Chapter Outline
- • Child Health: Concept and Importance
- • Historical Background: Child Health
- • Indian Perspective: Child Health
- • Child Health Nursing
- • Family-centered Care
- • Cost Containment
- • Advanced Preparation of Pediatric Nurse
INTRODUCTION
Pediatrics is commonly known as the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician. The word pediatrics and its cognates mean healer of children; they derive from two Greek words, pais = child and iatros = doctor or healer. Pediatrics is the study and care of children in sickness and health, i.e. preventive, promotive, curative and rehabilitative care of children (Fig. 1.1). In developing countries in the world, this care is extending to children up to 10–12 years of age. In developed countries, children up to adolescence are covered under pediatric care and child health care support.
But the term pediatrics is no more seems to be appropriate to use, as it appears to be doctoring children. Child health concepts and practice have changed. The child health care is most appropriate than pediatric care as it covers multipronged activities in child health care. Child health care is a complex field, requiring an interdisciplinary involvement to meet its needs. This team includes geneticists, pediatrician, biochemists, psychologists, pediatric-surgeons, educationist, pediatric nurse, dietician, dentists. The contribution from these professionals is important for safe journey of our future generation.
CHILD HEALTH: CONCEPT AND IMPORTANCE
Child health refers to a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity in matters relating to growth and development of fetus during antenatal period and from birth of the baby till five-year of age. It implies health care of the fetus during antenatal period which refers to antenatal pediatrics, health care of neonates from birth to 28 days, care of infants up to one year, care of toddler from one year up to two years, care of preschool child from two years to five years of age, and care of the school going children.
The health of the children is also very important not only because they are the asset and future of their families and nation but also because health status, health behavior and lifestyle, thus form during childhood determines quality of life during the following years of2 life. The health of the children differs from place to place and in the same place. It is assessed in terms of child morbidity and mortality. The factor which affect the health of children include poverty, ignorance, illiteracy, age, sex, environment, size of the family, malnutrition, lack of access to maternal and child health services, etc.
HISTORICAL BACKGROUND: CHILD HEALTH
Pediatric is a relatively new medical specialty. Greek physicians and philosophers; Hippocrates, Aristotle, Celsus, Soraneus, and Galen, understood the differences in growing and maturing organisms that necessitated different treatment. In the first century ad, Celsus was reported to be the first one to state that children require different treatment from adults. A 2nd century ad manuscript by the Greek physician and gynecologist Soraneus of Ephesus dealt with neonatal pediatrics. Soraneus wrote the first known manuscript devoted to pediatrics. Byzantine physicians; Oribasius, Aëtius of Amida, Alexander Trallianus, and Paulus Aegineta stand out for their contributions to child care. The Byzantines also built brephotrophia, ‘baby shelters,’ or ‘children's hospitals.’ Islamic writers served as a bridge for Greco-Roman and Byzantine medicine and added ideas of their own especially Haly Abbas, Serapion, Rhazes, Avicenna, and Averroes, The Persian scholar and doctor al-Razi (865–925) published a short treatise on diseases among children. The first printed book on pediatrics was in Italian (1472), Bagallarder's Little Book on Disease in Children. Paulus Bagellardus a Flumine (d.1492) De Infantium Aegritudinibus et Remediis 1472, Bartolomaeus Metlinger (d.1491) Ein Regiment der Jungerkinder 1473, Cornelius Roelans (1450–1525) no title Buchlein, or Latin compendium, 1483, and Heinrich von Louffenburg (1391–1460) Versehung des Leibs written 1429 published 1491; together form the Pediatric Incunabula, four great medical treatises on children's physiology and pathology.
Industrial revolution brought remarkable changes in the lives of people. New intellectual climate of the Renaissance made people to observe, to ask questions of different aspects of child health in conducting experiments and made to leave findings for others. The recognition of childhood diseases differ from adult diseases led to the establishment of hospital devoted solely for children. In the Western world, the first generally accepted pediatric hospital is the Hôspital des Enfants Malades (French: Hospital for Sick Children), which opened in Paris in June 1802 on the site of a previous orphanage. From its beginning, this famous hospital accepted patients up to the age of fifteen years, and it continues to this day as the pediatric division of the Necker-Enfants Malades Hospital, created in 1920 by merging with the physically contiguous Necker Hospital, founded in 1778.
