NURSING CARE OF
CHILDREN
Theme:
INTRODUCTION TO THE NURSING CARE OF CHILDREN
OBJECTIVES:
Overview
1. Discuss current social, economic, and
political trends and factors influencing child health in the
2. Discuss the effects of immigration,
poverty, homelessness, migrant farm work, and violence on children and their
health.
3. Summarize the current status of children's
health in the
4. Summarize strategies to prevent
unintentional childhood injuries.
5. Discuss the effects of problems with
access to health care and lack of health insurance on children's health status.
6. Identify elements of family-centered care.
7. Discuss the influence of professional
standards on child health nursing.
8. Discuss the importance of each role of the
child health nurse.
9. Discuss the importance of utilizing
evidence-based practice in caring for children.
Ethical & Legal
Considerations
1. List state, federal, and judicial laws impacting
child health nursing practice.
2. Identify the elements of informed consent
relative to children.
3. Describe a situation in which a minor can
consent to health care or refuse medical care.
4. Describe child health nursing practices
that can decrease the risk of malpractice claims.
5. Discuss common ethical dilemmas related to
child health nursing practice.
Family
System
1. Define the term "family".
2. Discuss theoretical foundations of family
nursing: system's theory, nursing theories, and social science theories.
3. Describe components of comprehensive
family assessment, including techniques and tools.
4. Describe different types of family
structures.
5. Summarize cultural, social, and economic influences
on the family.
6. Identify indicators of healthy and
dysfunctional families.
7. Discuss the role of the nurse in
supporting parents and fostering positive child-rearing practices relative to
parenting tasks (related to developmental stages), parenting styles,
socialization of children, discipline, and special parenting situations.
8. Use critical thinking and nursing process
to plan effective nursing care for the family system.
During the 20th century, amazing progress has been made
in scientific and technological fields. The genetic code has been discovered,
people are living longer than ever before, and very low birth weight infants
have survived. However, the status of children and their health has not kept
pace with these accomplishments. For example, one in two children live in a
single parent family at some point in their childhood; one in three is a year
or more behind in school; one in eight is born to a teenage mother; and one in
60 sees his or her parents divorce in any given year (Children's Defense Fund,
2000). On the positive side, child health care has changed from a strictly
curative approach to a disease prevention and health promotion model. The role
of the pediatric nurse has expanded from child caretaker to child advocate.
Today, pediatric nursing focuses on preventing acute and chronic illness while
promoting normal growth and development. This focus requires a broad knowledge
base consisting of an understanding of the culture at large, a host of health
and illness issues, and a wide range of clinical competencies.
This chapter begins with an overview of social changes
as they affect children. It describes the status of children's health, their
health problems, and their care. The focus of the chapter then turns to a
discussion of the roles of pediatric nurses and concludes with a discussion of
differentiated practice roles and advanced practice.
Pediatric Nursing in a Changing Society
Societal Trends Impacting Children
Children are members of families, communities, populations,
and overall society, which shape the context, experiences, and opportunities
of their lives. Their well-being is inextricably linked to the well-being of
their families, communities, and the society in which they live. In a world
that is continually changing, emergent societal trends have profound effects
on the environment surrounding children and their families, and now pose
formidable challenges to children, their families, and their health. These
trends include
§
immigration,
§
poverty,
§
homelessness,
§
migrant
farm workers,
§
and
violence.
Immigration
Currently
in the
With each
new wave of immigrants comes debate about whether they contribute to the
economy or create a drain on public and private resources. Concerns also
include perceived threats to the public health and order from infectious
diseases, increased crime, and diverse social mores (American Academy of
Pediatrics [AAP] Committee on Community Health Services, 1997). These debates
have raised the issue of eligibility of immigrants for health, educational,
and social services. Some have argued that this group should not be entitled to
any local, state, or federal benefits. States that have a large number of
immigrants (
The health status of immigrant children can be compromised
due to intestinal parasites, poor diets, dental problems, tuberculosis,
hepatitis A, hepatitis B (particularly in those children from Southeast Asia),
and other conditions originating in their country of origin (Worley, Worley, & Kumar, 2000). They are
also at risk because of significant language, cultural, financial, and legal
barriers to receiving health care. Their families often delay seeking care for minor
conditions until they become more serious. Another factor affecting their
underutilization of health services is the possibility that family members may
have different immigration statuses. When one member is an illegal
(undocumented) immigrant, the entire family may limit access to care for fear
of an investigation (AAP, 1997).
