Clinical Decision Making Case Study

Nursing has a history of late pre-term (LP) infants being admitted to post-natal, only to end up being transferred to neonatal within the first 48hours of life for feed related conditions such as hypoglycaemia. In order to address the needs of LP infants, there needs to be adequate plans in place the provide adequate care and nutrition for the unique needs of a LP infant. The following discussion will highlight the need for parental education and adequate postnatal management of an LP infant. This case study involves a New Graduate Registered Nurse (NGRN) employed in a neonatal unit and their clinical decision making with a late preterm infant experiencing hypoglycaemia. This case study will show a traceable trail of the NGRN by incorporating the Te Ara Model of Values set by the District Health Board (DHB); partnership, courage, empowerment, people mater, and safety (Taranaki District Health Board, 2019). It will demonstrate the use of communication with clients and across multidisciplinary teams. The legal, ethical and professional obligations of a registered nurse will be demonstrated and adhered to throughout.

The NGRN focuses on a family-centred care model; children are dependent on their primary caregivers for all their physical and emotional needs (Kuo et al, 2015). For care to be family-centred it should always be planned in collaboration with the family; respecting culture, beliefs and values (Kuo et al, 2015). Primary caregivers are encouraged to stay with their infant and actively participate in cares when appropriate/possible. Caregivers provide informed consent for procedures and remain fully informed of their infant’s health status. Caregivers should be regularly informed of progress toward home so that goals and plans can be set to prepare their own readiness for discharge. Nurses, paediatricians, registrars, location consultant, social work, speech and language therapists, visiting neurodevelopmental therapists and Māori health are all part of a multi-disciplinary team that communicate daily to ensure care is cohesive and the best clinical outcomes are achieved. Incorporating family-centred care into all nursing interactions is an example of the Te Ahu values set by the District Health Board (Taranaki District Health Board, 2019). These values also align with the ethical standards outlined by the Code of Conduct, (2012) set by The Nursing Council of New Zealand under the Health practitioners’ Competence Assurance Act, (2003).

Consent is gained from the parents of the LP infant discussed in this case study to demonstrate the NGRN’s clinical decision-making. When gaining consent for this assignment the parents are informed that their privacy would be adhered to with the use of pseudonyms and no identifying factors would be mentioned. By giving the consumer all the details, and allowing them to ask, and have questions answered, allows them to provide informed consent. For consent to be informed a consumer must be given all relevant information, have understood the information and they must give their consent voluntarily (Johnstone, 2015). When providing care to a consumer and their whānau, privacy, along with consent are two of the main ethical issue that must always be considered, this encourages and supports the delivery of care and shows competence as a nurse (Burgess, 2008).

Within the neonatal clinical setting the paediatrician discusses concerns about the feeding of an LP infant currently on the post-natal ward. The LP infant, Katie [Pseudonym] is born to parents who both identify as Māori. Mum, Lisa [Pseudonym], Dad, James [Pseudonym] and their extended whānau currently reside an hour and a half away from the hospital. Lisa, James and Katie are supported in their hospital stay by the maternal grandmother and maternal aunt. Katie was born at 35+4 weeks gestation weighing 2200g. When examined by paediatric staff they are found to have a low temp at 36.4 degrees Celsius, some mild work of breathing, tachypnoeic at times with mild intercostal recession. Katie has had 1x low blood sugar, <2.5 mmol/l and been given 1x dose of dextrose gel followed by a breastfeed, as per protocol.

Late preterm is defined as births between 34+0 to 36+6 weeks gestation (Muelbert, Harding, & Bloomfield, 2018). Muelbert, Harding, and Bloomfield, (2018) state that care of a LP infant in a postnatal ward can vary and location of the postnatal ward can impact on management, practice and outcomes. LP infants have immature organs and systems, compromised immunomodulatory response, increase risk of inflammatory injury and oxidative stress (Crippa et al., 2019). A survey of clinicians in Australia and New Zealand found significant variations in the approach to nutritional support of LP infants while waiting for the mother’s milk to meet their infant’s needs (Muelbert et al., 2018). The variation in practice is hypothesised by Muelbert et al. (2018) to be due to the lack of high-quality evidence to support optimal nutritional support for LP infants. Feeding of late preterm infants can present challenging due to characteristics such as relaie hypotonia, ineffective suck, uncoordinated suck, swallow breath when feeding (Crippa et al., 2019). This leads to LP infants at greater risk of hypoglycaemia, hypernatremia and hyperbilirubinemia (Crippa et al., 2019).

