Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals.

BACKGROUND: Decisions about treatments for extremely preterm infants (EPIs) born in the 'grey zone' of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine. METHODS: The online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents' views based on profession and neonatal unit designation. Further questions explored respondents' conceptual understanding of viability. RESULTS: 336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22+1 and 24+0 weeks' gestation. Registrars/fellows were more likely to select a lower threshold at 22+0 weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22+0 weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be 'viable' if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team. CONCLUSION: Compared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants <23 weeks' gestation.

Italian Nurses' Attitudes Towards Neonatal Palliative Care: A Cross-Sectional Survey.

PURPOSE: Neonatal palliative care becomes an option for critically ill neonates when death is inevitable. Assessing nurses' attitudes towards, barriers to, and facilitators of neonatal palliative care is essential to delivering effective nursing care. METHODS: This study was conducted from January to September 2015 and involved Italian nurses employed in Level III neonatal intensive care units in 14 hospitals in northern, central, and southern Italy. A modified version of the Neonatal Palliative Care Attitudes Scale (NiPCAS) was adopted to assess nurses' attitudes. FINDINGS: A total of 347 neonatal nurses filled out the questionnaire. The majority were female (87.6%), with a mean age of 40.38 (±8.3) years. The mean score in the "organization" factor was 2.71 (±0.96). The "resources" factor had a mean score of 2.44 (±1.00), while the "clinician" factor had a mean score of 3.36 (±0.90), indicating the main barriers to and facilitators of implementing palliative nursing care. CONCLUSIONS: Italian neonatal nurses may face different obstacles to delivering neonatal palliative care and to improve their attitudes in this field. In the Italian context, no facilitators of, only barriers to, palliative care delivery were identified. CLINICAL RELEVANCE: Nurses' attitudes towards neonatal palliative care are essential to supporting nurses, who are constantly exposed to the emotional and moral distress connected with this field of end-of-life nursing care.

What Keeps Neonatal Nurses Up at Night and What Gets Them Up in the Morning?

BACKGROUND: Occupational stress in neonatal nursing is a significant professional concern. Prolonged exposure to morally distressing patient care experiences and other healthcare issues may lead to worry among nurses. When worry becomes excessive, nurses and advanced practice registered nurses may lose joy that gives meaning to their work. Enhancing meaning in work may have a positive impact on nurse satisfaction, engagement, productivity, and burnout. PURPOSE: To explore neonatal nurses' top professional satisfiers and top professional worries and concerns. METHODS: A descriptive study was conducted in a convenience sample of neonatal nurses to identify the top professional satisfiers that get them up in the morning and the top professional worries and concerns that keep them awake at night. RESULTS: Complete data were available for 29 neonatal nurses. The top professional satisfiers were caring for infants and families, making a difference, witnessing resilience, intellectual challenge of specialty, positive working relationships with colleagues, and educating parents and families. The top professional worries and concerns were staffing, missed care, workload, making a mistake, and failure to rescue. IMPLICATIONS FOR PRACTICE: Healthcare and professional organizations must develop strategies to address occupational stress in today's complex healthcare environment. Identifying professional worries and concerns may help nurses navigate challenging and distressing situations. Furthermore, understanding nurses' professional satisfiers may promote personal and professional resiliency and help organizations create healthier workplace environments. IMPLICATIONS FOR RESEARCH: Future studies are needed to test effective interventions that may promote professional satisfaction and help neonatal nurses cope with occupational stressors.

Development and use of an adjusted nurse staffing metric in the neonatal intensive care unit.

OBJECTIVE: To develop a nurse staffing prediction model and evaluate deviation from predicted nurse staffing as a contributor to patient outcomes. DATA SOURCES: Secondary data collection conducted 2017-2018, using the California Office of Statewide Health Planning and Development and the California Perinatal Quality Care Collaborative databases. We included 276 054 infants born 2008-2016 and cared for in 99 California neonatal intensive care units (NICUs). STUDY DESIGN: Repeated-measures observational study. We developed a nurse staffing prediction model using machine learning and hierarchical linear regression and then quantified deviation from predicted nurse staffing in relation to health care-associated infections, length of stay, and mortality using hierarchical logistic and linear regression. DATA COLLECTION METHODS: We linked NICU-level nurse staffing and organizational data to patient-level risk factors and outcomes using unique identifiers for NICUs and patients. PRINCIPAL FINDINGS: An 11-factor prediction model explained 35 percent of the nurse staffing variation among NICUs. Higher-than-predicted nurse staffing was associated with decreased risk-adjusted odds of health care-associated infection (OR: 0.79, 95% CI: 0.63-0.98), but not with length of stay or mortality. CONCLUSIONS: Organizational and patient factors explain much of the variation in nurse staffing. Higher-than-predicted nurse staffing was associated with fewer infections. Prospective studies are needed to determine causality and to quantify the impact of staffing reforms on health outcomes.

