Influence of a Palliative Care Protocol on Nurses\u27 Perceived Barriers to Palliative Care and Moral Distress

The World Health Organization (2013) states palliative care for children should begin at diagnosis which may even occur prenatally. Neonatal palliative care is variable due to the high technological, curative environment in the newborn intensive care unit, and the uncertain prognoses of infants born at the edge of viability. The purpose of this EBP project was to determine the influence of establishing a neonatal palliative care protocol on nurses’ perceived barriers to palliative care and moral distress. Corley’s Moral Distress theory and Stetler’s Model were used as guides for the framework of the project. The protocol, based on guidelines supported by the American Academy of Pediatrics and the National Association of Neonatal Nurses, included forming a care team for the infant and family and educational sessions for the nurse based on the End of Life Nursing Education Curriculum. Pre-invention and post-invention surveys were administered which measured perceived barriers and moral distress. The pre intervention and the post-intervention groups differed by gender (X2(1) = 4.483, p\u3c0.05) and formal education (X2(2) = 6.357, p\u3c0.05). A significant decrease in perceived barriers were found in (a) medical staff support palliative care (t (42) = 2.031, p\u3c0.05), (b) physical environment for palliative care (t (43) = 3.216, p\u3c0.01), (c) policies/guidelines are present for palliative care (t (41) = 2.634, p\u3c0.05), (d) palliative care options are given to families (t (42) = 2.075, p\u3c0.05), and (e) team member express opinions, values, and beliefs (t (43) = 2.951, p\u3c0.01). A significant decrease in moral distress was noted in the concepts of witnessing providers giving false hope to families (t (43) = 2.321, p\u3c0.05) and working with unsafe providers (t (41) = 2.300, p\u3c0.05). A significant increase was noted, though, in the concept of working with incompetent providers (t (41) = -2.152, p\u3c0.05). The neonatal palliative care protocol has been adopted by the clinical agenc

Risk factors, predictive markers and prevention strategies for intrauterine fetal death. An integrative review

According to World Health Organization (WHO), fetal death is defined as the death of the fetus prior to its complete expulsion, independent of the duration of pregnancy, thus only ascribing the term stillbirth to fetal deaths in the case of pregnancies after 28 weeks of gestation. The great progress of perinatology care is reflected in a significant reduction in the rate of stillbirths, especially in well-developed countries, with approximately 98% of stillbirth cases now occurring in poor and developing countries. Stillbirth powerfully impacts both the patient and the practitioner. Because nearly half of stillbirth cases result from apparently uncomplicated pregnancies, we considered it critical to review the known predictive markers for intrauterine fetal death. In both preterm and term infants, perinatal mortality is increased in fetuses small for their gestational age, and this risk grows proportionally with the severity of the fetal growth restriction. A protracted first stage of labor has not been associated with an increased risk of perinatal mortality and morbidity, but a prolonged second stage of labor has been associated with mortality and neonatal morbidity characterized by sepsis, seizures, and hypoxic-ischemic encephalopathy. Ultrasound examination of the placenta and the umbilical cord is essential for appropriate pregnancy monitoring. Various findings from ultrasound examination have been related to variable adverse perinatal outcomes, including intrauterine fetal death. After reviewing the evidence for predictors of intrauterine fetal death, we offer a general strategy for reducing the likelihood of stillbirths

Determining the Effect of Evidence Based Low-Stress Nursing Care on Premature Infants’ DNA Methylation

Background Evidence has shown that premature infants in the newborn intensive care units (NICU) experiencing stress in the areas of parental detachment, painful procedures, and exposure to noxious stimuli undergo DNA methylation (Montirosso & Provenzi, 2015). These epigenetic changes cause poor long-term psychological and social outcomes similar to post-traumatic stress disorder. Purpose The purpose of this phase of the study is to provide additional education for the nurses and the parents to provide evidence-based low-stress nursing care. Methods Lighting and sound will be measured during the study to enable nurses to control the levels of noxious stimuli. Reduction in noise to less than 45 dB is recommended (Committee on Environmental Health, 1997). Nursing staff will be educated on the use of non-pharmacological agents for pain management during pain-inducing procedures. The use of kangaroo care will be promoted throughout the unit by the use of modest incentives for nurses and families. A pain assessment tool will be used to guide pain relief measures (Altimier, et al, 2015) along with comfort measures to improve physiologic stability (Altimier, et al, 2015). Implications This research project looks at providing low-stress nursing interventions to these vulnerable infants mitigating adverse DNA outcomes. Kangaroo Care regulates heart rate (Charpak et al., 2020), improves growth (Charpak, et al.,2020), decrease the length of stay (Ludington-Hoe, et al., 2008). Pain exposure results in epigenetic changes and adverse long-term developmental outcomes (Montirosso & Provenzi, 2015). Noxious stimuli, sound \u3e70 dB causes changes in heart rate, blood pressure, pulse oximetry, respirations, peristalsis, glucose consumption (Graven, 2000). The correlation between interventions and DNA changes is significant to better understand the impact of evidenced-based practice nursing care. Educating nursing staff about the benefits and methods of low-stress nursing care could change the NICU environment by decreasing noxious stimuli, improving pain management, and increasing parental bonding leading to improved patient outcomes

Determining the Effect of Circadian Lighting on Premature Infants’ DNA Methylation

Background Evidence shows that premature infants in the NICU experiencing stress in the areas of parental detachment, pain, and exposure to noxious stimuli undergo DNA methylation (Montirosso & Provenzi, 2015). These epigenetic changes cause long-term effects similar to PTSD. Purpose The purpose of this study is to determine the effects of evidence-based low-stress nursing care including circadian lighting on premature infants’ DNA methylation levels at SLC6A4 alleles. Methods The study will be conducted in 3 phases with infants admitted to the level III NICU. The anticipated number of participants is 150 to 200. The first phase includes obtaining a baseline oral swab for DNA in the control group. Phase two begins with evidence-based nursing care. Focus of care will be to reduce pain by low-stress nursing care. After 50 infants’ data are collected, phase three will begin with circadian lighting. The initial swab will be obtained before 2 days of age. The second will be obtained 24 hours before discharge. The baseline swab shows the levels of methylation due to maternal stress passed to the infant. This compares methylation levels from hospitalization to those inherited from mom. Implications Circadian Lighting, which changes morning, evening, and night helps create a 24- hour cycle with calming light tones to aid in creating their circadian rhythm (Linander et al., 2020). Bright light exposure at night causes DNA methylation changes (Fonken & Nelson, 2016). Environmental lighting affects biological processes and sleep states (Miriam & Ariagno, 2000). Cycled lighting decreases length of hospital stay and increased weight gain (Miriam & Ariagno, 2000). Current research demonstrates stressful events cause DNA changes in premature infants (Montirosso et al., 2016; Montirosso & Provenzi, 2015). This research provides low-stress interventions to infants mitigating DNA changes. DNA methylation is significant to understand the impact of nursing care