Nurses Providing End-of-Life Care for Infants and Their Families in the NICU: A Review of the Literature

Development and Feasibility Evaluation of a Family-Centred Neonatal End-of-Life Care Protocol

AIM

To develop a family-centred end-of-life care protocol and evaluate its feasibility.

DESIGN

The draft protocol was created by integrating literature review results and existing protocols and interviewing bereaved parents. A Delphi study and an experts' review were conducted to refine the draft, followed by feasibility testing with neonatal intensive care unit nurses.

RESULTS

A 71-item protocol based on an integrated end-of-life care model and the family-centred care concept was developed, comprising three sections: principal guidelines, communication during end-of-life care and five substeps (4, 17 and 71 items, respectively) according to changes in an infant's condition. The feasibility was confirmed by an increase in competency and a positive attitude towards infant end-of-life care participants who completed the protocol education.

CONCLUSION

The protocol was feasible and improved nurses' competency and attitude in providing end-of-life care for infants and parents requiring support due to the loss of their infants. It can positively impact the well-being of parents who have experienced the loss of their infants in neonatal intensive care units and enhance family-centred care within the units.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Application of the family-cantered end-of-life care could support infants' dying process and improve bereaved parents' quality of life in neonatal intensive care units.

IMPACT

This study increased neonatal end-of-life nursing needs' awareness among nurses and parents during bereavement. It offered preliminary evidence regarding the feasibility of a neonatal end-of-life care protocol developed in this study.

REPORTING METHOD

AGREE Reporting Checklist 2016.

PATIENT OR PUBLIC CONTRIBUTION

We interviewed bereaved parents to develop the draft protocol and involved neonatal care experts for the Delphi study and neonatal nurses (who would use the protocol) as feasibility test subjects.

TRIAL REGISTRATION

This was a doctoral dissertation and did not require protocol registration as the feasibility test involved a single neonatal intensive care unit.

Breaking bad news: Comparing the perception of the role, barriers and experiences of neonatal intensive care and well-baby nursery nurses

BACKGROUND

Nurses accompany patients throughout the breaking bad news process.

AIM

The aim of the research was to compare neonatal intensive care unit (NICU) nurses and well-baby nursery (WBN) nurses on their role, barriers and experiences in breaking bad news to parents/relatives during hospitalization.

STUDY DESIGN

A cross-sectional comparative study.

RESULTS

Two medical centres in Israel were employed. A 39-item questionnaire was distributed with 140 nurses participating in the study. STROBE Checklist was used. A total of 140 nurses participated in this study. There was no significant overall difference (p ≤ .45) between NICU and WBN nurses in their perception of their role in breaking bad news. Differences were found in barriers to the role which included a lack of information, lack of time and communication issues. No differences were found in the nurses' experiences in breaking bad news. NICU and WBN nurses reported that they received no support (n = 40, 58.8%; n = 45, 64.3%, respectively). No breaking bad news specialty team existed in either unit (NICU: n = 64, 91.4%; n = 60, 87.0%).

CONCLUSIONS

Nurses in the WBN and NICU are involved in breaking bad news. The role of the nurse has not been fully acknowledged making it difficult to perform. Nurses' experiences in breaking bad news were varied. Nurses facing challenges should be provided guidance and support. This needs to be implemented.

RELEVANCE TO CLINICAL PRACTICE

The role played by nurses in breaking bad news has not been fully acknowledged making it difficult to perform. Nurses need to receive formal training and support in order to improve this practice.

Ecological predictors of cultural competence among nurses in the neonatal intensive care unit: A cross-sectional descriptive study

Active migration and globalization have led to increased opportunities for critical care nurses to care for patients from diverse racial and cultural backgrounds. This study thus aimed to identify the individual, interpersonal, and organizational factors affecting cultural competence levels among neonatal intensive care unit (NICU) nurses based on an ecological model. This was a cross-sectional descriptive study that included 135 NICU nurses in South Korea. A hierarchical multiple linear regression analysis was conducted using the proposed ecological model, and a regression model for each of the four subdomains of cultural competence was constructed and compared. NICU nurses' cultural competencies were influenced not only by the "necessity of multicultural education" and "ethnocultural empathy" at the individual level but by the "hospital's readiness and support for cultural competencies" at the organizational level. To promote the cultural competence of nurses in critical care settings, environmental and organizational support should be improved, along with developing strategies that focus on nurses' individual characteristics. It is also necessary to investigate the "intersectionality" of the effects of individual and environmental factors on cultural competence.