One of the most common reasons for LP infants requiring nutritional support is the perceived risk of hypoglycaemia (Muelbert et al., 2018). Newborn hypoglycaemia is defined as blood glucose <2.6 mmol/L of blood (Muelbert et al., 2018). At birth, maternal circulation is abruptly ceased (Muelbert et al., 2018). Normal transitional adaption to postnatal life and blood glucose concertation is usually stabilised by 72hours of life; disruptions to this pathway cause hypoglycaemia (Muelbert et al., 2018). Neonatal hypoglycaemia has many factors that it is influenced by: gestational age, birth weight, body stores, metabolic conditions, and pregnancy maternal health (Muelbert et al., 2018). 50% of hepatic glycogen stores are deposited between 36- and 40-weeks gestation, these are a key source of glucose in the new born period (Muelbert et al., 2018).

After discussing with the paediatrician and other nursing staff, the NGRN visits the post-natal ward to discuss a plan for the care of Katie. It is immediately apparent to the NGRN that the maternal grandmother appears hostile in her manner of communicating. Time is then given to speak directly to her about her concerns. Having a previous early preterm infant that spent 6-weeks in neonatal care had been a traumatic experience for the paternal grandmother and her fear for her moko reflected her own traumatic experience. Trauma-informed care is patient-centred care (Pihama et al., 2017). Because of how trauma can be perceived differently in different cultures, culture can affect trauma symptoms, health care experiences and subsequently the provision of trauma-informed care (Pihama et al., 2017). A negatively perceived hospital encounter can influence consumers future hospital encounters, expectations and outcomes (White et al., 2018)

The colonial trauma history of New Zealand Māori echoes across generations (Pihama et al., 2017). Trauma associated with the colonial removal of power and resources, including cultural beliefs, language, traditions and practices left Māori compounded by poverty, discrimination and racism, socio-economic and health inequities (Wilson & Haretuku, 2015). This traumatic history is directly linked to the health disparities between Māori and non- Māori, which continue to grow today (Wilson & Hickey, 2015). Being Māori not only automatically increases risk of premature birth but also of other co-morbidities. A referral to the Kaimahi Hauora support team is sent. This team provide holistic support for consumers and their whānau throughout their hospital stay and act as a cultural liase on behalf of whānau (Taranaki District Health Board, 2019).

Practicing in a way that support collaboration and coordination of Māori health and social wellbeing when working with Māori whānau, Hapū, Iwi and Māori leaders, shows commitment to building and approaches that are founded with an understanding that a strong Māori relationship is an essential component to improving health outcomes (Reid & Robson, 2007). The District Health Board support the Treaty of Waitangi as the founding document of partnership between the Crown and Hapū and recognise that the Treaty Principles of partnership, protection and participation are integral to all Government practices and policies (Taranaki District Health Board, 2015). By engaging with appropriate health services and ensuring their involvement in care, this allows a wider pool of resources to contribute to wellbeing and help close the health inequity gap. Ministry of Health (2013) reported that the rate for unmet needs in primary health for Māori was 1.5 times greater than non- Māori, with 47% of Māori woman experiencing unmet needs (Ministry of Health, 2013).

It is crucial to recognise the power relationship a nurse has, especially in such a vulnerable situation of a mother allowing the handling and care of her child (Stein-Parbury, 2014). When examining an infant consent is gained before and during each step of the examination, as well as explaining what you are examining for. This ensures caregivers maintain control and rights over their infant and help avoid feelings of domineering. This can help minimise the nurse-client power imbalance and provide autonomy over their whānau health (Nursing Council of New Zealand, 2012b); whilst talking to parents/caregivers is important, it is also important to communicate with the infant, by having positive communication experiences and being shown respect from infancy, children may then grow up to have autonomy over their own body and health (Stein-Parbury, 2014).

It is perceived by staff that the best care for Katie would be to be admitted to the neonatal ward for management of her hypoglycaemia and feeding. Registered Nurses are accountable to competencies outlined by the Nursing Council of New Zealand (2012), competency 1.5 states that nurses must provide culturally safe care. Cultural safety is determined by the client, not the nurse (Ramsden, 2015). It is not to be viewed as solely race or ethnicity centred, the whole identity of a person should be considered (Ramsden, 2015). An important factor in providing safe care is that clients are fully informed of their rights under The Code of Rights, (2012), which states consumers have the right to receive information, as well as the right to refuse treatment (Health and Disability Commissioner, 2012)

When discussing clinical decision making with parents and treatment planning, it is essential that the procedure and reasoning are explained to consumers in a way that provides information they understand and can process to make health decisions. Robson, Cormack and Cram (2007) suggest education is a critical part of attaining a high standard of physical and mental health. It is identified by White et al. (2014) that Māori have poorer health literacy than non- Māori and that cultural literacy can affect attitude, perception and behaviours. This can affect how information is delivered and received, affecting decisions and actions of both health provider and health consumer (White et al., 2014).

