419 - Support clinicians in Neonatology help manage moral distress, palliative care and complex ethical challenges

In neonatology, end-of-life and complex ethical issues are frequent. This may lead to moral distress (MD). Several tools exist to manage MD, although an array of different strategies is thought to be optimal.

Objective:

To investigate the impact of Support Clinicians in the NICU, trained to manage MD, palliative care and complex ethical challenges

Design/Methods:

We trained an interdisciplinary team (nurses, RTs, pharmacists, fellows, social workers, etc) of 45 support clinicians (SC) in a large level 4 NICU (courses, workshops, conferences) in order for one to be present at all times in the unit. These mentors received additional training in end-of-life care, reflective exercises and moral empowerment strategies. Ethical discussion spaces were created: interdisciplinary case discussions for level of care decisions and group reflective debriefing. Support clinicians are surveyed every 2 months (open and closed-ended questions) to assess 1) if they have used their training and how 2) the impact of their role on patient care and MD and 3) their ongoing educational needs (with education to fill the knowledge gaps). After 2 years of this program, a quality improvement evaluation was performed, combining all questionnaires, cases discussed and clinical debriefings.

Results:

45 SC are active and assist more than 400 other clinicians in a level 4 unit. All were satisfied with all their hours of training and judged them useful. 75% of the participants use their skills on average 1-2 times a week. In 87% of the cases, it is to help with communication with parents and/or palliative care: SC offered direct support to families or to clinicians. 60% of all cases SC managed were related to MD: when managed in a step-wise fashion, many experiences of MD did not escalate, for example one SC reports: “I listened and supported a colleague who is experiencing moral distress at work due to a complex clinical situation. I also made her realize that this is amplified by what is happening at her home due to recent changes in her family dynamics.” Many situations involving MD were also reported to the medical team or one of the assistant nurse managers when initial self-reflective steps were insufficient. This led to practical interventions: naming and recognizing MD, harnessing clinicians’ resilience, calling for an interdisciplinary meeting or debriefing, asking for help (clinical ethics consultation, palliative care consultation) and rarely seeking legal advice.

Conclusion(s):

A support clinician interdisciplinary team, trained to manage moral distress and complex situations, is useful and appreciated in neonatology.