The immigrant population's access to health care services
also affects their psychological well-being. For many children and their
families, the immigration process poses unique stresses. Individuals may be
torn by conflicting social and cultural demands while trying to adapt to an
unfamiliar environment. Other stresses include differences between social and
economic status in their country of origin and the United States, separation
from support systems, and, for illegal immigrants, fear of deportation (Hulewat,
1996).
Poverty
Families are classified as being in poverty if their
annual income falls below official poverty thresholds (Table 1-2). In 1999, the
poverty rate for all Americans was 11.8%, the lowest rate since 1979. For
children under age 18, the poverty rate was 16.9%, again the lowest rate since
1979 (U.S. Census Bureau, 2000). Although the rates have improved, one in five
children still lives in poverty. Rates of poverty, including childhood poverty, are highest for
minority groups. However, the majority of
poor children are white because whites are the largest population group
in the
Family structure has an important bearing on child
poverty. Poverty rates for children in married couple families are much lower
than for those in families headed by a single parent. The explanation for this fact is that when both spouses are
present, there are two potential (and, frequently, actual) breadwinners. Almost half of all poor
children live in single parent households. The risk of poverty in these households
is high for several reasons, including low wages for women, the low educational
attainment of many single mothers, and low rates and levels of child support
from fathers (McLoyd,
1998).
Several factors are at the root of child poverty. Slow
growth in wages, the rising
inequality in earnings, significant loss of low-skill, high-wage jobs due to a
decline in manufacturing industries, and workers' lack of education and skills
account for much of the increase in child poverty in recent years. In the past
two decades, average earnings have not grown much. At the same time, there has
been an increase in the inequality of earnings among workers. Today, the top 5%
of American families make nearly 20 times the average income of the bottom 20%
of families (Betson & Michael, 1997). This gap is
the widest it has been in the 52 years for which annual income statistics exist
(Children's Defense Fund, 2000). Educational level is an indicator of market
skills that yield higher
earnings. The education of the adults in the family is critical for die family
income. As education rises, the number of adults who are not in the labor force
and who experience a period of unemployment during the year declines
dramatically.
Family income also has significant effects on the
well-being of children and adolescents. Poor children are at greatest risk for
the physical, social, and emotional effects of living in poverty (Sidel, 1996)
(Figure 1-1). Some of the effects of living in poverty are listed in Figure
1-2. Compared with nonpoor children, poor children experience diminished
physical health. They have higher than average rates of death and illness from
almost all causes except suicide and motor vehicle accidents, which are most
common among white, nonpoor
children (Behrman, 1996). They also have a higher
prevalence of illnesses such as asthma, respiratory infections, anemia, and
gastrointestinal infections. Infant mortality rate is closely linked to
poverty, and children born to
poor families are at great risk of infant death (Annie Casey Foundation, 2000).
Deficits in children's nutritional status
are associated with poverty. Stunted growth (low height for age), a measure of
nutritional status, is more prevalent among poor than nonpoor children
(Brooks-Gunn & Duncan, 1997).