This example was only gradually followed in other European countries. The [Charité] (a hospital founded in 1710) in Berlin established a separate Pediatric Pavilion in 1830, followed by similar institutions at [Saint Petersburg] in 1834, and at Vienna and Breslau now [Wrocław], both in 1837. The English-speaking world waited until 1852 for its first pediatric hospital, the Hospital for Sick Children, Great Ormond Street, some fifty years after the founding of its namesake in Paris. In the USA, the first similar institutions were the Children's Hospital of Philadelphia, which opened in 1855, and then Boston Children's Hospital (1869).
Pediatrics as a specialized field of medicine developed in the mid-19th century; under the influence of the Persian born Abraham Jacobi (1830–1919). He is known as the father of pediatrics because of his many contributions to the field. He was born in Germany, where he received his medical training, but later practiced in New York City. He was awarded the first professorship in pediatrics in America in 1870. Pediatric department in several hospitals in Newyork were started by Prof. Jacobi and he was one of the founders of American Pediatric Society, 1888.
Throughout the world, about a century and half ago, children were not considered as somebody who should be treated differently when illness occurs. It was in United States of America, for the first time, recognition was given to Pediatrics as a separate subject. Even Great Britain was more than fifty years behind in adopting Pediatrics as a specialty (Fig. 1.2).
INDIAN PERSPECTIVE: CHILD HEALTH
In India, Kashyapa Tantra written in bc had a chapter on Koumara Mritya, i.e. service to children. Perhaps this is the first record of pediatrics anywhere in the world. Our rich heritage of Ayurveda has detailed description of maternal and child health care. Sushruta, the Indian Hippocrates in his Sushruta Samhita, had devoted a chapter to Kaumarabrita (service to children). This was perhaps the first record of pediatrics in ancient India. Pediatrics was called Kaumarbhritya tantra. The Atharva Veda (1500 bc) describes children's diseases and Kaushika Sutra included pediatrics. Kashyapa and Jeevaka (400 bc) were well known pediatricians of ancient India. Kashyapa Samhita deals exclusively with pediatrics. Charaka wrote in details about the care and management of newborn in Sarira–Sthana and Ashtanga–Hridaya. The Charaka Samhita in fact mentions an international conference of scholars. Kaumarbhritya and Prasuti tantra talk of prenatal care, and also lay emphasis on neonatal care, care of the baby including feeding and management of illnesses of children. This includes—maternal care (with respect to food, drink, leisure, restricted work, sleep, etc.), neonatal care (cleaning, dressing, bath, procedure akin to cardiac compression), care of the umbilical cord, breastfeeding (including concept of a wet nurse), annaprasana (initial eating of solid food), daily care of eyes and skin, and common symptomatology in childhood illnesses.
Till independence in our country, medical care of children was under professors of adult medicine. The idea that the children are not miniature adults, took some time to dawn on medical profession. Many of the problems seen in young children and neonates are different in nature and approach and treatment were quite different from that of adults. The focus and scope of pediatrics, the health problems of children vary widely among the nations and problems are complex in children of the developing countries. In the developing countries which represent three quarter of humanity, many children suffer due to diseases that are attributable to poverty and poor hygiene.
Our state Tamil Nadu has the honor and pride of having created the first post of Professor of Pediatrics in India at the Madras Medical College even though there were fairly well-developed Pediatric Departments in centers like Mumbai, Patna and Kolkata. The creation of the first Pediatric Department at the Government General Hospital, Madras in the year 1948 with late Prof. ST Achar, a Professor of Medicine turned Pediatrician as the first Professor of Pediatrics, Madras Medical College, paved the way for the birth of the speciality of Pediatrics in Tamil Nadu. Later due to the untiring combined efforts of Dr ST Achar, Dr V Balagopal Raju and Dr MS Ramakrishnan, a separate Hospital for Pediatrics at Egmore was created. Now in all states in India, there are many children's hospital under public sectors and private sectors too. Almost all medical colleges in India offer specialist and super-specialist training for doctors and nurses in the field of pediatrics.
CHILD HEALTH NURSING
Pediatric nursing is ‘the practice of nursing with children, youth, and their families across the health continuum, including health promotion, illness management, and health restoration’. Although the pediatric nurse must be knowledgeable about a wide range of medical conditions and treatment options, pediatric nursing is ‘not ‘med-surg nursing’ on little people’. It requires knowledge of both child development and of the physiological differences between children and adults. It also is family-centered, recognizing both the vital role that families play in children's lives, growth, and development and that this must be reflected in children's care when they are ill. Family-centered care involves collaborative partnerships between families and health care professionals, built on respect for diversity and grounded in the family's strengths, choices, and values. In addition to family-centered care, pediatric nurses attempt to provide atraumatic care, that is, therapeutic care that utilizes ‘interventions that eliminate or minimize the psychological and physical distress experienced by children and health care system’ (Fig. 1.3).
