Christine A. Fortney

ARMY WOMEN'S REASONS FOR CONDOM USE AND NONUSE

PURPOSE The purpose of this study was to examine Army womens condom use patterns, reasons for condom use and nonuse, and what is liked about and problems associated with condom use. METHODS Army women (n = 131) from military posts around the country were recruited. The women ranged in age from 18 to 68 years (M = 30.5, SD = 10.5). The sample was of mixed ethnicity. Questionnaires were distributed by the units and returned directly to the principal investigator. Participants completed a series of anonymous open- and closed-ended questions regarding their experiences with condoms. Closed-ended questions were analyzed with descriptive statistics and open-ended responses were content analyzed (McLaughlin & Marascuilo, 1990). CONCLUSIONS Regular condom use was low in this sample. The most often cited responses as to why women liked using condoms included peace of mind, protection, or ease of use. The most cited problems and subsequent disuse included irritation/inflammation, breakage, improper fit, or ruining the moment. Results differed by consistency of condom use. Regular users of condoms reported a lower percentage of problems using condoms.

Medical record documentation and symptom management at the end of life in the NICU.

Purpose:In neonates, the course of illness is often unpredictable and symptom assessment is difficult. This is even truer at the end of life (EOL). Time to death can take minutes to days, and ongoing management of the infant is needed during the time between discontinuation of life-sustaining treatment and death to ensure that the infant remains free of pain and suffering. The symptoms experienced by neonates as they die, as well as best ways to treat those symptoms, are understudied. The purpose of this study was to examine symptoms exhibited by neonates at the EOL and the treatments used to manage those symptoms as documented in the medical record during the last 24 hours of life. Subjects:The sample included 20 neonates who died at a large childrens hospital. Design:This was an exploratory, descriptive study. Methods:Descriptive data, such as diagnosis, ongoing therapy at time of treatment withdrawal or withholding, pharmacologic and nonpharmacologic interventions associated with treatment withdrawal, time of treatment withdrawal and death, age at time of death, signs and symptoms exhibited during EOL care, and pain scores, were abstracted from the infants medical record. Main Outcome Measures:Inadequate documentation in the medical record resulted in missing data that made it not possible to fully explore aspects of symptom management during the last 24 hours of life; however, some important results were found. Results:This study showed a difference in the way neonates approach the EOL period. Other findings were that most infants in the study received pain medication, even though pain scores were infrequently documented and drug dosages varied across infants. Finally, documentation of nonpharmacologic interventions utilized at the EOL was also lacking.

A New Framework to Evaluate the Quality of a Neonatal Death

Management of the infant in the neonatal intensive care unit (NICU) focuses on stabilization and survival but sometimes death is an inevitable outcome. Dying neonates deserve a good death. It is unknown whether we are providing neonates with a good death. This article introduces a framework describing components needed for a good death in the NICU. Initially based on an adult model, this new framework incorporates appropriate components of Emanuel and Emanuels framework (1998) and puts them into a context applicable to neonates. The proposed concepts and relationships will require future testing and revision as indicated by the evidence.

Outcomes of preterm infants following discussions about withdrawal or withholding of life support

Objectives To describe the frequency of postnatal discussions about withdrawal or withholding of life‐sustaining therapy (WWLST), ensuing WWLST, and outcomes of infants surviving such discussions. We hypothesized that such survivors have poor outcomes. Study design This retrospective review included registry data from 18 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Infants born at 22‐28 weeks of gestation who survived >12 hours during 2011‐2013 were included. Regression analysis identified maternal and infant factors associated with WWLST discussions and factors predicting ensuing WWLST. In‐hospital and 18‐ to 26‐month outcomes were evaluated. Results WWLST discussions occurred in 529 (15.4%) of 3434 infants. These were more frequent at 22‐24 weeks (27.0%) compared with 27‐28 weeks of gestation (5.6%). Factors associated with WWLST discussion were male sex, gestational age (GA) of ≤24 weeks, birth weight small for GA, congenital malformations or syndromes, early onset sepsis, severe brain injury, and necrotizing enterocolitis. Rates of WWLST discussion varied by center (6.4%‐29.9%) as did WWLST (5.2%‐20.7%). Ensuing WWLST occurred in 406 patients; of these, 5 survived to discharge. Of the 123 infants for whom intensive care was continued, 58 (47%) survived to discharge. Survival after WWLST discussion was associated with higher rates of neonatal morbidities and neurodevelopmental impairment compared with babies for whom WWLST discussions did not occur. Significant predictors of ensuing WWLST were maternal age >25 years, necrotizing enterocolitis, and days on a ventilator. Conclusions Wide center variations in WWLST discussions occur, especially at ≤24 weeks GA. Outcomes of infants surviving after WWLST discussions are poor. Trial registration ClinicalTrials.gov: NCT00063063.

