Exploring the transition into practice of general paediatricians from a Canadian residency program.

BACKGROUND: Paediatric training programs are committed to graduating paediatricians able to function independently in professional practice. The focus of this study was to gain understanding of a training program's strengths and deficiencies, while also exploring new methods to aid in transitioning trainees into practice. METHOD: Using the CanMEDS framework, semi-structured focus groups were conducted with recently graduated paediatricians. Data were analyzed using qualitative content analysis. RESULTS: Three focus groups were completed, including a total of nine participants. Key themes were identified pertaining to CanMEDS roles. Particular strengths were found in medical expert for managing acute illnesses, communicator for engaging in difficult conversations, and health advocate in responding to diverse patient populations. Relative deficits were recognized in collaborator for connecting patients with community services, leader related to practice development and management, and scholar for cultivating critical appraisal. Opportunities for training program growth included ensuring community exposures were timely and varied, engaging additional community preceptors in training and giving appropriate expectations and mentoring to trainees to develop as scholars. CONCLUSIONS: Educators need to be mindful of the exposures that trainees receive in residency. New graduates may also ultimately benefit from mentorship in the community or ongoing contact with their past training program.

The Ventricular Assist Device in the Life of the Child: A Phenomenological Pediatric Study.

What is it like for a child to live with an artificial heart? The use of some medical therapies in children requires developmental considerations, is associated with psychosocial consequences, and calls for ethical sensitivities. A critical case is the ventricular assist device (VAD), a mechanical pump used to support the functioning of a failing heart. As a pediatric therapy, the device can be used as a temporary solution for poor heart function, a bridge to transplantation or recovery, or as a destination therapy. While the mechanical-technical operation of the VAD is well understood, the clinical-technical aspects of young people living with this device are largely unexplored. Drawing on interviews of school-aged children, the aim of this phenomenological study is to explore how a VAD may structure or condition a child's meaningful experience of their world outside the hospital. The driveline of an implanted VAD is the peripheral attachment, extruding through the skin to connect the controller-power supply. The materiality of the device may be interruptive, restrictive, and disturbing to the psycho-physical being and sense of self-identity of the child as a child. And while a child equipped with a VAD is not necessarily conspicuous among other children, the child may experience the device as an exposing presence, while living with the worry of a caregiver who takes on the role not simply of parent but of watchful health professional. A phenomenological understanding of the VAD should assist parents and caregiving health professionals knowing how to deal with specific issues arising in the life of the VAD child.

The First Cry of the Child.

Vociferous, shrill, and piercing-the first cry of the newborn infant signals that a new and separate life has begun. Separated from the body of the mother, the newborn cry serves to call for care, support, and protection. Yet, what is it that is expressed in the first cry? Or is the cry not really a matter of expression at all? In what sense may the cry be meaningful? Although we may be able to explain the function of the cry, we are puzzled by the enigma of its meaning. In this study, the science of the first cry is complemented with its physiognomy and genesis. It asks how the primal inceptuality and elemental sensibility of the first cry may be qualitatively explored and understood on the basis of what we have learned from embryology, neonatology, and related medical research. The phenomenological physiology of the first cry of the newborn challenges us to cautiously speculate on its significance for the health sciences, the adult, and the child.

A descriptive report of end-of-life care practices occurring in two neonatal intensive care units.

BACKGROUND: In Canada and other developed countries, the majority of neonatal deaths occur in tertiary neonatal intensive care units. Most deaths occur following the withdrawal of life-sustaining treatments. AIM: To explore neonatal death events and end-of-life care practices in two tertiary neonatal intensive care settings. DESIGN: A structured, retrospective, cohort study. SETTING/PARTICIPANTS: All infants who died under tertiary neonatal intensive care from January 2009 to December 2013 in a regional Canadian neonatal program. Deaths occurring outside the neonatal intensive care unit in delivery rooms, hospital wards, or family homes were not included. Overall, 227 infant deaths were identified. RESULTS: The most common reasons for admission included prematurity (53.7%), prematurity with congenital anomaly/syndrome (20.3%), term congenital anomaly (11.5%), and hypoxic ischemic encephalopathy (12.3%). The median age at death was 7 days. Death tended to follow a decision to withdraw life-sustaining treatment with anticipated poor developmental outcome or perceived quality of life, or in the context of a moribund dying infant. Time to death after withdrawal of life-sustaining treatment was uncommonly a protracted event but did vary widely. Most dying infants were held by family members in the neonatal intensive care unit or in a parent room off cardiorespiratory monitors. Analgesic and sedative medications were variably given and not associated with a hastening of death. CONCLUSION: Variability exists in end-of-life care practices such as provision of analgesic and sedative medications. Other practices such as discontinuation of cardiorespiratory monitors and use of parent rooms are more uniform. More research is needed to understand variation in neonatal end-of-life care.

Antenatal consultation for parents whose child may require admission to neonatal intensive care: a focus group study for media design.

BACKGROUND: For parents whose child may require admission to a neonatal intensive care unit (NICU), the antenatal consultation is often their first point of contact with the child's medical team. Consultation challenges health professionals, as parents may be anxious, overwhelmed, or even exhausted by what is and what might occur. Despite consultation being a common practice, there is a paucity of research on how to support practitioners and parents. The purpose of this study was to gain insights into important relational aspects of antenatal consultation that may be used to spur the development of media to support consultation. METHODS: Focus group, as a data collection method, was employed to gather insights about antenatal consultation from a total of 50 hospital staff and 17 NICU parents from a large urban NICU program in western Canada. Qualitative content analysis was applied to the obtained materials to explicate themes that may serve as necessary understandings for media design. RESULTS: Participating hospital staff and parents expressed their desire for a good antenatal consultation with comments grouped under the following themes: supporting the building of a caring relation; sharing information in conversation; and, preparing for what is to come. CONCLUSIONS: To support the emerging relations of baby, parent, and hospital staff, a good antenatal consultation needs to convey care, understanding, and empathy; create possibilities for open and genuine conversations; and, foster the buildings of respect, confidence, and trust.

The ethics of an ordinary medical technology.

Some routinely applied hospital technologies may have unintended consequences for patients and their families. The neonatal cardiorespiratory monitor, a computer-like display used to show an infant's vital functions, is one such technology that may become part of a parent's day-to-day being with his or her hospitalized child. In this phenomenological study, I explored how the monitor may mediate parental sensibilities, reshaping the contact of parent and child. This exploration speaks to understanding the relational ethics of even the seemingly most ordinary of medical technologies in clinical contexts.

On ethical (in)decisions experienced by parents of infants in neonatal intensive care.

This study was a phenomenological investigation of ethical decisions experienced by parents of newborns in neonatal intensive care. I explore the lived meanings of thematic events that speak to the variable ways that ethical situations may be experienced: a decision that was never a choice; a decision as looking for a way out; a decision as thinking and feeling oneself through the consequences; a decision as indecision; and a decision as something that one falls into. The concluding recommendations spell out the need for understanding the experiences of parents whose children require medical care and underscore the tactful sensitivities required of the health care team during moral-ethical decision making.

Towards the Womb of Neonatal Intensive Care.

Within the mother's womb, life finds its first stirrings. The womb shelters the fetus, the growing child within. We recognize the existential traces of a wombed existence when a newborn calms in response to being held; when a newborn stills in response to his or her mother's heartbeat; and, when a newborn startles in the presence of bright light. Yet, how does experiential human life begin within another human being? What are the conditions and paths of becoming for the fetus within the womb? And for the child born early, what "womb" welcomes the premature child in neonatal intensive care?