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

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

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

Rosie Moore, RN, DNP

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Religious Ethics

The religious ethics theory focuses on religion, which is depicted by the parent’s upbringing and the older family members typically.  One particular faith, Jehovah’s Witness, does not allow for blood transfusions.  This is very important when you have a baby in the NICU (Neonatal Intensive Care Unit) that is in need of the transfusion and the parent will not consent.  The treating neonatologist will need to get a court order to do the transfusions.  In an extreme emergency, if two doctors sign off that it is an emergency, then the baby will receive the transfusions while they await the court order.  As a parent of a premature baby myself, I could not imagine not doing everything I could to save my child.  But in this case, the religious code of ethics is based on the upbringing of the parent (Denisco & Barker, 2012).

The parent refusing to allow treatment of transfusions to their baby, would be a hindrance to the baby’s care, while at the same time as nurses we are trying to promote a  family-centered type of care involving the caregivers in the decision making and treatment  (Meadow, Feudtner, Matheny Antommaria, Sommer, & Lantos, 2010).  When my baby was in the level 3 critical NICU, they had open rooms, because the babies were too critical to be in closed rooms.  I watched a baby in front of us get sicker by the day and hearing the nurses and the doctors speak about the need for a blood transfusion and other treatments.  By the time they gave the baby the blood transfusion, it was too late, and the baby was terminal.  You as the parent are watching and hearing this because in this type of critical setup, there is nothing between you and the next bed except a curtain and in front of you, there is not a curtain.  As a nurse I thought to myself, how can they be having this discussion right in the open this way? As a parent I thought, how can these parents watch their baby die? I thought about how those nurses felt and if I were the nurse in that situation, what would I have done.

With the use of the religious ethics, we may not agree with the family, but as nurses, we need to respect the other person’s customs and beliefs as long as the baby is being taken care of and there is not a medical threat to the baby’s life.

References

Denisco, S. M., & Barker, A. M. (2012). 25. In 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., Feduter, C., & Matheny-Antomennaria, A. H. (2012, April 13, 2010). A premature infant with necrotizing enterocolitis. Special Articles-Ethics rounds. http://dx.doi.org/10.1542/peds.2010-0079

Rosie Moore, RN, DNP

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Is There Still a Nursing Shortage

It seems that the nursing shortage has been an issue since I was going to school.  I remember at one point I received a one year full scholarship to go to nursing school my first year; then the 2nd year I received a letter that stated the President decided the nursing shortage was over and cut my full scholarship for the second year, forcing me to get student loans. That is enough to make you mad! But now as I practice as a nurse, I see that there is still a shortage of nurses in many fields (Moore, 2015). For instance in the hospital what I see is that they do not hire too many nurses because if they have too many on the unit and they don’t float them to another unit, they will send them home without pay because there is not sufficient work. When my son was in the Neonatal Intensive Care Unit, I had to walk past high risk antepartum, one day the lights were dim, and there was no one around. I got a bit concerned that something had happened.  There was a sign that said, “unit closed.” When I inquired, someone stated that the unit was closed because the patient census was down.  Of course two days later, it reopened.

I see that nurses are overworked because of the shortage as well.  The shortage is only getting worse as the years go by because the baby boomers are soon going to be retiring and there are no new nurses to take their place (“Focus on Education,” 2010). There are also articles that speak about new nurses graduating, but their minimal level of education required will be the bachelor’s level plus all the clinical involved with that level.  There are entrance exams to some nursing schools, making it difficult for the student to pass.  Of course, education should be taken to the next level due to the more complex illnesses and family dynamics that we have today.

In order to not continuously have a shortage, employers need to realize that yes there is a shortage and hiring more staff to help the current nurses and not over tap them will be more productive in the long run.  The medical cases are getting more complex these days for patients in the hospital, therefore making it important for nurses to have a higher level of education. The colleges have to start sending representatives to the high schools to start recruiting future nurses so that when they graduate, we can add more nurses to the profession.  Recruiters need to present the pros and cons of being a nurse and look for candidates that will be a good fit for the nursing profession.