Qualitative Study of Nurses' Experiences as They Learned to Provide Neonatal Palliative Care

OBJECTIVE

To describe the experiences of nurses as they learned to provide palliative care in the NICU.

DESIGN

Interpretive description.

SETTING

Four NICUs in three Canadian provinces, including one rural center and three tertiary centers.

PARTICIPANTS

Nine NICU nurses with 3 to 21 years of experience who provided neonatal palliative care.

METHODS

We collected data using online interviews that we recorded and transcribed. We analyzed data using immersion, inductive coding, reflective memoing, and thematic analysis.

RESULTS

Participants received little or no formal education in neonatal palliative care and instead learned to provide this care through observation and experience. Participants said it was important to find meaning in their work, which contributed to their motivation to learn to provide high-quality neonatal palliative care. Participants described challenges, including unit cultures in which early palliative care was not embraced. We identified three overarching themes that represented the participants' experiences: Meaning-Making in Neonatal Palliative Care, Challenges in Providing Neonatal Palliative Care, and Ill-Prepared to Provide Neonatal Palliative Care.

CONCLUSION

Standardized education may improve the quality of care and nurses' experiences with neonatal palliative care. We recommend designing and evaluating a standardized curriculum on neonatal palliative care.

Palliative Care for Infants in the Neonatal Intensive Care Unit: A Scoping Review

This scoping review aimed to explore the characteristics of neonatal palliative care in the neonatal intensive care unit, including the features, contents, and experiences of infants, parents, and nurses during palliative care. Five databases (PubMed, Cochrane, CINAHL, Research Information Sharing Service, and Korean Studies Information Service System) were searched to identify relevant articles published between 2011 and 2020. From the systematic search and review process, 13 studies that met the eligibility criteria were selected for the analysis. From the literature review, 2 key principles were found to facilitate neonatal palliative care: family-centered care and integrative care in the neonatal intensive care unit. In addition, the themes found in this review included (1) providing comfortable care to dying infants with respect to infants and offering parents choices, (2) therapeutic communication, (3) support with respect, and (4) bereavement care for parents of dying infants in the neonatal intensive care unit. Caregivers require effective communication, manpower support, emotional support, educational programs, and well-defined protocols. The evidence mapped and synthesized in this review indicates the need to facilitate the provision of palliative care in the neonatal intensive care unit in line with the unique needs of infants, parents, and nurses.

Describing Nurses' Work and Educational Needs in Providing Neonatal Palliative Care: A Narrative Review

Nurses in NICUs report insufficient education as a persistent barrier to providing quality neonatal palliative care (NPC). Since existing literature on educational interventions in NPC is limited, this review aimed to identify and narratively synthesize literature both about nurses' attitudes toward NPC and the NPC education received by nurses. We conducted a nonsystematic narrative literature review. Four themes were identified from the 28 articles included in this review. These were as follows: (a) nursing work in NPC, (b) NICU nurses' experiences and perceptions of NPC, (c) facilitators and barriers to nursing work in NPC, and (d) educational interventions in NPC. This literature review identified studies about NICU nurses' experiences and education in providing NPC. NICU nurses both desired and lacked education in NPC. This literature review identifies the importance of developing and evaluating NPC education for nurses.

Chinese Neonatal Nurses' Lived Experiences of Providing End-of-Life Care in the NICU: A Descriptive Phenomenological Study

BACKGROUND

Although end-of-life care (EOLC) has been well-studied, the experience of neonatal intensive care unit (NICU) nurses in China, where little EOLC training is provided, requires further investigation.

PURPOSE

To explore the lived experience of EOLC delivery among NICU nurses, to provide evidence to enhance nurses' EOLC skills and improve their overall quality.

METHODS

This qualitative study adopted a phenomenological approach. A total of 11 NICU nurses participated in semistructured in-depth interviews between June and July 2022 at the First Affiliated Hospital of University of Science and Technology of China (USTC). Colaizzi's 7-step method was used to analyze the data.