Treatment options are discussed with the whānau, including the use of IV glucose or the placement of a nasal gastric tube (NGT) for enteral formula feeds. Lisa stated she wants her infant feed, whether formula or breastmilk, but ultimately would like to breastfeed. A second lot of dextrose gel is then administered in the neonatal ward as per the protocol, however, this time the RN follows this up with formula via the NGT. Katie is lethargic and showing no interest in feeding, this combined with her seemingly uncoordinated suck swallow means enteral feeds via NGT ensure she can be feed adequate nutrition, without the need of in intravenous line (Crippa et al., 2018). Assurance is given to Lisa that support would be provided to establish breastfeeding; a referral is sent to the neonatal lactation consultant.

Katie’s parents biggest concern is separation from their infant, a common association and reality of the neonatal unit due to inadequate space. The neonatal unit has three rooming in rooms, these rooms are used primarily for whānau who are close to discharge to prepare them for life at home, or for whānau admitted from the community. Research suggests that to establish breastfeeding rooming in and skin-to-skin contact encourages breastfeeding behaviour, stimulating innate reflexes in new-borns, accelerates neurophysiological development and is positively associated with breastfeeding duration with preterm infants (Crippa et al., 2019). Crippa et al. (2019) states that compared to infants born at term, LP infants are less likely to exclusively breastfeed at the hospital and post discharge; requiring more time to acquire breastfeeding skills. After discussing the plan with the multidisciplinary team it is agreed that the whānau come and room in a neonatal rooming in room.

With the right support, Katie after 2 weeks stay in the neonatal unit is discharged home fully breastfeeding. According Ministry of Health, (2017), report on maternity, of the infants receiving breast milk either exclusively, fully or partially at two weeks post birth, Māori were the lowest. Post discharge from the neonatal unit an infant is followed up at home by their lead maternity carer, the unit homecare nurse, who is a lactation consultant, as well as a well child provider. Most discharges from the postnatal ward are followed up briefly by their LMC and then by a well child provider, this can present a gap in needs being meet in LP infants who may require extra nutritional support, and lead to a readmission.

Boyle et al. (2015) suggest LP infants require additional care beyond the normal new born care. Early care planning is essential in the management of LP infants care away from the neonatal setting to minimise neonatal admissions (Muelbert et al., 2018). With limited research around the safe, efficient and effective management of these needs in a postnatal ward, this leaves a gap for research in the literacy. Harron et al. (2017) findings state that 10.6% of LP infants had readmissions within the first 30 days of discharge, hypothesizing that the longer lengths of stay benefit LP infants due to the increased psychosocial and medical support. There is lack of evidence to support safe discharge time for gestational age, however, Harron et al. (2017) report that for each additional day new born stay the likeliness of readmission rate for LP infants decreases by 8.6%.

Late pre-termers have a unique care requirement to support adequate transition post-birth. Majority of LP admissions to the neonatal unit are nutrition related. The importance of establishing breastfeeding while also being mindful of the infant getting adequate nutrition for their gestation is paramount in the first few days post birth. There is a lack of evidence to support the management of LP infants in a post-natal environment, this adds significant pressure to neonatal intensive care units. This case study maintains the anonymity and confidentiality of the consumer while demonstrating their assessment, clinical decision making and planning process. The case study critically analyses the rationale for decision making and supported with appropriate literature. Communication skills are demonstrated consistently throughout, engaging with consumers in a culturally appropriate manner with a patient-centred focus; as well as demonstrating the ability to work and plan care as part of a multi-disciplinary team. The Te Ahu values are evident throughout this case study and provide a traceable trail of evidence to support the NGRN working in partnership with both the client and the multi-disciplinary team, courage was shown in advocating for the client to provide their whānau with culturally appropriate care, ensuring the parents of an infant maintain autonomy helps to ensure clients feel empowered to make the best decisions for their infant. This contributes to ensuring people matter and feel valued as clients and whānau and that their nursing practice remains safe, providing a safe and trusting environment of care when people feel their most vulnerable.