So, pediatric nursing is a medical specialty that promotes the care, both urgent and preventative, of children and youth. Nurses in this field must have a wide range of knowledge, including the physiological differences between children and adults.
This specialized care propels nurses into different roles, including caregiver, health promoter and prevention of infection, advocate and educator, counselor, consultant, advocate, care coordinator, or health systems manager. They may work as researchers or at the advanced practice level as pediatric clinical nurse specialists. Pediatric nurses may practice in many locations, including the home, hospitals, clinics, long-term care facilities, and schools.
Goals of Pediatric Nursing
- Enhance the care of children and adolescents worldwide
- Recognize the rights of the child to promote and advocate for the health, well-being/welfare and development of children
- Encourage communication between pediatric nurses to help further the care of all children.
- Promote a therapeutic relationship between parent and child
- Accomplish family-centered care
- Promote continued growth and development.
Trends in Child Health Nursing
Remarkable changes have occurred in the field of pediatric nursing in recent years. Modern approach of child health care emphasizes on preventive care rather than curative care. Illness is the situations when individual faces physical, physiological, and mental difficulties. So concept of care of ‘Whole child’ is possible only in normal situation, not in illness. Moreover, most childhood diseases are preventable, and nurses play pivotal role to prevent those diseases and render services at the door step of the families.
Health promotion and holistic care of children is an emerging trend. According to UNICEF, assistance for fulfilling the needs of children should no longer be confined to only one aspect like nutrition or immunization but it should be wide-based and geared to their long-term growth and development ensuing holistic health care of children. Nursing care of children of modern time, highlights health promotion and disease prevention as national attention. Hospital stay of even acutely ill child is made brief, and parents are encouraged to render care with technological support. For example, parents are better able to assess the respiratory status of their asthma child with the support of pick flow meter and can control some exacerbations by nebulization of medications.
Acceptance of family-centered care of children impart more responsibility on pediatric nursing and pediatric nurse. The philosophy of family-centered care is to recognize and respect the pivotal role of family in the lives of both well and ill children. The pediatric nurse maintains liaison between family and health team to set treatment/care plan and thus to prevent psychological trauma or mental stress of both child and family. Family-centered philosophy in health care setting respects choices of family members, provide input, and are given information that are understandable by them. The family's inputs are honored, and its strengths are recognized. Some hospitals have started child life programs to help children and their families cope up with the stress of illness, anxiety due to hospitalization, etc. In family-centered care, not only the needs of the child but the needs of the family members are also considered.
FAMILY-CENTERED CARE
Children's health care needs cannot be identified in the absence of the family. Family-centered care recognizes that the family is the major participant in the prevention of diseases and promotion of health of a child or adolescent. As such, the families have the right and responsibilities to participate individually and collectively in determining and satisfying the health care needs of their children and adolescent. The health care provider realized that the family, community and society surrounding the child have a particular way of life and culture. Being family-centered means that policies regarding access, availability and flexibility take into consideration the various structures, functions, cultural background of family in the community being served. Family-centered care reflects an understanding of the nature, role and understanding of children's health, illness, disability, or injury in the family and the impact of family structure, function and dynamics on both risks to ill health and promotion of health.
Without family, children's health care needs cannot be identified. Children face environmental health hazards as a result of their family's social and economic circumstances and lifestyle. They are vulnerable to particular disease because of their genetic predisposition; and they may suffer physical health consequences of family stress such as unemployment, divorce, parental disability. Furthermore, because children generally are not in a position to seek health care on their own, even when illness symptoms are present, the decision to seek health care is family matter.5
A community health care provider (primary level) must therefore understand not only physical health risks of a child but also family stress as well as various social, economic, psychological, emotional and cultural factors that influence a family's decision to seek health care for a child. Finally, because compliance with a prescribed treatment for children is likely to be influenced by their family, family impact must also be considered when deciding on a child's plan of care (Fig. 1.4). The issues of guardianship, privacy, legal responsibility and informed consent must always be considered in every pediatric procedure. In a sense, pediatricians and pediatric nurses often have to treat the parents and sometimes, the family, rather than just the child.