RESULTS

Five main themes were identified: (a) multiple emotions are experienced during EOLC delivery; (b) EOLC delivery is stressful from various sources for nurses; (c) expressing empathy and compassion is important; (d) ethical and clinical decision-making are key components of EOLC delivery; and (e) there are challenges in improving neonatal EOLC understanding and delivery.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The experience of EOLC among Chinese NICU nurses is multidimensional and intensive. Institutions or units must establish and implement related protocols and guidelines to address differences between clinical practice and ideal protocols for neonatal EOLC. Educational programs that consider nurses' personal and interpersonal factors, including local culture, must be developed. Neonatal nurses in Western countries encountering Chinese-born parents who have lost their infants can gain an understanding of parents' perceptions from this study. Future research should focus on developing and testing interventions to train and support NICU nurses working with end-of-life neonates.

Clinician perception of care at the end of life in a quaternary neonatal intensive care unit

Introduction

Care for neonates at the end of life (EOL) is often challenging for families and medical teams alike, performed suboptimally, and requires an experienced and compassionate clinician. Much literature exists on adult and pediatric EOL care, but limited studies examine the neonatal process.

Methods

We aimed to describe clinicians' experiences around EOL care in a single quaternary neonatal intensive care unit as we implemented a standard guideline using the Pediatric Intensive Care Unit-Quality of Dying and Death 20 tool.

Results

Surveys were completed by 205 multidisciplinary clinicians over three time periods and included 18 infants at EOL. While most responses were high, a meaningful minority were below goal (<8 on 0-10 scale) for troubling symptom management, conflict between parents and staff, family access to resources, and parent preparation of symptoms. Comparison between Epochs revealed improvement in one symptom management and four communication categories. Satisfaction scores related to education around EOL were better in later Epochs. Neonatal Pain, Agitation, and Sedation Scale scores were low, with few outliers.

Discussion

These findings can guide those aiming to improve processes around neonatal EOL by identifying areas with the greatest challenges (e.g., conflict management) and areas that need further study (e.g., pain management around death).

Neonatal intensive care unit nurses knowledge and attitude toward neonatal palliative care: review of the literature

Aim

To review studies regarding neonatal nurses' knowledge and attitude toward neonatal palliative care (NPC).

Method

The researchers searched internet sources such as Google Scholar for NPC, Nurses, Knowledge, Attitude, and Educational Intervention.

Results

Subheadings identified in the literature review were Nurses Knowledge toward NPC in NICU, Nurses Attitude toward NPC in NICU, correlation between Knowledge and Attitude toward NPC in NICU, The Effect of Educational program on Nurses Knowledge and Attitude toward NPC in NICU, and the Predictors of Knowledge and Attitude toward NPC among Nurses in NICU and Barriers to NPC provision and improvement.

Conclusion

There are few studies from different nations regarding NPC found nurses have an inadequate knowledge of NPC, which also reflects their attitude.

Worker Experiences of the Work Health and Safety Impacts of Exposure to Dying and Death in Clinical Settings: A Qualitative Scoping Review

Workers employed in clinical healthcare settings often encounter dying and death of patients as a part of their role. This scoping review aimed to explore the physical and psychosocial OHS impacts on health workers exposed to death within their occupational role and their inherent coping strategies. Six electronic databases PsycINFO (Ovid), Medline (Ovid), AMED (EBSCO), CINAHL (EBSCO), and Proquest Social Sciences were searched for peer reviewed research articles published between March 1971 and April 2022. PRISMA-ScR guidelines were followed. Three authors independently assessed articles for inclusion. Fifty-three studies with focus settings in hospitals, hospice, general practice and residential care were identified. Five main themes were developed and organized using and ergonomic systems approach: Cultural Environment, Workplace, Job Demands, Impacts and Coping. The findings demonstrate that caring for dying patients, the dead and their families in clinical settings impacts workers emotionally, physically, behaviorally and spiritually.

Fewer Patients per Nurse Does Not Offset Increased Nurse Stress Related to Treatment Uncertainty and Mortality in the Neonatal Intensive Care Unit

BACKGROUND

Many inpatient healthcare institutions' nurse staffing plans systematically assign fewer patients to nurses when patient acuity is high, but the impact of this strategy on components of nurse stress has not been thoroughly investigated.

PURPOSE

To examine the relationship between nurse-to-patient ratio assigned based on NICU patient acuity with the Nurse Stress Scale (NSS) subscales Death and Dying, Conflict with Physicians, Inadequate Preparation, Lack of Support, Conflict with Other Nurses, Work Load, and Uncertainty Concerning Treatment.

