Women’s Health and Neonatal Care – JRM Nurse Consultants

April 04 2020

Religious Ethics in the NICU: Balancing Beliefs and Life-Saving Care

The ethical situation that comes to mind this week is religious ethics. This theory focuses on religion, often shaped by a parent’s upbringing and older family members. For example, Jehovah’s Witness parents do not allow blood transfusions. This becomes critical when a baby in the Neonatal Intensive Care Unit (NICU) needs a transfusion. In such cases, the treating neonatologist may need a court order to administer the transfusion. In extreme emergencies, if two doctors sign off that immediate action is necessary, the baby will receive the transfusion while the court order is pending.

As a parent of a premature baby myself, I could not imagine not doing everything possible to save my child. Yet religious ethics prioritize the parents’ beliefs, even when medical decisions are life-saving (Denisco & Barker, 2012).

The parents’ refusal can hinder care, but nurses must promote family-centered care, involving caregivers in decision-making whenever possible (Meadow, Feudtner, Matheny Antommaria, Sommer, & Lantos, 2010).

I recall my experience in a level 3 critical NICU, where many rooms were open due to the infants’ conditions. I watched a baby deteriorate rapidly, and the healthcare team discussed urgent transfusion needs openly. As a parent, it was heartbreaking. As a nurse, I wondered how I would handle such a situation, balancing professional responsibilities with compassion for the parents.

The nurse manager at the time criticized the parents, calling their decisions ignorant. While part of me understood her frustration, the compassionate nurse in me knew these parents faced an agonizing choice. I reminded the manager that, regardless of personal opinions, our role was to support the family, ensure the infant’s safety, and provide care—whether or not the parents agreed. By law and ethical standards, the baby would receive the transfusion if medically necessary, often by court order, but our empathy and guidance were essential for the parents during this crisis.

With religious ethics, we may not agree with the family, but as nurses, we must respect their customs and beliefs as long as the baby’s life is not in immediate danger. Compassion and empathy guide us in navigating these difficult situations.

References:
Denisco, S. M., & Barker, A. M. (2012). Advanced practice nursing: Evolving rules for the transformation of the profession (2nd ed., pp. 569-581). Retrieved from https://campus.capella.edu/web/library/home

Meadow, W., Feudtner, C., & Matheny-Antommaria, A. H. (2010, April 13). A premature infant with necrotizing enterocolitis. Special Articles – Ethics Rounds. http://dx.doi.org/10.1542/peds.2010-0079

January 01 2020

Passive Descent vs Pushing in Second Stage of Labor

Most recently I was asked to comment on whether during the second stage of labor ( which is the onset of full cervical dilation) should be passive descent vs. pushing. In my opinion, it all depends on what policy the treating practitioner uses. I worked at a high level labor and delivery unit up North where women were flown in if it was an emergency or bad delivery anticipated or trauma. But we also were a Catholic Hospital and took care of the indigent. We had a teen obstetrics clinic in the area (not related to the hospital) but it was across the street. They handled all the teenage pregnancies that came through their doors. It was managed by two very caring midwives. At this clinic, the girls not only received prenatal care but they also received information on how to take care of their babies. The girls were referred to pediatricians to get healthcare for the babies and to school counselors to help them get their GED’s. But the best part was that these midwives taught natural childbirth at their clinic. When a girl came into labor, they went into the birthing room and they did perineal massage to do natural descent. They worked with the contractions. These girls rarely had any perineal tears.

