The use of neonatal palliative care: Reducing moral distress in NICU nurses

The ethical dilemmas faced by nursing professionals can lead to moral distress and the abandonment of nursing as a career. This is especially true in intensive care nursing where mortality is more prevalent. Neonatal nurses face a particularly high rate of moral distress when dealing with the treatment and loss of critical infants. This distress is compounded when nurses feel that the care they are providing is not in the best interest of the infant. Providing palliative care at the end-of-life may alleviate some of this distress, but only if palliative care is implemented consistently and effectively. Several barriers exist to implementing effective palliative care. The primary barrier is the lack of education of neonatal staff in the correct definition and application of end-of-life comfort care. This includes education in communication, assessment of needs, and implementation. A neonatal-specific palliative care team (or individual palliative care nurse) can fill this gap in education to accommodate effective care. A consistent, effective neonatal palliative care program is essential. Such a program affords the opportunity for compassionate communication with the family, a decrease in moral distress for nurses, and the provision of quality end-of-life care for the neonate.     

Educational interventions in end-of-life care: part II: psychometric development of an instrument to measure nursing comfort after an educational intervention in end-of-life care: the "Comfort Level Caring for Dying Infants" (CLCDI)

PURPOSE: This article describes the psychometric development of an instrument that was used to measure nurses' comfort level with care of the dying before and after an educational intervention. PARTICIPANTS: 112 registered nurses working in a level III neonatal intensive care unit (NICU) were included. METHOD: Using a quantitative method, the validity and reliability of the instrument, "Comfort level in Caring for Dying Infants" (CLCDI), was assessed for content validity and internal consistency. RESULTS: The instrument was found to be reliable, but the content validity was questionable, and merits further testing. CONCLUSIONS: Given the results of the current study, the authors plan further refinements to the instrument.     

Observations of oral hygiene care interventions provided by nurses to hospitalized older people

Dependent older hospitalized patients rely on nurses to assist them with the removal of plaque from their teeth, dentures, and oral cavities. Oral care interventions by 25 nurses on post-acute units, where patients have longer hospital stays, were observed during evening care. In addition to efforts to engage patients in oral care, nurses provided the following interventions: (a) supporting the care of persons with dentures; (b) supporting the care of natural teeth; (c) cleansing the tongue and oral cavity; and (d) moisturizing lips and oral tissues. Patients' oral hygiene care was supported in just over one-third of encounters. Denture care was inconsistently performed, and was infrequently followed by care of the oral cavity. Nurses did not encourage adequate self-care of natural teeth by patients, and infrequently moisturized tissues. Evidence-based oral hygiene care standards are required to assist nurses to support patients in achieving optimal oral hygiene outcomes.     

End-of-life care: an educational intervention for rural nurses in southeastern USA

AIM: To assess the impact of three educational presentations as an intervention for increasing knowledge of end-of-life care for rural nurses in assisted living and nursing home environments. DESIGN: A repeated measures design (quantitative component) evaluated the effects of the educational intervention. Two open-ended questions yielded qualitative data. SAMPLE AND SETTING: A convenience sample (n = 9) of Registered Nurses and Licensed Practical Nurses employed in an assisted living facility or nursing home in the rural, southeastern region of the USA. Level of nursing experience ranged from 6 to 28 years. ANALYSIS: Frequency distributions, difference of means test for paired samples. RESULTS: Post test scores were significantly higher (t = 6.999; p < 0.001) than pretest scores regarding overall knowledge on end-of-life care. Attitudes and perceptions of participants changed in defining what constitutes a 'good death'. CONCLUSIONS: Classroom educational presentations are an effective means of changing attitudes and improving end-of-life care knowledge. Additional education and support for rural nursing personnel involved with residents of long-term care may enhance end-of-life care.     

Innovative solutions: leading the way: an innovative approach to support nurses on general care units with an early nursing intervention team.