High Technology Care
High technology care benefits pediatric nursing care. Advancement in the domain of medical field has created the care of sick children too technologically versatile. ‘Telemedicine and tele-monitoring are commonplace now,’ as care coordination is made electronically. Electronic medical records allow nurses to immediately access important information of child like prior health history, medications, lab reports and co-existing medical conditions—whether care was provided at the current facility or another location. This provides a more complete and accurate clinical picture, ensuring that the patient receives the appropriate care for his or her condition.
Currently, every hospital tries to offer a specialized intensive care unit exclusively for newborns, children, called Pediatric Intensive Care Unit (NICU, PICU). Children requiring highest level of care during their treatment and recovery receive special care in NICU, PICU. A team of pediatric intensivists works closely with specially trained pediatric nurses, respiratory therapists and other health care professionals to provide round-the-clock, high-tech care in a compassionate environment that supports parents and encourages them to take an active role during their child's hospital stay.
Technological advancement in the working place challenges nurse for continuing nursing education. They need to be oriented on specialized equipment like ventilators, specialized beds and cribs to accommodate patients with special needs, cardio-respiratory monitoring, computer charting and documentation, peritoneal dialysis monitoring and specialized syringe pumps. Day by day this stream of nursing is becoming popular, and student nurses aspire to be a high tech pediatric nurse. They want to be skillful in rendering care in trauma populations, as well as children with a variety of medical/surgical diagnoses.
Evidence-based Practice (EBP)
Trend in evidence-based practice is enriching the domain of pediatric nursing. Scientific enquiry about care and support is an integral part of nursing practice. Research and EBP initiated by nurses, and particularly bedside nurses, are important components to develop a body of knowledge. EBP can be applied to any problem that seeks solution, and nurses need to make decisions on the best available evidences.
Few steps are involved in the process of EBP. The problem seeking solution needs to be framed as question/questions, need to search for evidences in literature, search for evidences assess for evidences make decisions evaluate performance.
Atraumatic Care
There are lot of advances, changes in pediatric care and treatment which is traumatic, painful upsetting and frightening. Children experience both physical and psychological stresses in the pediatric care setting. They experience psychological distress like anxiety, fear, anger, disappointment, sadness, shame, or guilt. They also experience the physical distresses like sensory stimuli such as pain, temperature extremes, loud noises, bright lights or darkness. Health professionals must be aware of the stresses and strive to provide intervention which is safe, effective and helpful.
Atraumatic care is the provision of therapeutic care in environments, by personnel and through the use of interventions that eliminate or minimize the physical and psychological distresses experienced by the children and their families in the health care system (Fig. 1.5).6
It promote sense of comfort minimize child's separation from family. It prevents injury minimize pain, provide privacy respect religious differences. It helps to cope up stress and prepare the child before procedure. Basic principles involved in atraumatic care are: (i) prevent or minimize the child's separation from the family, (ii) promote sense of comfort and secured, (iii) prevent or minimize bodily injury and pain, and (iv) promote a sense of control.
It is an integral part of pediatric nursing care and needs to include following interventions:
- Maintaining positive, supportive and loving relationship with child
- Foster parent-child relationship during hospitalization
- Physical and mental preparation of child before any procedure
- Prevent injury and minimize pain
- Protect child's sensitivity by providing privacy
- Provide play for free expression of fear and aggression
- Involve parent (if possible) in nursing intervention to obtain child's better cooperation
- Respect cultural and religious differences child and his family.
COST CONTAINMENT
It is a management technique used to control rising cost of medical treatment. In this arrangement, clients need not to pay whatever charges determined by the hospital for their service. Instead, client will agree to pay on in advance a fixed amount of money for necessary services for specially diagnosed conditions. It is achieved in various ways in health care setting by cutting nursing positions, or improving the process of care and minimizing nonlabor resources. Last few years the government, insurance companies, hospitals and health care providers have made concerted effort to reform health care delivery system of our country and control rising cost.
The current practice of child health nursing requires nurses to aware about cost containment of adopting procedures to the specific needs of children and families. By reducing mortality rates, length of stay, cost and complications and by increasing family satisfaction and readiness and ability to function upon discharge, nurses make significant contribution to both the quality of hospital services and the containment of hospital cost.