Poverty also affects children's cognitive abilities
and achievement. A child's poverty status at 3 years of age predicts the
child's IQ at age 5, and persistent poverty has more adverse effects on a child's cognitive
functioning than transitory poverty. In addition, children from lower
socioeconomic status perform less well than nonpoor children and middle class
children on test scores, grade retention, course failures, and placement in
special education, high school graduation rates, high school drop-out rates,
and the completed numbers of years of schooling. School achievement also
declines with the time spent in poverty, and the chance a child will be
retained in a grade or placed in special education increases 2%-3% for every
year that the child lives in poverty. In fact, long-term poverty is associated
with deficits in verbal, mathematical, and reading skills that are two to three
times greater than those associated with current poverty status. Poverty also
affects a child depending on when, during the child's life, poverty is
experienced; poverty during the first five years of life will affect the
completed years of schooling more than if poverty occurs during middle
childhood and adolescence (Brooks-Gunn & Duncan, 1997; McLoyd,
1998).
There is a higher prevalence of emotional and behavioral
problems (e.g., externalizing, internalizing) among poor and low socioeconomic
status children and adolescents than among children from families where there
is higher income. The externalizing behavior problems include disobedience,
fighting, difficulty getting along with others, and impulsivity, which become
more prevalent the longer the children live in poverty. The internalizing
behavior problems include anxiety, sadness-depression, and dependency
(Brooks-Gunn & Duncan 1997; McLoyd, 1998).
Homelessness
An increasing number of children and families in all
communities in the
Homelessness was initially a phenomenon of large urban
areas but more recently has swept across the nation, affecting midsize cities
as well as suburban and rural areas. Contributing to the rise of homelessness
in midsize cities is the migration of disadvantaged families from large urban
settings to smaller towns and cities in search of a safer environment and a
better life for their children. The homeless population is disproportionately
represented by African-Americans (U.S. Department of Housing and Urban
Development [HUD], 1999).
Several societal problems contribute to the increasing
rate of homelessness among American families, including the following (AAP,
1996):
•
Increases
in poverty
•
Lack
of affordable housing
•
Decreases
in availability of rent subsidies
•
Unemployment,
especially among those who have held only marginal jobs
•
Personal
crises such as divorce, domestic violence, and substance abuse
•
Cutbacks
in public welfare programs
•
Deinstitutionalization
of the mentally ill
Having been abused or neglected by a household member
as a child is a risk factor for homelessness. Another factor is living in a
foster home, a group home, or other out-of-home placement as a child, such as a
residential treatment center or juvenile detention (HUD, 1999).
Homeless children experience the specific health
effects directly related to homelessness, as well as the effects of poverty,
the umbrella issue of homelessness. The most common physical health problems
include upper respiratory, ear, and skin infections, gastrointestinal disorders
(diarrhea), and infestations (scabies, lice) (AAP, 1996). Compared with housed
children, homeless youth have a higher incidence of chronic health problems
such as asthma, anemia, visual and neurological deficits, eczema, and
trauma-related injuries (Weinreb, et al., 1998). The
conditions in many private and public shelters place children at risk of lead
poisoning and other environmental hazards. Many health problems may predate
shelter entry, including crowding in doubled-up housing situations, or exposure
to the elements and lack of sanitary facilities in public places. Access to
health care, especially preventive care (immunizations, well child services),
is impaired for homeless families. Because caregivers are struggling to meet
the family's basic demands for food and shelter, health becomes a lower
priority. When they do seek health care, they are more likely to use emergency
services for preventive and sick care than housed families (Ensign & Santelli, 1998).
To date,
the struggle to provide adequate food and nutrition to homeless families has
proven to be an over-whelming task. Homeless families have little access to
cooking facilities, and families living in shelters report having less access
to food than they previously had, with more children going hungry or
eating once per day. The children are especially at risk for malnutrition.
Inadequate benefits and difficulties in accessing food and entitlements are
the major mediators of hunger and poor nutrition in the homeless. The vast
majority of homeless families are headed by women who rely on Aid to Families
with Dependent Children (AFDC) as their primary source of income, and problems
are often compounded by failure to receive benefits to which they are entitled,
erroneous case closings, and benefit reductions. Loss of these benefits has
been shown to have directly contributed to loss of housing. In addition, the
children of these women who are eligible to receive benefits under the federally
funded Special Supplemental Food Program for Women, Infants, and Children (WIC)
often do not receive benefits. Families with limited resources are often left
with no other alternative than emergency food assistance facilities, and in
many cities, such facilities have reported having to turn away people in need
because of lack of resources.