One day one of the midwives was on vacation and the other one was in the clinic and could not get there this one time and one of their girls came in almost completely dilated and effaced. The resident on duty that evening was one of the most arrogant doctors I had ever seen, he had smart remarks before he even got in the room with her. He went inside to do her exam and he rammed into her and the girl nearly jumped three feet, I calmed her down as she was a scared 15-year-old girl. She screamed and he said listen you had something much bigger in there than my finger, I quickly stated, doctor that is enough. He said, yes she is dilated, get her in the delivery room, I said that the girls go to the birthing rooms and deliver there in a more holistic approach; his reply was, we don’t have time for that garbage, get her pushing and delivered. This poor child gave birth and had tears from front to back, she was in such pain, as she could not have an epidural or pain meds since she was already effaced and 10 cm. I did not have kids at that time, but could only imagine by the grips of my hand and the tears and screaming that she was suffering. I was barely 21 years old. The midwife came finally after she closed the clinic at 7pm to check on her patient and was so angry after the patient told her what happened. She brought up the incident to the hospital administrator who placed the doctor on probation. He had a few incidents with me and some other nurses and eventually was fired from the residency at that hospital. Knowing the hospital’s practice for each unit and also what the practitioner believes is very important (Denisco & Barker, 2012). Some doctors will approach labor and delivery with a more holistic approach. This would be an approach that Jean Watson’s theory on caring would fit in to.

References

Denisco, S. M., & Barker, A. M. (2012). 25. In Advanced practice nursing: Evolving rules for the transformation of the profession (2nd ed., pp. 547-567). Retrieved from https://campus.capella.edu/web/library/home

January 01 2020

Compassion in the NICU: Balancing Expertise, Empathy, and Family-Centered Care

One of the clinical challenges I see in the Neonatal Intensive Care Unit (NICU) is staff complacency. When nursing becomes just a job, passion can be lost, and nurses may move through the motions. We may forget that what is routine for us is a first experience for the families we care for.

Approaching every patient and parent with kindness and empathy is critical. Body language, tone of voice, and facial expressions reveal our genuineness. Even when busy, we must prioritize compassion, putting ourselves in the parents’ shoes to determine the level of care they need.

A common issue in the NICU is assessing infant readiness for oral feeding in premature babies. Opinions vary among staff about the best approach. My experience as a mother allowed me to see both sides: as a parent and as a healthcare professional.

During my son’s NICU stay, he was fed initially via NG tube and later transitioned to bottle feedings. One weekend, I was feeding him multiple times while spending the day with him, but a nurse unfamiliar with us took over, claiming I was feeding him incorrectly and causing aspiration. I was only allowed to hold him. Despite prior arrangements with management for private-room feedings due to a hospital-acquired infection, the nurse acted abruptly.

I was devastated and cried for days. When I reported the incident to the head nurse, it was documented, and the weekend nurse later apologized. Ultimately, it was discovered that the baby’s aspiration was unrelated to how I fed him, and a Mickey G-tube was inserted to facilitate safe feeding and expedite discharge.

This experience highlights the importance of patient-centered care in the NICU. The Colorado model emphasizes including patients—and in this case, parents—in decision-making, respecting their preferences, religious or cultural considerations, and personal choices (Goode, Fink, Krugman, Oman, & Traditi, 2010). Nurses may excel technically, but if parents are excluded, care is incomplete. Compassion, communication, and inclusion are as essential as clinical expertise.

Reference:
Goode, C. J., Fink, R. M., Krugman, M., Oman, K. S., & Traditi, L. K. (2010, August 10). The Colorado patient-centered interprofessional evidence-based practice model: A framework for transformation. Worldviews on Evidence-Based Nursing, 96–105.

October 10 2019

A Gap in Practice in the NICU

Most recently I was asked to write as a contributor for a textbook called Comprehensive Neonatal Nursing 6th edition about what gaps there are in teh neonatal intensive care units. The editors Carole Kenner, Leslie B. Altimier, and Marina V. Boykova, put together this textbook to support practice strategies and sound clinical decisions in teh neonatal intensive care unit. My focus is on a NICU toolkit. https://www.amazon.com/Comprehensive-Neonatal-Nursing-Care-Sixth/dp/0826139094/ref=sr_1_1?keywords=9780826139146&linkCode=qs&qid=1570765494&s=books&sr=1-1

The specific gap in practice in the neonatal intensive care unit (NICU) is the challenge that parents face when they are discharged home. The underlying assumptions of these issues include a lack of confidence to be able to take care of the baby, not enough information to understand the machines, a lack of practice time, and increased readmission rates to the hospital within 30 days of discharge from the NICU. Regarding the population parents of premature babies, the argument that is most often heard from the nurses and the NICU team is that the parents have been in the NICU watching the nurses for the last five to seven months and they should be able to take care of their infant (Hutchinson, Spillett, & Cronin, 2012).