References

Moore, M. (2015). The nursing shortage and the doctor shortage are two very different things. Retrieved from http://www.washingtonpost.com/news/to-your-health/wp/2015/06/05/the-nursing-shortage-and-the-doctor-shortage-are-two-very-different-things/

The future of nursing: Focus on education. (2010). Retrieved from http://nursejournal.org/articles/the-future-of-nursing-infographic/

Rosie Moore, RN, DNP

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The Need for Nurses in Schools

For many families that have children in elementary through high school level with special needs for medications, it has become a question as to whether or not the school that they are zoned for has a school nurse. Many schools in Florida do not have nurses on staff (Florida Association of School Nurses website, n.d.).   In one article by the Orlando Sentinel, it notes that not all Orange County public schools have a nurse, in fact, their ratio out of 182 schools in Orange County, showed only 34 had nurses. One Orange County school mentioned that they have an RN and she helps a lot because it frees up the teacher to focus on her classroom instead of the child that is sick. The article went on to say that some tasks are delegated by the RN to non-clinical personnel, for instance, an assistant principal or secretary when the nurse is not in the school (Roth, 2011).

In my opinion, although parents of children administer injectables like epinephrine for allergic reactions or insulin, they are the parents that have been taught to watch for certain symptoms in their child that they see day in and day out.  They have a working knowledge of the situation should it arise. The school personnel, may be taught when to administer medications like epinephrine or insulin, but if they have never used it, or administered it, how can they safely administer it? Will they know what symptoms to look for if there is a reaction?

In the state of Delaware, every school is required to have a registered nurse.  Some schools that have them receive the funding through the school system grants, or in the community (Roth, 2011).  I most recently went to a school that is private with an estimated tuition rate of $14,000 per year and service preschoolers through high school. The school has a large arts program and a population of about 2000 kids, each child receives an IPad upon admission to use for homework.  They stated that they did not have a school nurse, if a child warranted medical treatment of medications or breathing treatments, this would not be the school for the child.  I found it rather sad to see that value was placed more on the material things of an IPad (which I know can help advance a student) but really the computers work just fine; having a registered nurse to help in times of kids needing treatment, or a school teacher needing treatment is much more valuable to me.

References

Florida Association of School Nurses website. (n.d.). https://fasn.nursingnetwork.com/page/18381-school-nurses-save-money-

Roth, L. (2011, September 26). A nurse in every school? Not in Florida not even close. Orlando Sentinel. Retrieved from http://articles.orlandosentinel.com/2011-09-26/business/os-fewer-school-nurses-florida-20110925_1_school-nurses-practical-nurses-students-with-chronic-illnesses

Rosie Moore, RN, DNP

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Should APN’s Have a Higher Standard of Education?

Many people in the healthcare field ask if an advanced practice nurse should have a higher standard of education?  in my opinion, yes, an advanced practice nurse should have a higher standard of education.  They are the leaders that are setting examples for the new nurses coming on board.  If we do not improve the profession, then anyone can say they want to be a nurse but not have the right criteria to be a nurse.  Nurses are taking care of people’s health and in some instances the patients are critical; they should have a level of education that is higher.

Advanced practice nurses that are teaching our new nurses coming into the profession,  definitely need to be at a higher level.  If they are not teaching, then they are in management or conducting research.  A great way that they can practice their speaking in impacting our nursing laws is starting locally with the Florida Nurse’s Association.  There is a local chapter in many cities and they speak about nursing issues that are both at a local and national level. They have the ability through the association to bring it for review; in our state, for instance, they can bring the concern to Tallahassee so that they can get it resolved or even brought up nationally to Washington.  If as nurses we do not get involved in healthcare, then what will happen is we will allow politicians who are not involved in the day to day care of patients, to make decisions that too often are not good choices for our healthcare system.

Rosie Moore, RN, DNP

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What is a Nurse Consultant

Nurse consultants are a nurse who identifies problems and develop solutions to them.  Once the problem is identified, then a workable solution can be developed.  Patients and their families can be coached through these problems.

Nurse consultants offer medical education to patients, family, and healthcare professionals.  The nurse consultant can create customized care plans for the patient in order to promote wellness.

Nurse consultants provide and develop new ways to ensure that a patient’s well being and safety are met.  They also provide an insider’s view on medical issues to legal professionals.

If you would like more information on having a nurse consultant for an evaluation of your needs, please contact:

Rosie Moore 407-760-1662 info@windermerebabyand family.com

Rosie Moore, RN, DNP

Visit my Website to learn more www.rosiemoore27.com
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