Psychological problems identified most often among
homeless children include depression, anxiety, and behavioral problems.
Homeless children are more likely to exhibit poor attention span, trouble
sleeping, delayed speech, aggressive behaviors, shyness, and withdrawal (HUD,
1999). Poor school attendance resulting from family transience is also a
serious concern. Enrollment in school may be delayed lor
weeks because of lack of immunizations and records.
Nurses, together with other service providers such as physicians,
psychologists, and teachers can increase the local and national awareness of
the effects of homelessness on children and bring political attention to the
underlying causes of widespread poverty.
Nurses are in a unique position to advocate for
homeless children within the social services system concerning access to health
care, mental health care, and essential housing, nutritional, and educational
needs. Nurses can also advocate for making prenatal care available to homeless
mothers. Lack of such care places unborn homeless children at risk of low birth
weight, subsequent health problems, chronic diseases, and cognitive and
developmental problems. In addition, health problems are associated with
psychological problems, classroom performance, and drop-out rates, all of
which, gone unaddressed, can seriously compromise the future of homeless
children.
Migrant Farm Workers
Migrant
and seasonal farm workers constitute a major portion of the labor force in the
Agriculture
surpasses mining and construction as the most hazardous occupation in the
The
conditions of migrant life place families, and especially children, at
increased risk for contracting a variety of viral, bacterial, and fungal
infections, including rabies, anthrax, Rocky
Mountain spotted fever, tetanus, plague, typhoid, tuberculosis, HIV, and hepatitis. Crowded, unsanitary living conditions
create the opportunity for rapid disease spread. Lack of access to health care
services results in a high incidence of preventable disease in the migrant population.
The high incidence of tuberculosis in this population has been linked with
high rates of infection in migrant's countries of origin, substandard housing
and overcrowding, poor baseline health status, malnutrition, and lack of access
to preventive health care services. There are high rates of HIV infection in
the migrant population. Specifically, the number of women with HIV is rising,
putting children at risk for contracting the virus in utero
or at birth. Migrant women are particularly
at risk because of their lack of access to educational counseling,
prevention, and treatment services.
Migrant
children are frequently at risk nutritionally. Migrant communities often have
limited choices for the purchase of food, and their low incomes may preclude
them from receiving adequate amounts of nourishment. Furthermore, they often
lack the means for properly storing or preparing foods (e.g., lack of
refrigeration, impotable water). Though many are
eligible for supplementation through programs such as WIC and food stamps, many
do not participate because of multiple barriers to these services.
Iron-deficiency
anemia is a common diagnosis reported by clinics serving migrant children.
Child obesity is also raised as a major clinical concern given the link of
obesity to diabetes and hypertension in adult Hispanics (Gwyther
& Jenkins, 1998).
The
health status of these children is further threatened because of barriers to
health care such as family mobility, financial constraints, and legal (fear of
immigration penalties), language, and cultural barriers. The mobility of the
families impedes adequate follow-up and referral for health problems for the
children. Financial constraints stemming from being in a low-wage work group,
being paid according to how much is harvested, and lack of health insurance hinder
migrant farm workers from seeking health care for their children. Language is a
major cultural barrier for Hispanic workers who speak little English and for
health care providers who do not speak Spanish (
There
is a critical need for nurses working with migrants to advocate for the health
of migrant children. Nurses must not only act as health educators for migrant
families, but they must also aid them in negotiating a complex and dynamic
health care system that is unfamiliar. It is equally important that those
familiar with the lives of migrant families educate the public and its leaders
about the significant contributions of these workers to the economy. Further,
the research literature on migrant children has many critical gaps. Basic
information on the number and distribution of migrant children in the
Violence
As the 20th century ended, violence by and against
children declined. Yet it still occurs. Today children and adolescents are more
likely to be the victims of violent crime than the offenders. Violent crimes
include murder, forcible rape, robbery, and aggravated assault. Although the
number of children injured by violent crime has declined significantly, the
level of violence in the
An examination of other statistics on juvenile
violence is alarming. One statistical trend to consider is the numbers of
juveniles arrested for violent crimes. In 1999, 5% of juvenile arrests were for violent crimes. Comparing
racial groups indicates that, although African-American youths accounted for
15% of the juvenile population, they were involved in more than 50% of arrests
for murder and rape. Another 
trend
to examine is juveniles who are victims of homicide, which indicates a positive
trend in 1998. The homicide rate fell an estimated 14%, the fifth straight year
of decline. However, it still remains a major cause of death among
10-19-year-olds and the leading cause of death for black males 15-24 years of
age (Snyder & Sickmund, 1999).
