common among nurse managers. Future research should involve measurement of moral distress among nurse managers and exploration of effective interventions.

The Nursing Code of Ethics: Its Value, Its History.

To practice competently and with integrity, today's nurses must have in place several key elements that guide the profession, such as an accreditation process for education, a rigorous system for licensure and certification, and a relevant code of ethics. The American Nurses Association has guided and supported nursing practice through creation and implementation of a nationally accepted Code of Ethics for Nurses with Interpretive Statements. This article will discuss ethics in society, professions, and nursing and illustrate how a professional code of ethics can guide nursing practice in a variety of settings. We also offer a brief history of the Code of Ethics, discuss the modern Code of Ethics, and describe the importance of periodic revision, including the inclusive and thorough process used to develop the 2015 Code and a summary of recent changes. Finally, the article provides implications for practicing nurses to assure that this document is a dynamic, useful resource in a variety of healthcare settings.

Application impact analysis: a risk-based approach to business continuity and disaster recovery.

There are many possible disruptions that can occur in business. Overlooking or under planning for Business Continuity requires time, understanding and careful planning. Business Continuity Management is far more than producing a document and declaring business continuity success. What is the recipe for businesses to achieve continuity management success? Application Impact Analysis is a method for understanding the unique Business Attributes. This AIA Cycle involves a risk based approach to understanding the business priority and considering business aspects such as Financial, Operational, Service Structure, Contractual Legal, and Brand. The output of this analysis provides a construct for viewing data, evaluating impact, and delivering results, for an approved valuation of Recovery Time Objectives (RTO).

Does rural residence affect access to prenatal care in Oregon?

CONTEXT: Identifying how maternal residential location affects late initiation of prenatal care is important for policy planning and allocation of resources for intervention. PURPOSE: To determine how rural residence and other social and demographic characteristics affect late initiation of prenatal care, and how residence status is associated with self-reported barriers to accessing early prenatal care. METHODS: This observational study used data from the 2003 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) (N = 1,508), with late initiation of prenatal care (after the first trimester) as the primary outcome. We used Rural-Urban Commuting Area (RUCA) codes to categorize maternal residence as urban, large rural, or small/isolated rural. Multivariate logistic regression was used to evaluate whether category of residence was associated with late initiation of prenatal care after adjusting for other maternal factors. Association between categories of barriers to prenatal care and maternal category of residence were determined using the Cochran-Mantel-Haenszel test of association. FINDINGS: We found no significant association between residence category and late initiation of prenatal care, or residence category and barriers to prenatal care initiation. Urban women tended to be over age 34 or nonwhite. Women from large rural areas were more likely to be younger than 18 years, unmarried, and have an unintended pregnancy. Women from small rural areas were more likely to use tobacco during pregnancy. CONCLUSIONS: Maternal residence category is not associated with late initiation of prenatal care or with barriers to initiation of prenatal care. Differences in maternal risk profiles by location suggest possible new foci for programs, such as tobacco education in small rural areas.

Influence of family history of diabetes on health care provider practice and patient behavior among nondiabetic Oregonians.

INTRODUCTION: People with a family history of diabetes are at increased risk of developing diabetes; however, the effect of family history of diabetes on health care provider practice and patient behavior has not been well defined. METHODS: We analyzed data from the 2005 Oregon Behavioral Risk Factor Surveillance System, a state-based, random-digit-dialed telephone survey, to evaluate, among people with diabetes, associations between family history of diabetes and 1) patients' reports of health care provider practices, 2) patients' perceived risk of developing diabetes, and 3) patients' behaviors associated with an increased risk of developing diabetes. RESULTS: Compared with respondents at average risk, respondents with a positive family history (strong or moderate familial risk for diabetes) were more likely to report that their health care provider collects family history information about diabetes, discusses the risk of developing diabetes or other chronic conditions, and makes recommendations to change their diet or exercise behaviors to reduce the chance of developing diabetes. Respondents with a strong family history of diabetes were 5 times more likely to be very or somewhat worried about developing diabetes than were people at average risk (odds ratio [OR], 5.0; 95% confidence interval [CI], 4.0-6.2). Compared with respondents at average risk, respondents with a strong family history were more likely to report making changes in diet and exercise (OR, 1.7; 95% CI, 1.4-2.1). CONCLUSION: Integrating family history of diabetes into clinical practice offers opportunities to improve the effectiveness of diabetes detection and to promote interventions aimed at preventing or delaying the development of diabetes in people at high risk.