Statistics Related to Child Health
Children represent the future, and ensuring their healthy growth and development ought to be a prime concern of all societies. Child health status is assessed through measurement of morbidity and mortality. Some recent facts are:
- 17,000 children die every day, mostly from preventable or treatable causes.
- The births of nearly 230 million children under age 5 worldwide (about one in three) have never been officially recorded, depriving them of their right to a name and nationality.
- 2.5 billion people lack access to improved sanitation, including 1 billion who are forced to resort to open defecation for lack of other options.
- Out of an estimated 35 million people living with HIV, over 2 million are 10 to 19 years old, and 56 per cent of them are girls.
- Globally, about one third of women aged 20 to 24 were child brides.
- Every 10 minutes, somewhere in the world, an adolescent girl dies as a result of violence.
- Nearly half of all deaths in children under age 5 are attributable to undernutrition. This translates into the unnecessary loss of about 3 million young lives a year.
The frequently used mortality indicators related to child health are perinatal, neonatal, post neonatal, infant mortality and under five mortality rates.
Perinatal Mortality Rate (PMR): Perinatal mortality includes both late fetal deaths (stillbirths) and early neonatal deaths. According to International Classification of Diseases, the perinatal period lasts from the 28th week of gestation to the seventh day after birth. It is calculated as:7
PMR has greater significance as it is a yardstick of obstetric and pediatric care before and around the time of birth. The main causes of perinatal death are intrauterine and birth asphyxia, low birth weight, birth trauma, and intrauterine or neonatal infections.
Neonatal Mortality Rate (NMR): Neonatal deaths are deaths occurring during the neonatal period, commencing at birth and ending 28 completed days after birth. NMR is the number of neonatal deaths in a given year per 1000 live births in that year. It is calculated as :
Neonatal mortality is a measure of intensity with which ‘endogenous factors’ (i.e low birth weight, birth injuries) infect infant life. Each year, about 4 million newborns die before they are 4 weeks old and half of them die in their first 24 hours. It accounts for 40 percent of under-five mortality. Ninety eight percent of these deaths occur in developing countries. Neonatal mortality is generally related to short gestation and low birth weight, congenital malformations, and conditions originating in the perinatal period, such as maternal complications related to pregnancy or complications experienced by the newborn resulting from birth.
Postneonatal mortality rate: The annual number of deaths of infants ages 28 days to 1 year per 1,000 live births in a given year. Postneonatal mortality rate is the ratio of the number of deaths in a given year of children between the 28th day of life and the first birthday relative to the difference between the number of the live births and neonatal deaths in that year, the denominations sometimes simplified, less correctly, number of live births. The ratio is sometimes approximated as the difference between the infant mortality rate and the neonatal mortality rate.
Whereas neonatal mortality is dominated by endogenous factors, postneonatal mortality is dominated by exogenous (i.e. environmental and social) factors. The main causes of death during postneonatal periods are diarrhea and respiratory infections. Malnutrition is an additional factor, reinforcing the adverse effects of the infections. In developed countries, the main cause of postneonatal mortality is congenital anomalies. Studies show that postneonatal mortality increases steadily with birth order.
Infant mortality rate: The death of a baby before his or her first birthday is called infant mortality. The infant mortality rate is an estimate of the number of infant deaths for every 1,000 live births. This rate is often used as an indicator to measure the health and well-being of a nation, because factors affecting the health of entire populations can also impact the mortality rate of infants.
Under 5 mortality rate: Probability of a child born in a specific year or period dying before reaching the age of five years, expressed as a rate per 1000 live births. UNICEF considers this is as the best single indicator of social development and well-being rather than GNP per capita, as the former reflects income, nutrition, health care and basic education. The risk of a child dying before completing five years of age is still highest in the WHO African Region (90 per 1000 live births), about 7 times higher than that in the WHO European Region (12 per 1000 live births).
Reducing child mortality to achieve millennium development goal (MDG) 4: Overall, substantial progress has been made towards achieving MDG 4. The number of under-five deaths worldwide has declined from 12.7 (12.5, 12.9) million in 1990 to 6.3 (6.1, 6.7) million in 2013. This translates into 17 000 fewer children dying every day in 2013 than in 1990. About half of the world's under-five deaths in 2013 still occurred in only five countries: India, Nigeria, Pakistan, Democratic Republic of the Congo, and China. India (21%) and Nigeria (13%) together account for more than a third of under-five deaths worldwide.