Neonatal nurses' knowledge and beliefs about kangaroo mother care in neonatal intensive care units: A descriptive, cross-sectional study.

The aim of this study was to assess Jordanian neonatal nurses' knowledge and beliefs toward the application of kangaroo mother care in the neonatal intensive care unit. A cross-sectional, descriptive survey was performed using a convenience sample of 229 nurses. The findings revealed that the majority of the nurses agreed that kangaroo mother care was beneficial to both mothers and infants; however, 47.2% believed that it was not feasible for all preterm infants. The majority of nurses believed that kangaroo mother care should be restricted to infants on intravenous treatment, intubated, or with an umbilical catheter. The majority of the nurses correctly answered questions regarding kangaroo mother care. A significant relationship was found between the nurses' knowledge and their beliefs toward kangaroo mother care. The findings of this study provide insights into Jordanian nurses' knowledge and beliefs toward the kangaroo mother care approach. If addressed, these findings will help improve the practice and nursing care for preterm infants.

Exploring the Impact of a Dual Occupancy Neonatal Intensive Care Unit on Staff Workflow, Activity, and Their Perceptions.

In 2012, a tertiary neonatal intensive care unit (NICU) transitioned from an open plan (OP) to a dual occupancy (DO) NICU. The DO design aimed to provide a developmental appropriate, family-centered environment for neonates and their families. During planning, staff questioned the impact DO would have on staff workflow and activity. To explore the impact of changing from an OP to a DO NICU, a prospective longitudinal study was undertaken from 2011 to 2014, using observational, time and motion, and surveys methods. Main outcome measures included distance walked by staff, minutes of staff activity, and staff perceptions of the DO design. Results highlighted no significant difference in the distances clinical nurses walked nor time spent providing direct clinical care, whereas technical support staff walked further than other staff in both designs. Staff perceived the DO design created a developmentally appropriate, family-centered environment that facilitated communication and collaboration between staff and families. Staff described the main challenges of the DO design such as effective staff communication, gaining educational opportunities, and the isolation of staff and families compared to the OP design. Our study provides new evidence that DO provides an improved developmentally environment and has similar positive benefits to single-family room for neonates and families. Such design may reduce the larger floor plan's impact on staff walking distance and work practices. Challenges of staff transition can be minimized by planning and leadership throughout the development and move to a new design.

Neonatal nurse practitioner ethics knowledge and attitudes.

BACKGROUND: Neonatal nurse practitioners have become the frontline staff exposed to a myriad of ethical issues that arise in the day-to-day environment of the neonatal intensive care unit. However, ethics competency at the time of graduation and after years of practice has not been described. RESEARCH AIM: To examine the ethics knowledge base of neonatal nurse practitioners as this knowledge relates to decision making in the neonatal intensive care unit and to determine whether this knowledge is reflected in attitudes toward ethical dilemmas in the neonatal intensive care unit. RESEARCH DESIGN: This was a prospective cohort study that examined decision making at the threshold of viability, life-sustaining therapies for sick neonates, and a ranking of the five most impactful ethical issues. PARTICIPANTS AND RESEARCH CONTEXT: All 47 neonatal nurse practitioners who had an active license in the State of Mississippi were contacted via e-mail. Surveys were completed online using Survey Monkey software. ETHICAL CONSIDERATIONS: The study was approved by the University of Mississippi Medical Center Institutional Review Board (IRB; #2015-0189). FINDINGS: Of the neonatal nurse practitioners who completed the survey, 87.5% stated that their religious practices affected their ethical decision making and 76% felt that decisions regarding life-sustaining treatment for a neonate should not involve consultation with the hospital's legal team or risk management. Only 11% indicated that the consent process involved patient understanding of possible procedures. Participating in the continuation or escalation of care for infants at the threshold of viability was the top ethical issue encountered by neonatal nurse practitioners. DISCUSSION: Our findings reflect deficiencies in the neonatal nurse practitioner knowledge base concerning ethical decision making, informed consent/permission, and the continuation/escalation of care. CONCLUSION: In addition to continuing education highlighting ethics concepts, exploring the influence of religion in making decisions and knowing the most prominent dilemmas faced by neonatal nurse practitioners in the neonatal intensive care unit may lead to insights into potential solutions.

Oral dextrose gel to treat neonatal hypoglycaemia: Clinician survey.