References

• Taranaki District Health Board. (2019). Te ahu Taranaki DHB values. Received from http://www.tdhb.org.nz/dhb/values.shtml
• Taranaki District Health Board. (2015). Pae Ora framework and TDHB position statements. Retrieved from http://www.tdhb.org.nz/services/maori_health/documents/Pae_Ora_Framework_Position_Statement.pdf
• Boyle E.M., Johnson S., Manktelow B., Seaton, S.E., Draper, E.S., Smith, L.K. … Petrou, S.(2015). Neonatal outcomes and delivery of care for infants born late preterm or moderately preterm: a prospective population-based study. Archives of Disease in Childhood – Fetal and Neonatal Edition 100 (6), F479-F485. doi:10.1136/archdischild-2014-307347
• Muelbert, M., Harding, JE., & Bloomfiend, FH. (2018). Nutritional policies for late preterm and early term infants – can we do better? Seminars in Fetal and Neonatal Medicine 24(1), 43–47. doi:10.1016/j.siny.2018.10.005
• Pihama, L., Smith, L. T., Evans-Campbell, T., Kohu-Morgan, H., Cameron, N., Mataki, T., … Southey, K. (2017). Investigating Māori approaches to trauma informed care. Journal of Indigenous Wellbeing, 2(3), 18–31. https://journalindigenouswellbeing.com/media/2018/07/84.81.Investigating-M%C4%81ori-approaches-to-trauma-informed-care.pdf
• Kuo, D., Houtrow, A., Arango, P., Kuhlthau, K., Simmons, J., & Neff, J. (2012). Family-Centered Care: Current Applications and Future Directions in Pediatric Health Care. Maternal and Child Health Journal, 16(2), 297–305. doi:10.1007/s10995-011-0751-7
• Wilson, D., & Haretuku, R. (2015). Te Tiriti o Waitangi/Treaty of Waitangi 1840: its influence on health practice. In. D. Wepa (Ed.), Cultural safety in Aotearoa New Zealand. (2nd ed., pp. 79-99). Melbourne, Australia: Cambridge University Press.
• Stein-Parbury, J. (2014). Patient and person. (5th ed.). Sydney, Australia: Elsevier.
• Privacy Act (1993).
• Nursing Council of New Zealand. (2012a). Code of conduct for nurses. Retrieved from http://www.nursingcouncil.org.nz/content/download/421/1838/file/Code%20of%20Conduct%20Booklet%20full.pdf
• Nursing Council of New Zealand. (2012b). Competencies for registered nurses. Retrieved from http://www.nursingcouncil.org.nz/content/download/263/1205/file/Competencies%20for%20registered%20nurses.pdf
• Health and Disability Commissioner. (2012). Code of rights. Retrieved from https://www.hdc.org.nz/media/1241/code-of-rights-july-2012.pdf
• Ministry of Health. (2013). The health of Māori adults and children. Retrieved from http://health.govt.nz/system/files/documents/publications/health-maori-adults-children-summary.pdf
• Robson, B., Cormack, D., & Cram, F. (2007). Social and economic indicators. In B. Robson, R. Harris (Eds.), Hauora: Māori standards of health IV. A study of the years 2000-2005 (pp. 3-10). Wellington, New Zealand: Te Rōpū Rangahau Hauora a Eru Pōmare.

• Reid, P., & Robson, B. (2007). Understanding health inequities. In B. Robson, R. Harris (Eds.), Hauora: Māori standards of health IV. A study of the years 2000-2005 (pp. 21-32). Wellington, New Zealand: Te Rōpū Rangahau Hauora a Eru Pōmare.
• White, C., Reid, S., & Damiris, V. (2014). Māori health literacy research: Gestational diabetes mellitus. Retrieved from http://www.moh.govt.nz/notebook/nbbooks.nsf/O/F6CDB34BBE65334CCC257D10006C7300/$file/GDM-report-FINAL.pdf
• Crippa, B.L., Colombo, L., Morniroli, D., Consonni, D., Bettinelli, M.E., Spreafico, I., … Mosca, F. (2019). Do a few weeks matter? Late preterm infants and breastfeeding issues. Nutrients, 11(2),312. doi:10.3390/nu11020312
• Ministry of Health. (2019). Report on Maternity 2017. Retrieved from https://www.health.govt.nz/system/files/documents/publications/report-maternity-2017-may19.pdf
• Harron, K., Gilbert, R., Cromwell, D., Oddie, S., & van der Meulen, J. (2017). Newborn Length of Stay and Risk of Readmission. Paediatric and perinatal epidemiology, 31(3), 221–232. doi:10.1111/ppe.12359
• Health and Disability Commissioner. (2012). Code of rights. Retrieved from http://www.hdc.org.nz/media/1241/code-of-rights-july-2012.pdf
• Johnstone, M. (2013). Ethical and professional practice. In J, Crisp., C, Taylor., C, Douglas., & G, Rebeiro (Eds.), Potter and Perry’s fundamentals of nursing (4^th ed., pp. 138 – 159). Sydney, Australia: Elsevier
• Health Practitioners Competence Assurance Act (2003).
• Taranaki District Health Board. (2019). Te Poari Hauora-ā-Rohe o Taranaki. Retrieved from http://www.tdhb.org.nz/services/maori_health.shtml