Ethical Perspectives in Child Health Nursing
Pediatric nurses are trained in child development, health care and diseases of children. They deal with infants all the way up to adolescent children. These nurses are specialized in examining both the physical and psychosocial well-being of a child and often struggle with ethical and socio-cultural dilemmas. The ethical issues pediatric nurses face can be quite challenging at times, as they must often professionally solve conflicts involving a family's personal values.
Ethics: Ethics refers to well-founded (Fig. 1.6) standards of right and wrong that prescribe what humans ought to do, usually in terms of rights, obligations, benefits to society, fairness, or specific virtues. Ethical standards also include those that enjoin virtues of honesty, compassion, and loyalty.8
And, ethical standards include standards relating to rights, such as the right to life, the right to freedom from injury, and the right to privacy. Such standards are adequate standards of ethics because they are supported by consistent and well-founded reasons.
Nursing ethics: A valuable resource for helping to define nursing ethics is a nursing Code of Ethics. Ethical behavior for nurses is described in various codes, such as American Nurses Association Code for Nurses, Canadian Nurses Association Code for Nurses, etc. A nursing Code of Ethics is usually developed by a nursing organization that has some responsibility for defining nursing standards, explicitly stating the requirements for ethical nursing practice. Despite their various differences, most nursing Codes of Ethics agree highly on various fundamental ethical considerations, such as informed consent, respect for confidentiality, professional competence, and patient safety. The important principal values highlighted in different nursing code of ethics are providing safe, compassionate, competent and ethical care; promoting health and well-being; preserving dignity; promoting and respecting informed decision-making; maintaining privacy and confidentiality; promoting justice; and being accountable.
Bioethics: Bioethics is the application of ethics to health care. Bioethics has been very important toward the development of nursing ethics. Bioethics emerged as a new discipline in the late 1900s and helps to address growing ethical questions in the health sciences.
Ethical principles: The most widely recognized bioethical framework in the health sciences is referred to as principlism. Principlism is based on the view that clinical care has to attend to fundamental ethical principles. The most popular principlist framework in the health sciences, has been published by Beauchamp and Childress.
According to Beauchamp and Childress, four major principles that should define ethical care are autonomy, beneficence, non-maleficence, and justice. These principles are also important in solving ethical dilemmas.
The principle of autonomy is based on the right to self-determination, which is operationalized through the doctrine of informed consent. This requires that patients should be free to choose or refuse health care interventions, without pressure or coercion, and should be given all of the information needed about their condition and possible treatments/interventions, so they can make an informed choice.
The principle of justice requires fairness in determining which resources or services an individual or group will receive.
Beneficence relates to the requirement for clinicians to help others, to actively seek to do good.
Nonmaleficence refers to the Hippocratic Oath: primum non nocere. Clinicians cannot intentionally inflict harm.
Although harm may be a secondary effect of beneficial care, it cannot be desired and it should be minimized. So in some instances the caregivers and parent need to weigh the principle of beneficience against the principle of nonmaleficence.
Some ethicists have developed ‘contextualist’ frameworks, where ‘good and bad’ is understood through an analysis of the particular situation in question.
Ethical dilemmas: Ethical dilemmas, also known as a moral dilemmas, are situations in which there are two choices to be made, neither of which resolves the situation in an ethically acceptable fashion. In such cases, societal and personal ethical guidelines can provide no satisfactory outcome for the chooser. It is a situation in which no solution seems completely satisfactory. Ethical dilemmas are among the most difficult situations in nursing practice.
Common Ethical Dilemmas
Nurses need to involve in common issues on ethical decision-making in ethical dilemmas. Such issues are refusal of treatment, euthanasia, prolongation9 of life, prenatal genetic screening, abortion, in-vitro fertilization, allocation of scarce medical resources and rights of children in health care research, etc.
Moral dilemmas for pediatric nurses arise from power conflicts about treatment in which the nurse may need to decide whether to continue to cooperate with the health team and follow the physicians’ directions or not to follow them. Legal issues related to consumer protection act, malpractice and negligence are great challenges in all areas of nursing practice and also in child care.
Ethical Concerns in Child Health Care
It can be envisioned that these problems can be particularly challenging in the context of pediatrics, where patients are commonly incapable of adequately expressing their needs. Parents must be involved in decision-making process and informed about available options. Very little literature has examined the ethical challenges confronted by pediatric nurses. However, to review ethical considerations related to the nursing care of children and their families is necessary.
Focusing on pediatric nursing, nurses practicing as moral agents should be particularly sensitized to the vulnerabilities confronted by children and their families, and actively advocate for improving their well-being.