In an effort to improve patient outcomes, there has been a global initiative to prevent avoidable adverse events. The rapid response team or medical emergency team concept has been in existence for the past several years and there has been a significant improvement in patient outcomes. This article will describe one institution's success in taking this concept even further by rounding on general care units before patient problems are evident. The focus of this discussion will be on the remarkably positive nursing staff outcomes that have been achieved as a result of a program called the Early Nursing Intervention Team, a totally nurse-led program.     

Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital

AIM: To determine the prevalence and contributing factors of moral distress in medical and surgical nurses. BACKGROUND: Moral distress from ethical conflicts in the work environment is associated with burnout and job turnovers in nurses. METHOD: A prospective cross-sectional survey using the Moral Distress Scale tool was administered to medical and surgical nurses at an adult acute tertiary care hospital. RESULTS: The survey was completed by 260 nurses (92% response rate). The intensity of moral distress was uniformly high to situations related to physician practice, nursing practice, institutional factors, futile care, deception and euthanasia. Encounter frequencies for situations associated with futile care and deceptions were particularly high. Encounter frequencies increased with years of nursing experience and caring for oncology and transplant patients. CONCLUSION: Moral distress is common among nurses in acute medical and surgical units and can be elicited from different types of situations encountered in the work environment. Nursing experience exacerbated the intensity and frequency of moral distress. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies aimed to minimize exposure to situations of moral distress and augment mechanisms mitigating its effect on nurses are necessary to enhance job satisfaction and retention.     

Managing distress in oncology patients: description of an innovative online educational program for nurses

The American Psychosocial Oncology Society and the Individual Cancer Assistance Network have launched the online continuing education accredited program "ICAN: Distress Management for Oncology Nursing" to address the ability of oncology nurses to assess, treat, and refer patients with a range of psychosocial problems. An important goal of the program is to reduce traditional barriers to psychosocial oncology education by providing the oncology nursing community with easy access to information from experts in the field. There are 4 Internet webcasts: Nurse's Role in Recognizing Distress in Patients and Caregivers; Assessment Recommendations; Treatment Strategies; and Principles and Guidelines for Psychotherapy and Referral. The program examines the prevalence and dimensions of patient distress and offers instruction on how to effectively integrate screening tools, such as the Distress Thermometer and Problem Check List, into clinical practice. It provides details on relevant interventions and referral algorithms based on the National Comprehensive Cancer Network Guidelines for Distress Management. It explores the devastating impact of psychological distress on quality of life, and the unique position of nurses in busy inpatient settings, outpatient clinics, and offices to detect, intervene, and refer to appropriate services. Providing information over the Internet addresses common barriers to learning, including schedule and time constraints.     

The impact of an educational intervention for elderly care nurses on care recipients' and family relatives' ratings of quality of care: a prospective, controlled intervention study

BACKGROUND: Low competence levels among nursing staff have been associated with lower quality of elderly care. However, interventions aimed at improving nursing staff competence have not always been evaluated for their possible impact on the quality of elderly care. An educational intervention in the form of a workplace "toolbox" was shown to have positive effects on nursing staff competence and work satisfaction. It was therefore of interest to investigate whether the intervention had any effect on residents' and/or their family members' ratings of the quality of elderly care. OBJECTIVES: The aim of this study was to evaluate the possible effects of an educational intervention for nursing staff on care recipients' and their relatives' ratings of the quality of elderly care. DESIGN: The study was a prospective, non-randomized, controlled intervention. PARTICIPANTS AND SETTINGS: Care recipients and their relatives in two elderly care organisations in Sweden. METHODS: Practical instruments and educational materials for improving staff competence and work practices were collated in a workplace "toolbox", which was introduced in the intervention organisation in February of 2003. Care recipients and their relatives' ratings of the quality of care were measured pre and post-intervention by questionnaire and compared to quality ratings in a reference organisation, where no toolbox was introduced. RESULTS: Neither care recipients' nor relatives' ratings of the quality of care changed significantly over time in the intervention organisation. Furthermore, there were no significant interaction effects over time between organisations for quality of care ratings. Methodological weaknesses, such as low response rates, may have influenced results. CONCLUSIONS: The results of this study raise questions regarding the alleged positive association between staff competence and work satisfaction and care recipients' perceptions of the quality of care.     

