Missed Nursing Care in Pediatric and Neonatal Care Settings: An Integrative Review.

INTRODUCTION: Missed nursing care is required care that is delayed, incomplete, or left undone during a nurse's working shift. Missed nursing care is most often studied in adult populations; however, it may have significant consequences in pediatric and neonatal care settings. The purpose of this integrative review is to describe missed nursing care in pediatric and neonatal nursing care settings. METHODS: SCOPUS and PubMed were used in the literature search. Multiple combinations of the keywords and phrases "missed nursing care," "pediatric," "neonatal," "care left undone," or "nursing care rationing" were used for the literature search. Missed nursing care is a relatively new topic as the first article on the subject was published in 2006; therefore, inclusion criteria were set to English articles published between January 1, 2006 and October 11, 2019 that reported on missed nursing care in pediatric and neonatal inpatient care settings. RESULTS: Fourteen articles met inclusion criteria. Missed nursing care in pediatric and neonatal nursing care settings is associated with workload, patient acuity, work environment, and nurse characteristics, and is related to prolonged hospitalization of preterm infants. CLINICAL IMPLICATIONS: Providing nurses with an adequate amount of resources and tools to avoid missed nursing care will continue to improve care delivery. Missed nursing care and related patient and nurse outcomes in diverse pediatric and neonatal samples remains an area for future research.

Simulation in midwifery education: A descriptive explorative study exploring students' knowledge, confidence and skills in the care of the preterm neonate.

Undergraduate midwifery programs across Australia have embedded simulation into their curriculum although there is limited but emerging evidence to support the use of simulation as an effective teaching strategy. The purpose of this study was to evaluate the impact that a simulated learning activity (insertion and management of a neonatal nasogastric tube), had on midwifery students' knowledge, confidence and skills post-simulation, and on completion of a clinical placement. A descriptive explorative study was undertaken in two phases. Phase 1: Midwifery students (n = 60) completed a purpose-designed questionnaire to assess their knowledge, confidence and skills, pre and post simulation. Phase 2: Students (n = 46) repeated the questionnaire to reassess their knowledge, confidence and skills after the completion of a neonatal nursery placement. The findings demonstrate that simulation is an effective learning strategy in an undergraduate midwifery program. Students' knowledge, confidence and skills increased significantly post-simulation activity (p0.001). A further increase in these areas was noted post-placement. Key aspects that contributed to student learning included; the demonstrators' level of knowledge, expertise and currency of practice, as well as the role the student assumes in the simulation activity.

The Beneficence of Cuddle Therapy in Hyperekplexia: A Case Report.

BACKGROUND: Benevolent injustice occurs when well-intentioned treatment efforts produce an outcome that limits the potential of a patient. The unintended harm can result in significant moral distress for the family and the healthcare team. CLINICAL FINDINGS: We discussed an ethical dilemma regarding a neonate who had suspected seizure and hypoxic-ischemic encephalopathy after home birth delivery. The healthcare team experienced moral distress about the mother's desire to not use anti-seizure medications and instead trial other interventions such as cuddling. Subsequently, clinical analysis ruled out a seizure disorder. Genetic studies on this neonate confirmed hereditary hyperekplexia, which presented as exaggerated Moro reflex and apnea that mimicked seizure. INTERVENTION: We discussed how applying any one of the 4 basic ethical principles of autonomy, beneficence, nonmaleficence, or justice could counteract benevolent injustice and moral distress. OUTCOMES: Discussions with the patient's mother and nurse allowed the team to overcome their reluctance to try the mother's treatment recommendations. This resulted in adopting the seemingly counterintuitive intervention of cuddling that turned out to be effective for this neonate with hereditary hyperekplexia. PRACTICE RECOMMENDATIONS: The moral distress associated with benevolent injustice should be identified early to minimize long-term consequences to the patient, family, and healthcare team. Healthcare teams should learn to apply ethical principles when discussing patient care concerns in an unbiased manner. Guided ethical discussions allow us to be more efficient in providing family-centered care that aligns with the patient's best interest.

Improving the Clinical Skills and Knowledge of Midwives and Nurses Caring for Late Preterm Neonates.