Two of the most common ethical questions that arise in pediatric health care are: How should health care decisions for children be made? Who should make these decisions? For example, any treatment considered contrary to the child's best interests can be withheld or withdrawn, even if this may result in death (e.g. withdrawal of mechanical ventilation). Developed countries encourage society to engage in a thorough debate about the economic, cultural, social, religious and moral consequences of imposing limits on which patients should receive intensive care.
Accepted standards in palliative sedation can also be practiced with children, as long as this is based on the child's best interests and that the ‘principle of double effect’ is respected. In other words, sedation and analgesia can be administered in the context of end-stage terminal illness even if this happens to compromise ventilation and results in death, as long as the doses that are used are intended solely for the requirements for sedation and analgesia and not for death. If death resulted as an adverse effect of providing necessary sedation and analgesia to a dying patient, and there was no other way to manage the discomfort and pain, then the unintended death can be legally and ethically excusable.
Although young children may not have a legally recognized right to independently consent to health care, nurses, physicians, and other health care professionals should consider seeking children's assent whenever possible. Assent implies that health care information should be provided to children, adapted to their ability to understand, and their voluntary cooperation should be solicited as much as is reasonably possible. Solicitation of the child's assent would help promote attention and regard for the child's own moral outlook toward proposed health care.
A clinical ethics committee has been developed to assist patients, families, and health care teams. An ethics consultation involves a process of clarification of the principal ethical concerns, an examination of legal and ethical norms relevant for the case, and a reconciliation of these toward a plan of action that is maximally attentive to all of the morally meaningful considerations. It should be highlighted that an ethics consultant or ethics committee should not function as a ‘moral police or arbiter’. These should serve as consultation resources for those who are involved with a case where there is an ethical concern. An ethics consultation can be conducted with part or all of the clinical team. This can be helpful for strengthening inter-professional collaboration. An ethics consultation can also include the patient and family, to help reconcile disagreements or conflicts to develop a cohesive plan of care.
Various ethics consultation models have been described in the literature. The rapprochement framework can be helpful in pediatrics. Rapprochement, adapted from the work of Canadian philosopher Charles Taylor, seeks to bridge the various ethical views, values, and preferences involved with the case, through a gradual cultivation of common understandings. These common understandings provide the groundwork for developing treatment agreements while strengthening the quality of the relationship between the patient, family, and health care team.
Given the complex responsibilities that pediatric nurses are required to fulfill, nurses have important insights into considerations of a child's best interests, recognition of parental perspectives and the voice of the child, as well as the particular challenges of providing nursing care in selected clinical cases. Mechanisms should be in place to assist nurses in addressing nursing-specific ethical concerns to ensure they can provide care according to respected pediatric standards. These can include the active inclusion of nurses in inter-professional team meetings to review cases or problems,10 where the meeting chairperson ensures that nurses have an opportunity to speak and have their concerns treated seriously. Nurses should have access to ethics consultants for discussing their ethical concerns, both privately and within a group discussion, depending on the nature of the concern. Ethics consultants should be sensitized to the moral complexities of nursing responsibility and practice. In some situations, access to a nursing ethics consultant or nursing ethics committee may be particularly important, to ensure nursing-specific concerns are adequately addressed. These ethics review and consultation processes should then seek to reconcile nursing concerns with those of others, such as physicians, patients, and families.
ADVANCED PREPARATION OF PEDIATRIC NURSE
Pediatric Nurse Specialist
Pediatric nurse specialist is another emerging concept. This advanced practice nurses provide direct care to acute and chronically ill children, and participate in the support of systems, education, and consultation in a variety of settings including intensive care units (Fig. 1.7), emergency departments, other inpatient units, as well as ambulatory, rehabilitative and specialty-based clinics. Pediatric clinical nurse specialists are the ones, responsible for any kind of emergency care. Their role involves recognizing the pediatric patients needs, both physical and emotional, and to treat them accordingly. They usually work within hospital settings. They are mostly focused on patient's education. They teach both the patients and their families how to go about the necessary care. So, growth of specialization within the field of pediatric medicine has had an impact on nursing care. Pediatric Clinical Nurse Specialists (PCNS), collaborate with members of the health care team to enhance patient care and provide clinical expertise to patients in the pediatric setting.