In recent years, injuries and deaths among children
and adolescents from firearms, specifically handguns, have increased. In 1998,
firearms were involved in 85% of all homicides, and 60% of all suicides in
adolescents were committed with a firearm (Snyder, 1999). The presence of a gun
in the home increases the risk of homicide, suicide, and injury to family and
friends (Laraque, Spivak,
& Bull, 2001). Recent evidence suggests that the majority of firearms used
in suicide attempts and accidental shootings are stored in the home of the
victim or in the home of a relative or friend (Grossman, Reay,
& Baker, 1999). Although, in recent years, a great deal of attention has
understandably been focused on tragic school shootings and homicides, school
violence rates are declining overall (Children's Defense Fund, 2000). In fact,
school-associated violent deaths are rare occurrences. Students are much more likely to be the victims of
violent crimes away from school than at school (Snyder & Sickmund, 1999). Even though violent crimes in schools have decreased, physical
fights, thefts, weapon carrying, teacher victimization, and fear of school
environments have increased. The most effective strategies for reducing
violence in schools involve coordination among education, law enforcement,
social service, and mental health systems.
Nurses must become involved in responding to the
increases in firearm-related deaths in children by encouraging gun control
legislation. Laws to hold gun owners responsible for how their guns are stored
in the event a child is injured may lead to decreases in rates of accidental
firearm deaths. A number of gun design options have been proposed to decrease
the likelihood of unintentional injury. These include trigger locks, lock
boxes, personalized safety mechanisms, and trigger pressures that are too high
for young children. However, it is not conclusive if these measures will
decrease injuries and deaths (AAP, 2000). Until guns are no longer accessible
to children, education should inform all adults about gun hazards and safety.
Nurses can be involved in this education process by teaching families about
firearm safety.
Home:
1. Communicate the risks of keeping a firearm in the
home.
2. Advise that it's safest not to keep a firearm in
the home.
3. Review safe methods of storage.
4. Educate caregivers to teach children not to touch
or handle firearms.
5. Explain that handguns and semiautomatic weapons pose
the greatest risk of intentional and unintentional injury for children. The
reason for this is because they are more often stored unsafely and are more
often involved in serious injuries and deaths.
6. Explain to caregivers that it is easier to keep guns
away from adolescents than to keep adolescents away from guns, which are often
glamorized in the media. Caregivers should watch for signs of depression or
changes in behavior since teens feeling this way are at increased risk
for suicide.
School:
1. Incorporate violence prevention programs in school
curricula at an early age, including firearm violence. Examples of such
programs include conflict resolution, alternatives to violence, anger
management, risk awareness, and coping skills.
2. Have after-school programs for youths, and obtain
community support for such programs.
Community:
1. In an effort to reduce the romaticization
of guns in the popular media, urge the development of violence-free programming
among child health and education advocates, and the television and motion
picture industries.
2. Support legislation that regulates the manufacture
and importation of classes of guns, such as handguns and assault weapons, and
that requires background checks for weapons purchased at gun shows.
3. Improve playgrounds and parks to make safe play
areas for children.