BACKGROUND: Due to changes in funding, late pre-term neonates are no longer admitted to neonatal units unless diagnosed with a specific medical condition. Consequently, neonates born at a gestational age of 35 weeks and 0 days to 36 weeks and 6 days are cared for on postnatal wards. Compared with full-term infants, late preterm neonates are at increased risk of hypothermia, hypoglycemia, hyperbilirubinemia, feeding difficulties, respiratory complications, and mortality. METHOD: An educational intervention focusing on the care of the late preterm neonate was developed, and quantitative data were collected pre- and post-intervention to assess the effect on knowledge, skills, and attitudes. RESULTS: Of the midwives and nurses who participated, 65% (n = 13) strongly agreed and 35% (n = 7) agreed their knowledge and confidence had increased. The mean score increased from a range of 20 to 25 pre-intervention to 22 to 25 post-intervention. CONCLUSION: The intervention increased the self-reported confidence and self-reported competence of participants, who also felt more supported caring for late preterm neonates. [J Contin Educ Nurs. 2019;50(12):551-556.].

Experience of neonatal intensive care unit nurses in providing developmentally-supportive care: A qualitative study.

Many challenges have been noted in the implementation of developmentally-supportive care principles in neonatal intensive care units, despite evidence that adhering to such care principles achieves positive results for the neonate. The aim of this study was to explore and describe compliance in adhering to developmentally-supportive care principles implemented in one neonatal intensive care unit in South Africa. An exploratory design was used in this qualitative study with purposive sampling to select eligible neonatal intensive care registered nurses (n = 14) as participants. Participants all worked in a 10 bed neonatal intensive care unit at a large tertiary care public hospital. Six audio-recorded interviews were conducted, with recordings subsequently transcribed and analyzed. Three main themes were identified: value of developmentally-supportive care, nature of developmentally-supportive care, and barriers to developmentally-supportive care. One of the main themes had subthemes, which substantiated the findings, and included parent involvement, nurse engagement, and holistic care. Study outcomes offer insight into the development or revision of policies and practices, which are crucial when implementing developmentally-supportive care, particularly in resource-poor settings where challenges are magnified.

Perinatal hospice care in the opinion of nurses and midwives.

OBJECTIVES: Perinatal medicine is a relatively new, dynamically developing branch of medicine. Its main purpose is taking care of a woman in the pre-conception period, pregnancy and delivery, as well as taking care of a newborn baby. The main aim of the study was to assess the state of knowledge and opinion on hospice perinatal care of professionally active nurses and midwives. MATERIAL AND METHODS: An original and anonymous questionnaire containing 30 questions was used for the study. 572 nurses and midwives from the Silesian Voivodeship took part in the study. The obtained data were analyzed. RESULTS: Only 31.6% of respondents defined the level of their knowledge of pregnancy and neonatal care as high. 12.8% of respondents were able to indicate the definition of perinatal care and accurately determine its goals. The women participating in the study were in favor of enclosing the information about not attempting resuscitation (DNAR) in medical record of children with incurable disease diagnosed in fetal life (99.3%). CONCLUSIONS: The study showed deficits in practical and theoretical knowledge of nurses and midwives in the area of hospice perinatal care. Lack of proper preparation is also one of the most frequently mentioned difficulties in taking care of a child and family with poor prognosis.

The Meaning of Giving Birth: Voices of Hmong Women Living in Vietnam.

Increasing knowledge about the sociocultural context of birth is essential to promote culturally sensitive nursing care. This qualitative study provides an ethnographic view of the perspectives on birthing of Hmong mothers living in the highlands of Vietnam. Unique cultural beliefs exist in Hmong culture about the spiritual and physical world as well as ritual practices associated with childbearing. This includes variations of ancestor worship, reincarnation, and healing practices by shamans. Traditionally, Hmong families take an active role in childbirth with birth frequently occurring in the home. Situated within a large collaborative anthropology project, a convenience sample of 8 Hmong women, who had recently given birth, were interviewed regarding the perinatal experience. In addition, ethnic traditional birth attendants (midwives) and other village women contributed perspectives providing richly descriptive data. This ethnographic study was conducted during 6 weeks of immersed participant observation with primary data collection carried out through fieldwork. Data were analyzed to derive cultural themes from interviews and observations. Significant themes included (1) valuing motherhood, (2) laboring and giving birth silently, (3) giving birth within the comfort of home and family, (4) feeling capable of birthing well, (5) feeling anxiety to provide for another child, and (6) embracing cultural traditions. Listening to the voices of Hmong women enhances understanding of the meaning of childbirth. Gaining greater understanding of Hmong cultural beliefs and practices can ensure childbearing women receive respectful, safe, and quality care.