A survey of moral distress in certified registered nurse anesthetists: A theoretical perspective for change in ethics education for advance practice nurses

ObjectiveThe aim of this study was to examine the relationship between moral distress that may affect patient safety, and the clinical practice model, assessing ethical decision-making skills of certified registered nurse anesthetists (CRNAs).MethodsA survey using the Ethical Stress Scale (ESS) and the Ethical Assessment Skills Survey (EASS) was conducted with 134 CRNAs.ResultsResults indicated no significant effect of practice model on level of moral distress or perceived ethical assessment skill knowledge [Wilks's lambda = 0.952, F (6, 256) = 1.068, P = 0.382, n² = 0.02]. A statistically significant positive correlation existed between importance and skill (r = 0.275, P = 0.001). CRNAs felt skilled to manage the actions or activities they deemed important.ConclusionCRNAs who perceived a higher skill level in addressing ethical issues experienced lower levels of moral distress. Findings indicate content-specific curricula for the CRNAs need to be evaluated for ethical decision-making skill assessment content.     

The relationship between moral distress and perception of futile care in the critical care unit.

PURPOSE: Study the relationship between moral distress (MD) and futile care in the critical care unit (CCU). SUBJECTS AND METHODS: A cross-sectional survey consisting of 38 clinical situations associated with MD related to 6 categories: physician practice, nursing practice, institutional factors, futile care, deception and euthanasia was distributed to 100 nurses at a single CCU. The intensity and frequency of MD were scored with Likert scale: 0-lowest and 6-highest. RESULTS: The survey was completed by 44 (44%) nurses. Median age was 33 years, 80% females. Median intensity of MD was high for the six categories and had no relationship with age, time in CCU or nursing practice. The encounter frequency of MD for futile care was the highest and was significantly related to age >33 years (p=0.03), time in CCU >4 years (p=0.04) and nursing practice >7 years (p=0.01). CONCLUSION: MD associated with clinical situations representing futile care increased with time in CCU. Future interventions are required to minimize the exposure to futile care situations and develop mechanisms to mitigate the effects of MD in the CCU.     

Psychiatric nursing consultation: the use of an inservice model to assist nurses in the grief process.

This paper proposes that death is a situation which nurses face on a daily basis. Anxiety, depression, and hostility are defined as feelings common to nurses in working with dying patients. Anxiety and depression were significantly lowered in nurses who attended at least three of the five inservice sessions. Hostility levels did not significantly change. This paper also examines the role of the psychiatric nruse consultant in assisting staff nurses to improve the quality of care provided by examining their own emotional system. The consultant can act as faciltator of the group process so that nurses can continue to function independent of the consultant after the consulting process has ended. The psychiatric nurse consultant can utilize inservice curricula such as the one described above to produce affective change in nurses who work with dying patients, which has the potential to improve the quality of care given to the dying.     

Providing care in the NICU: sometimes an act of love

The final phase of a research project is the communication of findings in a manner that is acceptable within the scholarly norms of a scientific community. While there exists in nursing a willingness to embrace many forms of inquiry, there remains a hesitancy to communicate study outcomes in alternative formats that are congruent with the innovative methods employed. This article serves a dual purpose. It presents a phenomenologic investigation of care provision in the NICU, and it serves as a forum for discussion of issues related to the conduct and communication of phenomenologic research.     

Nursing and rehabilitation: the interventions of nurses in stroke patient care

Summary

• ? The nature of the therapeutic interventions of nurses in the care of stroke patients is at the core of the debate over the exact role of the nurse in patient rehabilitation.
• ? The nature of that intervention is explored in the terms of previous writers in the area through a review of the English language literature published.
• ? The main conclusion is that even though the number and quality of publications has increased significantly, the nature of the nurse's specific interventions are still vague with the result that Henderson's claim for nurses to be the ‘rehabilitator par excellence’ still lies unfulfilled.
• ? This lack of precision enhances the possibility that the nature of the nurse's interventions will be defined and hence potentially constrained by other professionals.