Current Status of Children's Health
In January 2000, the U.S. Department of Health and
Human Services (DHHS) launched Healthy People 2010: National Health Promotion
and Disease Prevention Objectives, a comprehensive, nationwide health
promotion and disease prevention agenda. The document contains 28 focus areas
and 467 objectives designed to serve as a guide for improving the health of all
people in the
Because Healthy People (HP) 2010 emphasizes health
promotion and prevention, almost all of it pertains to nursing. Health
promotion and education are central to nursing practice; therefore, nurses need to
develop an awareness of the HP 2010 program and incorporate it as a benchmark
for their interventions. Nurses are well educated and prepared to work with individuals, families, and
communities to meet the special needs of vulnerable populations and to
eliminate health disparities. The public, by and large, trusts nurses and is
receptive to their teaching and intervention.
Nurses can use their unique position to help meet the goals of HP
2010 and, in doing so, can improve the health of all Americans: adults, children, and adolescents.
Infant Mortality
Infant mortality is an important measure of a nations health and a
worldwide indicator of health status. The infant mortality rate (IMR)
is the number of infant deaths during the first year of life per 1,000 live
births. IMR has shown an exponential decline in the 20th century from 200 per
1,000 live births in 1900 to a record low of 7.2 per 1,000 live births in 1998
(Martin, Smith, Matthews, & Ventura, 1999). Figure 1-3 demonstrates IMR by
race from 1915 to 1998. The low overall IMR in 1998 was the same as the record
low reported in 1997. It is the first time that there has been no improvement
in this measure in nearly four decades. The IMR in 1998 for white infants was
6.0 and for black infants, 14.3—a figure more than twice the rate for white
infants. This racial difference is a major national concern because the ratio
of black to white infant deaths has remained unchanged from 1990 to 1998. One
reason for this disparity in IMR is the high rate of low birth weight (LBW)
infants born to minority mothers, which suggests a decrease in the overall
health status or health care access of these women. IMRs
were also higher for infants whose mothers were teenagers or 40 years of age or
older, did not complete high school, were unmarried, began prenatal care after
the first trimester of pregnancy, or smoked during pregnancy (Guyer, Hoyert, Martin, Ventura, MacDorman, & Strobino, 1999).
The upward trend in infant survival has been due to improvements in perinatal care, such as high frequency ventilation, use of
surfactant therapy for the neonate, and improved public education efforts
(Figure 1-4). In spite of these improvements in infant mortality, the
Low Birth Weight
One reason for the racial disparity in IMRs and the poor ranking of the
Figure 1-5 also shows an increase between 1990 and 1999
in the LBW rate for infants born to white, American Indian, and Asian/Pacific
Islander women. The increase among white women has been shown to be
attributable to an increase
in multiple births (Guyer, Freedman, Strobino, & Sondik, 2000).
The increase in multiple births has been associated with an increase in
assisted reproductive technologies such as in vitro fertilization and,
to a lesser extent, with the rising age of childbearing. If this increase
continues, it is unlikely that there will be much improvement in the position
of the nation in infant mortality relative to other developed countries (Guyer, et al., 2000).
Immunization Rates
The reduction in incidence of vaccine-preventable
diseases is one of the most significant public health achievements of the 20th
century. The global eradication of smallpox in 1977 is an illustration of this
success (DHHS, 1999). Not only are immunized individuals themselves protected
from developing a potentially serious illness, but, also, if enough of the
population is immunized, transmission of the disease in a community may be
interrupted. This concept is known as herd immunity, i.e., the reduction
of the number of persons susceptible to a communicable disease by immunization,
thus preventing the spread of disease in epidemic proportions. Immunization
rates should be at least 80% to provide herd immunity. The increasing number of
safe and effective vaccines has improved the health status of millions of
Although immunization coverage is high in almost all states,
areas within each state and within major cities persist where substantial
numbers of underimmunized children reside.