Pediatric Nurse Practitioners
Pediatric nurse practitioners are recognized and well- accepted in developed countries. They take care of babies, young children and teenagers. This is a rising trend because everywhere nurses shoulder the major responsibilities of pediatric care, e.g. immunization, nutrition, hygienic care, demonstration, health education, etc. To provide therapies and treatments to children, nurses educate them and their families. So yes, they need broad exposure of orienting multitask skill ability training. The curriculum should combine both broad foundational knowledge essential for the care of children as a vulnerable population, as well as specialty knowledge in pediatrics. Attention is given to health promotion, prevention of disease and disability, disease process, treatment, clinical management, and family-centered care provided in a variety of community settings. The pediatric nurses can act as independent practitioner and fulfill an autonomous position as a member of an interdisciplinary health.
Pediatric Nurse Researcher
Child health nursing (CHN) is a complex field, requiring an interdisciplinary involvement and research to meet its needs. Pediatric nursing is ‘the practice of nursing with children, youth, and their families across the health continuum, including health promotion, illness management, and health restoration’. Although the pediatric nurse must be knowledgeable about a wide range of medical conditions and treatment options, CHN is ‘not ‘med-surgical nursing’ on little people’. Research in the field of CHN is needed to develop body of knowledge of both child development and safe and evidence-based child care. When PNS practice on the basis of science and research and document their practice outcomes, they validate their contributions not only to the health systems but also for the profession too.
Goal of CHN is to involve nurses in research, quality, and evidence-based practice in order to improve patient and family care outcomes. Research in CHN is important as this discipline needs more and more accuracy and scientific basis for intervention in child's body or mind. So emphasis is given towards documentation on measurable outcomes to determine the efficacy of interventions. It is necessary as pediatric nurses attempt to provide atraumatic care, that is, therapeutic care that utilizes ‘interventions that eliminate or minimize11 the psychological and physical distress experienced by children and their families in the health care system’.
We define excellence in nursing practice as a mindset of continually evaluating care challenges and improvements that result in enhanced outcomes for the patient, the family, and the organization. This includes disseminating findings in ways that benefit the children and families of the world. For example involvement of families in the care of children was studied by different researchers and reflected in the child health nursing curriculum.
In the late nineteenth and the first half of the twentieth century, many nurses in acute care setting ‘viewed mothers as unnecessary, bothersome, and at times, even harmful in the care of hospitalized children’. The effects of maternal deprivation were little understood. As a result, hospital visitation policies greatly restricted the frequency and amount of parental visits. However, it took the cumulative effect of research in the 1940s, 1950s, and 1960s on the effects of maternal deprivation to bring about real change in attitudes and policies.
Different studies in CHN established both the vital role that families play in children's lives, growth, and development and in children's care when they are ill. Family-centered care involves collaborative partnerships between families and health care professionals, built on respect for diversity and grounded in the family's strengths, choices, and values.
The child health nursing curriculum has also reflected changing attitudes and research on many issues, including the involvement of families in the care of children. While those involved in community health nursing, thought that mothers were essential for the survival of their children. In addition, the hospitalization period was viewed as a chance to educate poor children about good health habits and inculcate the values of the middle class into them without the interference of their parents.
In India, lot of studies have undertaken in the field of pediatric nursing. The goals of those researches are quality care, and evidence-based practice in order to improve patient and family care outcomes. But there is lacking in utilization of research results in evidence-based practice. The concept of evidence- based practice involves analyzing and translating published clinical research into everyday nursing practice. Moreover in our country, there is scarcity in inter-professional scholarly research in the field of pediatric and disseminating findings in ways that benefit the children and families of the world.
CONCLUSION
Remarkable changes have occurred in the field of pediatric nursing in recent years. Modern approach of child health care emphasizes on preventive care rather than curative care. Growth of specialization within the field of pediatric medicine has had an impact on nursing care of children.
Independent pediatric nurse practitioner can fulfill an autonomous position, she can also act as a member of an interdisciplinary health team. Acceptance of family-centered care of child, impart more responsibilities on pediatric nursing and pediatric nurses. Involving in research and findings newer techniques, pediatric nurses are contributing a lot in nursing sciences. Pediatric care needs specialized education and training of pediatric. Increasing number of HIV infected innocent children create problems in nurse. Problems among children due to unhealthy competition, comparison, single parent and family disruption are rising and it calls for increasing number of psychological pediatric care and nursing practices. With multi-tasking skills and knowledge, pediatric nurses provide therapies and treatments to children and they also educate them and their families.