The parents of premature babies have a higher stress level when the babies are discharged due to not receiving specific education to ease the transition home (Busse, Stromgren, Thorngate, & Thomas, 2013). In Miles’s (1994) study conducted via the Patient-Reported Outcomes Measurement Information System (PROMIS) following discharge from the NICU, it proved that there was a higher stress level for parents when they were discharged home. Premature infant readmissions were analyzed and it was determined that there was a 31% readmission rate to the NICU. The parents needed to be taught skills on how to avoid re-hospitalization (Hutchinson et al., 2012).

Premature babies were being born daily with multiple medical conditions that carried long term through the span of their lives. When they were transitioned to their homes, they required management of their special needs in the home setting. The transition program began 30 days before the baby was discharged to the home. If the teaching was not done prior to the discharge home, then when they went home, the baby was susceptible to errors made at home with medications, infection control, or treatment in general.

When a baby is taken home from the regular nursery it is noted to be a scary time for parents due to the newness of being a parent. For a parent of a premature baby, the anxiety increases especially if the baby had a long NICU stay. The parents are accustomed to having the nurses there for support but when they go home, they feel alone.

The proposed solution for this gap in service is the implementation of a NICU navigator tool kit. The toolkit is designed to help hospital nurses, doctors, therapists, social workers, and parents communicate more effectively towards reducing the parent’s anxiety surrounding their baby’s discharge to the home. The presentation of the NICU patient navigator toolkit contains evidence-based studies and real-life examples to demonstrate the toolkit’s necessity in the NICU.

References

Busse, M., Stromgren, K., Thorngate, L., & Thomas, K. (2013, August). Parent responses to stress: PROMIS in the NICU. Critical Care Nurse, 33(4), 1-13. http://dx.doi.org/10.4037/ccn2013715

Hutchinson, S. W., Spillett, M. A., & Cronin, M. (2012). Parents’ experiences during their infant’s transition from neonatal intensive care unit to home: A qualitative study. The Qualitative Report, 17(23), 1-20. Retrieved from http://www.nova.edu/ssss/QR/QR17/hutchinson.pdf

May 05 2019

When a Pregnancy is not Viable

I think that this is a hard decision for any mother to make when she is told that her baby may not be viable. I can see several ethical things here that would make a decision difficult to make. First of all, there is the termination of the pregnancy recommended because the baby will not be viable at birth, and then there is the religious aspect. These are both ethical situations that can be very difficult for parents when they have to make a decision. Doctors make decisions based on the viability of a baby and feel that if the baby will not make it, the pregnancy should be terminated. In a Christian hospital, for example, these conversations may not happen, because they do not do terminations of pregnancy, so that suggestion would not be made. However, at a non-Christian hospital, that type of discussion may happen there frequently.

Each hospital should have an ethics team to explain the choices to the mother so that a mother that does not believe in termination is aware that she does have the right to keep the baby until he passes. Allowing the parents to use their own judgment in a case like this, provides for better healing as they cope with the impending loss. The termination of a pregnancy before its time is devastating to any parent. A parent’s religious beliefs in the Lord keep them holding on for a possible miracle and we should not interfere in their decision making. If the miracle does not happen, those parents will find the way to grieve the loss but at least they were offered a choice and will not have to worry that the choice was not given to them and they will not have to live with the “what ifs.” This would be their way of coping with the death of that child (Denisco & Barker, 2012).

References

Rosie Moore, RN, DNP

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Category Archives: Women’s Health and Neonatal Care

Religious Ethics in the NICU: Balancing Beliefs and Life-Saving Care

Passive Descent vs Pushing in Second Stage of Labor

Compassion in the NICU: Balancing Expertise, Empathy, and Family-Centered Care

A Gap in Practice in the NICU

When a Pregnancy is not Viable