METHODS

A survey including the NSS tool items, demographic questions, and a question about nurse-to-patient ratio during the shift was administered. Cronbach's α, linear regression, and Spearman's correlation were used for data analysis.

RESULTS

Analysis of the 72 participating NICU nurses' survey responses showed fewer patients per nurse during the shift was negatively correlated with stress related to Death and Dying ( P < .001) and Uncertainty Concerning Treatment ( P = .002) subscale scores. This inverse relationship remained significant after controlling for education and years of experience.

IMPLICATIONS FOR PRACTICE

The observed higher stress can be inferred to be due to high patient acuity since fewer patients are assigned to nurses caring for high-acuity patients. Improvements in communication to nurses about patients' medical condition, treatment rationale, and information that should be conveyed to the family could reduce nurse stress from treatment uncertainty. Targeted education and counseling could help nurses cope with stress due to patient deaths.

IMPLICATIONS FOR RESEARCH

Interventions to reduce stress related to treatment uncertainty and death of patients among NICU nurses caring for high-acuity infants should be developed and evaluated.

Nurses' attitudes toward caring for terminally ill neonates and their families in Iran: a cross-sectional study

Providing care for terminally ill neonates is an important issue in NICUs. This research aimed to determine nurses’ attitudes toward providing care for terminally ill neonates and their families. A total of 138 nurses working in neonatal intensive care units (NICUs) affiliated to Tehran University of Medical Sciences participated in this cross-sectional study via convenience sampling in 2019. The Data collection tool was the Frommelt attitudes toward caring for terminally ill persons and their families scale. The nurses in this study had the most positive attitudes toward the items “nursing care should include the family of the terminally ill patient, too” (4.2 ± 0.6) and “the care provider can prepare the patient or his/her family for death” (4.1 ± 0.7). The nurses had the least positive attitude toward the item “the time spent on caring for terminally ill patients creates a sense of frustration in me” (1.06 ± 1). The mean score of the attitudes of NICU nurses toward caring for terminally ill neonates and their families indicates the necessity of improving this attitude.

Compassionate extubation protocol to improve team communication and support in the neonatal intensive care unit

OBJECTIVE

Compassionate extubation (CE) can be stressful for staff and families in the neonatal intensive care unit (NICU). Our quality improvement initiative developed and implemented a novel symptom management and family support checklist and post-debriefing template to improve team communication and staff support.

STUDY DESIGN

An interprofessional team performed a needs assessment, determined key drivers and intervention steps, and implemented changes using Plan-Do-Study-Act cycles. Outcomes included nursing perception of good communication with the medical team, nursing assessment of patient comfort after CE, and frequency of post-event debrief. Outcomes were analyzed using time series design with 12 months baseline data and 6 months post-implementation monitoring.

RESULT

Eighteen events were studied. Respondents endorsing "good" communication with the medical team increased by 60%, and debrief participation rate improved by 96%.

CONCLUSION

Implementation of a CE checklist and post-event debriefing sheet was associated with increased rate of debriefs and improved team communication.

Caring for Dying Infants: A Systematic Review of Healthcare Providers’ Perspectives of Neonatal Palliative Care

Objectives:

The palliative and hospice care movement has expanded significantly in the United States since the 1960s. Neonatal end of life care, in particular, is a developing area of practice requiring healthcare providers to support terminally ill newborns and their families, to minimize suffering at the end of the neonate’s life. This paper seeks to systematically summarize healthcare providers’ perspectives related to end of life, in order to identify needs and inform future directions.

Methods:

Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we systematically reviewed the literature discussing healthcare provider perspectives of neonatal end of life care ranging from year 2009 to 2020. To be included in the review, articles had to explicitly focus on perspectives of healthcare providers toward neonatal end of life care, be published in academic peer-reviewed sources, and focus on care in the United States.

Results:

Thirty-three articles were identified meeting all inclusion criteria. The literature covers, broadly, provider personal attitudes, experiences delivering care, practice approaches and barriers, and education and training needs. The experiences of physicians, physician assistants, nurse practitioners, and nurses are highlighted, while less is discussed of other providers involved with this work (e.g., social work, physical therapy).

Conclusion:

Future research should focus on developing and testing interventions aimed at training and supporting healthcare providers working with neonates at end of life, as well as addressing barriers to the development and implementation of neonatal palliative teams and guidelines across institutions.