AIMS: To determine the use of oral dextrose gel to treat neonatal hypoglycaemia in New Zealand (NZ), to identify barriers and enablers to the implementation of the guideline and to determine if there is variation in management between clinical disciplines caring for at-risk babies. METHODS: An online survey was distributed to clinicians (including doctors, midwives and nurses) caring for babies with neonatal hypoglycaemia via stakeholders and maternity hospitals. RESULTS: A total of 251 clinicians from all 20 District Health Boards (DHBs) completed the survey. Of the responding clinicians, 148 (59%) from 15 (75%) DHBs reported oral dextrose gel use in their hospital, and of these, 129 (87%) reported a local guideline. In 12 of 15 (80%) DHBs, oral dextrose gel could be prescribed by midwives. For a clinical scenario of a baby with neonatal hypoglycaemia, doctors were more likely to prescribe oral dextrose gel than midwives (odds ratio (95% confidence interval), 2.9 (2.2-3.8), P < 0.0001). Of 32 possible combinations of treatment options for this scenario, 31 were selected by one or more clinicians. A guideline was perceived to be the most useful enabler, and availability of oral dextrose gel was seen as the most important barrier. CONCLUSIONS: Oral dextrose gel is widely used to treat neonatal hypoglycaemia in NZ. Increasing availability of dextrose gel and the clinical practice guideline are likely to further increase the use of oral dextrose gel.

Parents attending to nurse visits and birth age contribute to infant development: A study about the determinants of infant development.

Life experiences and parenting play an important role in infant development. To prevent developmental risks and support parents in their educational role, it is important to identify the determinants of infant development. In this study, we investigate the association between child, maternal, family and social variables, and infant development, as well as we investigate the determinants of infant development. A sample of 86 healthy infants and their mothers participated in this study. At 11-months, infant development was assessed with Schedule of Growing Skills II (SGSII). To assess mother-infant quality of interaction, the dyads were observed in free play at 12-months using CARE-Index. Maternal sensitivity and infant cooperative behavior were correlated with SGSII global scores and sub-scales. Infant development was associated with maternal years of education, number of siblings, birth weight or risks in pregnancy. Number of nurse visits attended by parents during the infant first year and birth age were determinants of infant development.

Conflicts of conscience in the neonatal intensive care unit: Perspectives of Alberta.

BACKGROUND:: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. OBJECTIVES:: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. RESEARCH DESIGN:: Interpretive description was selected to help situate the findings in a meaningful clinical context. PARTICIPANTS AND RESEARCH CONTEXT:: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. ETHICAL CONSIDERATION:: Ethics approval from the Health Research Ethics Board at the University of Alberta. FINDINGS:: Three common themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse's voice, and the unique proximity of nurses. DISCUSSION AND CONCLUSION:: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection.

Neonatal nurses' response to a hypothetical premature birth situation: What if it was my baby?

BACKGROUND:: Evolving technology and scientific advancement have increased the chances of survival of the extremely premature baby; however, such survival can be associated with some severe long-term morbidities. RESEARCH QUESTION:: The research investigates the caregiving and ethical dilemmas faced by neonatal nurses when caring for extremely premature babies (defined as ≤24 weeks' gestation). This article explores the issues arising for neonatal nurses when they considered the philosophical question of 'what if it was me and my baby', or what they believed they would do in the hypothetical situation of going into premature labour and delivering an extremely premature baby. PARTICIPANTS:: Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia. ETHICAL CONSIDERATIONS:: Relevant ethical approvals have been obtained by the researchers. FINDINGS:: A qualitative approach was used to analyse the data. The theme 'imagined futures' was generated which comprised three sub-themes: 'choice is important', 'not subjecting their own baby to treatment' and 'nurses and outcome predictions'. The results offer an important and unique understanding into the perceptions of nursing staff who care for extremely premature babies and their family, see them go home and witness their evolving outcomes. The results show that previous clinical and personal experiences led the nurses in the study to choose to have the belief that if in a similar situation, they would choose not to have their own baby resuscitated and subjected to the very treatment that they provide to other babies. CONCLUSION:: The theme 'imagined futures' offers an overall understanding of how neonatal nurses imagine what the life of the extremely premature baby and his or her family will be like after discharge from neonatal intensive care. The nurses' past experience has led them to believe that they would not want this life for themselves and their baby, if they were to deliver at 24 weeks' gestation or less.

Strategic modeling of the neonatal nurse practitioner workforce.

BACKGROUND: Neonatal nurse practitioners (NNPs) play a vital role in the medical care of newborns and infants. There is expected to be a shortage of NNPs in the near future. PURPOSE: To assess the present NNP workforce and study the impact of potential policy changes to alleviate forecasted shortages. METHODS: We modeled the education and workforce system for NNPs. Forecasting models were combined with optimal decision-making to derive best-case scenario admission levels for graduate and undergraduate programs. DISCUSSION: Under the best-case scenario for the current system, the shortage of NNPs is expected to last 10 years. We analyzed the impact of improving the certification examination passing rate, increasing the annual growth rate of master's programs, and reducing the workforce annual attrition rate. We found that policy changes may reduce the forecasted shortage to 4 years. CONCLUSION: Present forecasts of demand for NNPs indicate that the existing workforce and education system will be unable to satisfy the growing demand. Policy changes may reduce the expected shortage and potentially improve access to care for newborns and infants.