Significant segments of this population are minority children. These areas are
of great concern because there is a potential for outbreaks and epidemics of
vaccine-preventable diseases. Another challenge is the emergence of a vocal
movement resisting childhood immunization requirements. All 50 states have
immunization requirements for entrance into school; however, some groups are seeking
changes in these state laws. They want to enable caregivers to choose how and
if their children are vaccinated. Exemptions are allowed from immunization
requirements for medical reasons in all states and for religious reasons in 48
states, and 15 states allow exemptions for philosophical reasons (National
Vaccine Advisory Committee, 1998). Children who are not immunized may create
health risks if they contract a vaccine-preventable disease because they can
transmit it to other family members, peers, friends, and neighbors. Yet,
vaccinations are among the safest and most effective preventive measure, and,
in general, a child is more likely to suffer complications from the disease
than from immunizations.
Child Mortality
Another indicator of children's health status is child
mortality. For children over 1 year of age, the overall decline in mortality
during the 20th century has been impressive (Figure 1-7). In 1900, the death
rate for children 1-4 years of age was about 2,000 per 100,000 population, 460
for 5-9-year-olds, 300 for children 10-14 years old, and 500 for
15-19-year-olds. By 1998, the death rates in these age groups had declined by
98%, 96%, 93%, and 85%, respectively (Murphy, 2000). The decline in
deaths for adolescents has plateaued since the 1960s.
At the beginning of the 20th century, the major cause of child mortality for
1-19-year-olds was infectious diseases. However, the mortality and morbidity
from all of these diseases are dwarfed by the numbers of children who die or
who are disabled as the result of unintentional injuries. Until recently,
injuries were commonly termed "accidents," suggesting that they were
unpredictable and unavoidable events affecting unlucky children. Today, the
term "injury" is favored because it more accurately suggests that
the problem can be averted and prevented.
Injury is defined as damage or harm to an individual
resulting in destruction of health, disability, or death (Deal, Gomby, Zippiroli, & Behrman, 2000). An
injury is classified as intentional or unintentional, denoting whether or not
it was meant to harm the victim.
Among children aged 1-19, unintentional injuries are
responsible for more deaths each year than homicide, suicide, congenital
anomalies, cancer, heart disease, respiratory illness, and HIV combined (CDC,
National Center for Injury Prevention and Control, 1999). Although unintentional
injuries are the leading cause of death for all children over 1 year of age,
the incidence varies by age. More than one-half of all unintentional
injury-related deaths occur in the 15-19-year-old group due to motor
vehicle-related injuries. Common subcategories of motor vehicle injuries
include (1) occupant (drivers and passengers), (2) bicycle-related, (3)
motorcycle, and (4) pedestrian injuries.
There is considerable variation in injury rates among
children depending on their age group. Among children under 1 year of age,
suffocation is the leading cause of unintentional injury-related death,
followed by motor vehicle occupant injury, choking, drowning, and fires or
burns. Some suffocation deaths in infants are due to entrapment of the head and
neck in cribs. Another cause is choking on food or an object, leading to airway
obstruction. For children aged 1—4 years, drowning is the leading cause of
injury death, followed by motor vehicle occupant injury, fires or burns, and
airway obstruction. Infants often drown in bathtubs, usually as a result of
poor supervision or neglect, whereas toddlers and young children fall into a
body of water such as a swimming pool, lake, or river, usually while
unsupervised. Among children aged 5-14, motor vehicle occupant-related injury
is the leading cause of death, followed by drowning, pedestrian injury (i.e.,
motor vehicle collisions with the child), bicycle injury, and fires or burns
(National SAFE KIDS Campaign, 1998). Pedestrian injury often occurs when a
child darts out between parked cars or into the street to get a ball or another
object. During adolescence (14-19 years), motor vehicle occupant injuries are
the primary cause of injury-related deaths. Driver inexperience and
alcohol use are key contributors to the high rate of fatal crashes in adolescents (Grossman, 2000).
