Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurements.

BACKGROUND: Perceived constraints to providing patient care in their own morally justified way may cause moral distress (MD) in neonatal nurses and physicians. Negative long-term effects of MD include substandard patient care, burnout and leaving the profession. AIM: To assess the immediate impact of perceived inappropriate patient care on nurses' and physicians' MD intensity, and explore a possible moderating effect of ethical climate. DESIGN: In a repeated measures design, after baseline assessment, each participant completed self-report questionnaires after five randomly selected shifts. Data were analysed with logistic and Tobit regression. PARTICIPANTS: Data were collected among 117 of 147 eligible nurses and physicians (80%) in a level-III neonatal intensive care unit in the Netherlands. RESULTS: At baseline, overall MD was relatively low; in nurses, it was significantly higher than in physicians. Few morally distressing situations were reported in the repeated measurements, but distress could be intense in these cases; nurses' and physicians' scores were comparable. Physicians were significantly more likely than nurses to disagree with their patients' level of care (p = 0·02). Still, perceived overtreatment, but not undertreatment, was significantly related to distress intensity in both professional groups; ethical climate did not moderate this effect. Substandard patient care due to lack of continuity, poor communication and unsafe levels of staffing were rated as more important causes of MD than perceived inappropriate care. CONCLUSIONS: Although infrequently perceived, overtreatment of patients caused considerable distress in nurses and physicians. Our unit introduced multidisciplinary medical ethical decision making 5 years ago, which may partly explain the low MD at baseline. RELEVANCE TO CLINICAL PRACTICE: MD might be prevented by improved continuity of care, safe levels of staffing and better team communication, along with other targeted interventions with demonstrated effectiveness, such as palliative care programs and facilitated ethics conversations.

Implementing structured, multiprofessional medical ethical decision-making in a neonatal intensive care unit.

BACKGROUND: In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest. SETTING: A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands. METHODS: Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important features were: all professionals who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed. RESULTS: Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians. CONCLUSION: Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement.

Nasogastric tube position and intragastric air collection in a neonatal intensive care population.

PURPOSE: For neonates receiving intensive care, nasogastric tube feeding is essential. Since nasogastric tube placement techniques are not well standardized and common verification methods can be unreliable, placement errors may lead to unsafe situations. In mechanically ventilated neonates and neonates on continuous positive airway pressure, malpositioning of the nasogastric tube may prevent excess air within the stomach to escape. In this study, we aimed to relate tube position to amount of air. The hypothesis was: the better the position of the tube, the smaller the amount of air in the stomach. SUBJECTS: A 1-year cohort of neonates in a level IIIc neonatal intensive care unit with a nasogastric tube. DESIGN AND METHODS: We retrospectively reviewed 326 radiographs and classified nasogastric tube position and gastric air. Descriptive statistics were used to describe demographic data. Kendal's tau statistic was applied to explore the relationship between nasogastric tube position and amount of gastric air. A Mann-Whitney U test was performed to confirm the differences in gastric air in neonates with Ch5 and Ch6 gastric tubes and neonates with Ch8 gastric tubes. RESULTS: One or both orifices of nasogastric tubes were in the esophagus in 7.1% of cases, tubes were curled up in the stomach in 35.3% of cases, and tube tips were beyond the pyloric sphincter in 5.5% of cases. Substantial or excessive air was found in 37.7% of cases. Kendal's tau value indicated that there was no significant correlation between nasogastric tube position and gastric air. The Mann-Whitney U value indicated that children with Ch5 and Ch6 gastric tubes had significantly more gastric air than children with Ch8 gastric tubes. CONCLUSION: Nasogastric tubes were malpositioned in nearly half of cases, and substantial or excessive air was found in more than one-third of cases. The hypothesis-the better the position of the tube, the smaller the amount of gastric air-was not confirmed by the data. However, a significant relationship was found between tube size and gastric air.