Outcomes of a Quality Improvement Initiative to Prevent Unnecessary Packed Red Blood Cell Transfusions Among Extremely Low Birth-Weight Neonates.

BACKGROUND: Extremely low birth-weight (ELBW) infants frequently receive packed red blood cell (PRBC) transfusions. Recent studies have shown that more restrictive PRBC transfusion guidelines limit donor exposure and reduce transfusion-related costs without any increase in adverse clinical outcomes. PURPOSE: We developed and implemented an evidence-based PRBC transfusion guideline for ELBW infants treated in our unit and then measured provider adherence to this guideline. METHODS/SEARCH STRATEGY: We performed a retrospective review of all PRBC transfusions given to ELBW infants in 2012 (preguideline) and the first half of 2014 (postguideline). We identified the indication for each transfusion by reviewing physiological/laboratory data and the daily clinical note. We then determine whether each transfusion met criteria according to our new evidence-based guideline. FINDINGS/RESULTS: When extrapolating the newly developed protocol to 2012 data, less than 15% of transfusions among ELBW infants would have met the current evidence-based standard. Conversely, during the first 6 months of 2014, 61% of transfusions were administered in adherence to the guideline (P < 001). Using current cost estimates, this represents a projected cost savings of $31,000 in that 6-month period. IMPLICATIONS FOR PRACTICE: A multidisciplinary approach to improving PRBC transfusion practices results in potentially safer, more cost-effective care for ELBW infants. IMPLICATIONS FOR RESEARCH: Given the frequency, potential harms, and costs associated with PRBC transfusions in ELBW infants, it seems both feasible and important to pursue prospective clinical trials comparing permissive and restrictive approaches to transfusion in this vulnerable population.

Care of the infant with neonatal abstinence syndrome: strength of the evidence.

There is little empirical evidence that guides management of infants with neonatal abstinence syndrome. The standard of care first described in the 1970s is still prevalent today, although it has never been tested in this population. Standard of care interventions include decreasing external stimulation, holding, nonnutritive sucking, swaddling, pressure/rubbing, and rocking. These interventions meet the goals of nonpharmacologic interventions, which are to facilitate parental attachment and decrease external stimuli. Many nursing interventions used in infants with neonatal abstinence syndrome have been tested in low-birth-weight infants, whose treatment often includes the same goals. Those interventions include music therapy, kangaroo care, massage, and use of nonoscillating water beds. Nursing attitude has also been shown to be impactful on parental attachment. The American Academy of Pediatrics recommends breast-feeding in infants whose mothers are on methadone who do not have any other contraindication. It also provides guidelines for pharmacologic management but cannot provide specific recommendations about a standard first dose, escalation, or weaning schedule. Buprenorphine has some evidence about its safety in newborns with neonatal abstinence syndrome, but high-powered studies on its efficacy are currently lacking. There are many opportunities for both evidence-based projects and nursing research projects in this population.

Perinatal data collection: current practice in the Australian nursing and midwifery healthcare context.

The collection of perinatal data within Queensland, Australia, has traditionally been achieved via a paper form completed by midwives after each birth. Recently, with an increase in the use of e-health systems in healthcare, perinatal data collection has migrated to an online system. It is suggested that this move from paper to an ehealth platform has resulted in improvement to error rates, completion levels, timeliness of data transfer from healthcare institutions to the perinatal data collection and subsequent publication of data items. Worldwide, perinatal data are collected utilising a variety of methods, but essentially data are used for similar purposes: to monitor outcome patterns within obstetrics and midwifery. This paper discusses current practice in relation to perinatal data collection worldwide and within Australia, with a specific focus on Queensland, highlights relevant issues for midwives, and points to the need for further research into the efficient use of an e-health platform for perinatal data collection.

Neonatal care in the home in northern rural Honduras: a qualitative study of the role of traditional birth attendants.

