Ethics Champion Programs.

A promising practice to promote moral agency in health care settings.

Burnout in Nurses Working With Youth With Chronic Pain: A Mixed-Methods Analysis.

Objective: Nursing is a rewarding but also challenging profession. Nurses are at risk for burnout and premature exit from the profession, which is detrimental to them, their patients, and the healthcare system. There are few studies examining the unique correlates of burnout in nurses working with pediatric populations. The current 2-study project used mixed-methods (qualitative and then quantitative) analysis to explore burnout in nurses working in an inpatient unit with youth with chronic pain. Method: Study I participants included all of the 32 nurses who worked in an inpatient pediatric unit, which admits patients with chronic pain. Qualitative analyses of focus groups were used to extract themes. These themes were examined via a quantitative battery completed by 41 nurses from 2 inpatient pediatric units with youth with chronic pain. Results: The themes were burnout, moral distress, negative beliefs about chronic pain, barriers to pain management, fear of losing compassion, coworker support as a coping method, time worked in the unit, professional self-efficacy, and negative views of the hospital environment. Quantitative results supported most of the qualitative findings, and taken together, the findings supported a model of burnout in nurses working with youth with chronic pain. Conclusions: Conclusions We integrated qualitative and quantitative findings to develop a model of nurse burnout. This model provides a framework for evaluating and targeting burnout in nurses working with pediatric patients with chronic pain.

Moral Distress in Pediatric Healthcare Providers.

Pediatric providers across professions and clinical settings experience moral distress. Higher moral distress correlates with intent to leave for all professionals. Physicians as professional group had the highest moral distress. Intensive care nurses had the highest moral distress for nurses. While all providers describe distressing scenarios as disturbing, physicians report situations as occurring more frequently. The most distressing situations include requests for aggressive treatments not in child's best interest, poor team communication and lack of provider continuity. Understanding moral distress as experienced by all pediatric providers is needed to create interventions with a goal of reducing provider turnover.

Policies on donation after cardiac death at children's hospitals: a mixed-methods analysis of variation.

CONTEXT: Although authoritative bodies have promulgated guidelines for donation after cardiac death (DCD) and the Joint Commission requires hospitals to address DCD, little is known about actual hospital policies. OBJECTIVE: To characterize DCD policies in children's hospitals and evaluate variation among policies. DESIGN, SETTING, AND PARTICIPANTS: Mixed-methods analysis of policies collected between November 2007 and January 2008 from hospitals in the United States, Puerto Rico, and Canada in 2 membership categories of the National Association of Children's Hospitals and Related Institutions. MAIN OUTCOME MEASURES: Status of DCD policy development and content of the policies based on coding categories developed in part from authoritative statements. RESULTS: One hundred five of 124 eligible hospitals responded, a response rate of 85%. Seventy-six institutions (72%; 95% confidence interval [CI], 64%-82%) had DCD policies, 20 (19%; 95% CI, 12%-28%) were developing policies; and 7 (7%; 95% CI, 3%-14%) neither had nor were developing policies. We received and analyzed 73 unique, approved policies. Sixty-one policies (84%; 95% CI, 73%-91%) specify criteria or tests for declaring death. Four policies require total waiting periods prior to organ recovery at variance with professional guidelines: 1 less than 2 minutes and 3 longer than 5 minutes. Sixty-four policies (88%; 95% CI, 78%-94%) preclude transplant personnel from declaring death and 37 (51%; 95% CI, 39%-63%) prohibit them from involvement in premortem management. While 65 policies (89%; 95% CI, 80%-95%) indicate the importance of palliative care, only 5 (7%; 95% CI, 2%-15%) recommend or require palliative care consultation. Of 68 policies that indicate where withdrawal of life-sustaining treatment can or should take place, 37 policies (54%; 95% CI, 42%-67%) require it to occur in the operating room and 3 policies (4%; 95% CI, 1%-12%) require it to occur in the intensive care unit. CONCLUSIONS: Most children's hospitals have developed or are developing DCD policies. There is, however, considerable variation among policies.

Ethical issues and access to healthcare.

Access to healthcare services is far from equitable and legitimately raises the question of justice. Healthcare insurance provides access for most Americans, but for the 15% without coverage, access to healthcare services is difficult at best. As limits are put upon the healthcare dollar at the same time that technology is advancing rapidly, the population is aging, and resources are shrinking, we must determine a just and fair process for allocating limited healthcare resources.

CE: "Medically futile" treatments require more than going to court.

With the unrelenting development of new medical technologies and increasingly more complex treatments, health-care providers sometimes find themselves faced with requests to provide treatments they believe to be medically futile. This language and resulting argument based on it can produce an adversarial posturing on the part of providers and families that frequently anticipates or threatens a legal solution. Although our legal system will choose sides on an issue, futility cases that have ended up in the courts have generally failed to definitively answer questions about how to address future dilemmas. A more helpful process is a clear procedure for addressing both sides of the question with the ultimate decision-making remaining within the health-care setting. The ethically appropriate solution lies within the context of a shared decision-making process between patient/family and physician/health-care provider that honors the values of both parties without assuming a unilateral decision-making stance. Case managers and direct-care providers, when faced with requests for treatments deemed to be medically inappropriate or futile, are challenged to understand and pursue this shared process.