The emotional impact of errors or adverse events on healthcare providers in the NICU: The protective role of coworker support

AIMS To examine the impact of errors or adverse events on emotional distress and professional quality of life in healthcare providers in the neonatal intensive care unit, and the moderating role of coworker support. BACKGROUND Errors or adverse events can result in negative outcomes for healthcare providers. However, the role of coworker support in improving emotional and professional outcomes has not been examined. DESIGN A cross-sectional online survey from a quality improvement initiative to train peer supporters in a neonatal intensive care unit. METHODS During 2015, 463 healthcare providers in a neonatal intensive care unit completed a survey assessing their experiences with an error or adverse event, anxiety, depression, professional quality of life and coworker support. RESULTS Compared with those who did not experience an error or adverse event (58%), healthcare providers who observed (23%) or were involved (19%) in an incident reported higher levels of anxiety and secondary traumatic stress. Those who were involved in an event reported higher levels of depression and burnout. Differences between the three groups (no event, observation and involvement) for compassion satisfaction were non-significant. Perceived coworker support moderated the association between experiencing an event and both anxiety and depression. Specifically, experiencing an event was associated with higher levels of anxiety and depression when coworkers were perceived as low in supportiveness, but not when they were viewed as highly supportive. CONCLUSION Findings suggest that errors or adverse events can have a harmful impact on healthcare providers and that coworker support may reduce emotional distress.

Parent Distress and the Decision to Have Another Child After an Infant's Death in the NICU

Objective: To examine associations among parent perceptions of infant symptoms/suffering, parent distress, and decision making about having additional children after an infants death in the NICU. Design: Mixed‐methods pilot study incorporating mailed surveys and qualitative interviews. Setting: Midwestern Level IV regional referral NICU. Participants: Participants were 42 mothers and 27 fathers whose infants died in the NICU. Methods: Parents reported on infant symptoms/suffering at end of life and their own grief and posttraumatic stress symptoms. Qualitative interviews explored decision making about having additional children. Results: Approximately two thirds of bereaved parents had another child after their infants death (62% of mothers, 67% of fathers). Mothers who had another child reported fewer infant symptoms at end of life compared with mothers who did not (p = .002, d = 1.28). Although few mothers exceeded clinical levels of prolonged grief (3%) and posttraumatic stress symptoms (18%), mothers who had another child endorsed fewer symptoms of prolonged grief (p = .001, d = 1.63) and posttraumatic stress (p = .009, d = 1.16). Differences between fathers mirrored these effects but were not significant. Parent interviews generated themes related to decision making about having additional children, including Impact of Infant Death, Facilitators and Barriers, Timing and Trajectories of Decisions, and Not Wanting to Replace the Deceased Child. Conclusion: Having another child after infant loss may promote resilience or serve as an indicator of positive adjustment among parents bereaved by infant death in the NICU. Prospective research is necessary to distinguish directional associations and guide evidence‐based care.

A qualitative study of nurse observations of symptoms in infants at end-of-life in the neonatal intensive care unit

OBJECTIVES Assessment and management of symptoms exhibited by infants can be challenging, especially at the end-of-life, because of immature physiology, non-verbal status, and limited symptoms assessment tools for staff nurses to utilize. This study explored how nurses observed and managed infant symptoms at the end-of-life in a neonatal intensive care unit. METHODOLOGY/DESIGNMETHODS This was a qualitative, exploratory study utilizing semi-structured face-to-face interviews, which were tape-recorded, transcribed verbatim, and then analyzed using the Framework Approach. SETTING The sample included 14 staff nurses who cared for 20 infants who died at a large childrens hospital in the Midwestern United States. MAIN OUTCOME MEASURES Nurses had difficulty recalling and identifying infant symptoms. Barriers to symptom identification were discovered based on the nursing tasks associated with the level of care provided. RESULTS Three core concepts emerged from analyses of the transcripts: Uncertainty, Discomfort, and Chaos. Nurses struggled with difficulties related to infant prognosis, time of transition to end-of-life care, symptom recognition and treatment, lack of knowledge related to various cultural and religious customs, and limited formal end-of-life education. CONCLUSION Continued research is needed to improve symptom assessment of infants and increase nurse comfort with the provision of end-of-life care in the neonatal intensive care unit.

Perspectives from bereaved parents on improving end of life care in the NICU.

Although improving end-of-life (EOL) care for children and their families is a national priority (American Academy of Pediatrics, Committee on Bioethics and Committee on Hospital Care, 2000; Institute of Medicine, 2003), research in the neonatal intensive care unit (NICU) is limited. To improve care, there is a critical need to understand the experiences of these infants and their caregivers. Therefore, we conducted a retrospective study to examine parent perceptions of their infants’ care at EOL in the NICU between 3 months and 5 years of their infant’s death (M = 38.10 months, SD = 16.87). As part of this pilot study, 29 mothers and 16 fathers representing 31 infants participated in qualitative interviews assessing parents’ satisfaction with their involvement in their infants’ care and decision-making and their advice to NICU providers. Four themes emerged from interview data, including parents as partners in care, communication with the health-care team, relationships with staff, and bereavement support. Both mothers and fathers generally felt positive about their role in treatment decisions, relationships with staff, and memory-making activities. Parents noted areas for improvement, including team communication, anticipatory guidance, family inclusion at bedside, and bereavement care. This study provides a deeper understanding of parents’ experience with their infants at EOL and highlights opportunities for enhancing care. Pediatric psychologists can play an important role in facilitating communication between parents and the health-care team as well as providing bereavement support for these vulnerable families.