Traditional birth attendants (TBAs) have limited ability to reduce maternal mortality, but may be able to have a significant impact on neonatal survival. This qualitative study explores TBAs' (possessive) experience with neonatal care in a rural Honduran community. In 6 semistructured focus groups, TBAs described services they routinely provide to newborns. Using Atlas.ti, Version 6.0. (ATLAS.ti Scientific Software Development GmbH, University of Berlin), transcripts were coded by bilingual researchers and analyzed by thematic content. TBAs demonstrated limited knowledge of newborn physiology, yet were aware of many internationally recommended practices. Despite attempts to follow recommendations, all TBAs expressed difficulty due to resource constraints. TBAs were strong advocates of immediate breast-feeding and skin-to-skin care, but they did not demonstrate knowledge regarding delayed bathing and thermal care. Most TBAs stated that a sick neonate could be identified immediately at birth; thus, infections or other illnesses developed in later days may be missed. TBAs did not believe they could have averted neonatal complications or deaths that had occurred under their care. For most healthy newborns, TBAs are the primary providers until the 2-month vaccine visit at the healthcare clinic. Improved TBA training focused on infection symptomotology, physiology, and thermoregulation for newborns may increase opportunities for improved health and timely referrals to healthcare facilities.

Balancing the scale: directions for future research for perinatal advanced practice nurses.

Advanced practice nurses, including midwives, are well positioned to conduct, participate, or both in both basic and translational research to improve the outcomes and processes of perinatal care. This article contains suggestions for future research by perinatal advanced practice nurses, conceptualized around a scale to promote balance in outcomes. More research is needed in a number of areas, examples include collaborative practice, normal birth, and translation of the evidence concerning skin-to-skin practice. Health disparities; maternal, neonatal, and infant morbidity and mortality; formula feeding; and other vulnerabilities need more research to decrease these problematic outcomes. Advanced practice nurses are encouraged to be actively involved in perinatal research, to help confront and reduce health disparities, and to apply evidence in practice, broadly promoting wellness for women and their families.

Development of a Web-based decision support tool to increase use of neonatal hyperbilirubinemia guidelines.

BACKGROUND: The 2004 American Academy of Pediatrics (AAP) guidelines for management of hyperbilirubinemia in the newborn infant at > or =35 weeks of gestation recommend that clinicians systematically asses the risk of severe hyperbilirubinemia before hospital discharge. Using the guidelines requires access to the printed nomograms, calculation of the infant's age in hours, and manual plotting of total bilirubin results. The combination of a common clinical problem with the existence of guidelines for best practice is an ideal target for clinical informatics tools to help improve compliance. A Web-based clinical decision support tool was developed on the basis of a combination of published data and linear extrapolation to automate the hour-specific risk stratification nomogram and phototherapy nomogram. METHODS: After BiliTool, the clinical decision support tool that contained the AAP clinical guidelines, was made publicly available, Web-site usage was monitored. An online survey composed of 10 multiple-choice, Likert-scale, and yes-no questions was made available. RESULTS: The number of site visits has increased over time. Of the 469 respondents to the survey, 297 respondents considered themselves tool "users". DISCUSSION: Rapid uptake and high ratings for clinical utility confirm that Web-based clinical decision support tools are in high demand and may increase use of clinical guidelines. Given the risk of human error with manual age calculation and nomogram plotting, this tool may also decrease the likelihood of medical errors, particularly with integration into the electronic medical record. Concomitant release of Web-based decision support tools with clinical guidelines would optimize the guidelines' adoption and implementation. Also, the integration of BiliTool into the electronic medical record may serve as a model for integrating other Web-based clinical decision support tools.

Use of the Optimality Index-United States in perinatal clinical research: a validation study.

The objective of this study was to assess the validity and observed effect size of a new instrument, the Optimality Index-United States (OI-US), for use in perinatal clinical research. Using a large, hospital-based, midwifery service clinical database that included complete obstetric data for 3425 women, we examined discriminant validity and the effects of two different scoring methods used with the OI-US. Discriminant validity was confirmed by comparing OI scores for women who remained low risk and did not require physician involvement in their care (OI score mean = 84%; standard deviation [SD] = 8%) compared to those whose condition changed to require physician involvement in their care (mean = 71%; SD = 10%; P < .001). Two methods of scoring the OI-US were compared, finding no significant difference and suggesting that the types of data available and the research question can drive this decision. Finally, effect size was calculated by two methods: Cohen's d (-1.4) and the effect size correlation (r = -0.548), the latter of which corresponds to a d of -1.3, both resulting in a similarly large effect size estimation. The OI-US is a new instrument that shows promise for use in perinatal clinical research, particularly when assessing more subtle clinical differences in outcomes between study groups.