Rates of unintentional injury deaths among children
have declined by 43% over the past several decades. Decreases in injury deaths
have been observed for every age group and for nearly all causes. Reductions
have been most evident among adolescents and for poisoning deaths (CDC,
The key approaches to injury prevention are education,
changes in the environment and
in products, and legislation or regulation. Education to promote changes in
individual's behaviors has reduced the risk of childhood injuries. Education by
health care professionals has increased individual safety behaviors, including
seat belt and car seat use, smoke detector ownership, and safe hot water
temperature. Nurses and other health care providers should incorporate
education about safety practices into routine health visits. Pediatric nurses
can play an important educational role by teaching caregivers about expected
behaviors for their child's upcoming developmental stage. This alerts them to
the types of injuries common to that age group and to potential environmental hazards.
Nurses can initiate safety programs in schools, neighborhoods, and cities
(Figure 1-8).
Changes
in the environment and in products can make children's physical surroundings,
toys, and clothing safer. Strategies that make children's environments safer
such as traffic calming to reduce or slow the speed of traffic in neighborhoods and fencing to
enclose swimming pools on all sides should be implemented in all communities
and be mandated by law. Legislation and regulation are among the most effective
tools to reduce injuries, and most environment and product modifications
require legal action. However, some laws have not been adopted in every state,
e.g., 35 states lack bicycle helmet laws (Bicycle Helmet Safety Institute,
2000), and most states do not require appropriate protection in automobiles
for children between the ages of 4 and 8. For maximum effectiveness, laws,
regulations, and policies must be supported by the public and enforced at the community level. A major
challenge is to coordinate all groups involved in unintentional injury prevention
to create a critical mass
for action (Schieber, Gilchrist, & Sleet, 2000).
Access to Health Care
For a growing number of children, access to health
care is hampered by lack of health insurance. The number of uninsured children
has been growing at an alarming rate. In 1999, approximately 11.9 million
children (one in seven) under the age of 19 lacked health insurance (U.S.
Census Bureau, 1999). Ethnic minority children are overrepre-sented
among the uninsured. They account for more than half of uninsured children.
Three-quarters of uninsured children are among the working poor, that is, in
families in which the head of the household is employed full time for all or
part of the year (Office of the Assistant Secretary for Planning and Evaluation
[OASPE], 1998).
Socioeconomic status largely dictates the source of
children's health insurance. Those from higher income families are more likely
to have private health insurance (90%) than are children from lower income
families (40%) (Brennan, Holahan, & Kenney,
1999). Uninsured children in low-income families experience substantial
difficulties in accessing health care. They tend to lack (1) the usual sources
of routine and sick care, (2) a primary care provider, and (3) recent visits to
health care providers. Uninsured children are more likely to be underimmunized and to go without needed medical services
due to the costs of care (Newacheck, Halfon, & Inkelas, 2000).
Despite high employment and a robust economy during
the previous 8 years, the number of uninsured children continued to grow.
Several factors have contributed to this situation, predominately welfare
reform. Between 1995 and 1997, 1.25 million individuals lost Medicaid coverage
due to welfare-to-work initiatives (Families USA, 1999). Many families who
left the welfare roles obtained low-paying jobs for which their employer did
not offer health insurance coverage or could not afford to pay the
contributions toward the insurance premiums. Although many adult members of families
were no longer eligible for Medicaid due to reforms, most of the children in
these families were and are still eligible for its benefits; however, many of
these families are unaware that their children continue to be eligible.
Additionally, some children lost their coverage because welfare administrators
failed to inform families of their continuing eligibility. Other families lost
coverage because of state administrative errors, barriers, and
misunderstandings. Finally, in some states, efforts were made to deter individuals
from applying for Medicaid (Sochalski & Villarruel, 1999).
In response to the growing problem of uninsured children
and to expand health insurance coverage for them, Congress enacted the State
Children's Health Insurance Program (SCHIP) as part of the Balanced Budget Act
of 1997. SCHIP was established as Title XXI of the Social Security Act. Not
since the enactment of Medicaid in 1965 has there been greater funding for
children's health insurance coverage. The purpose of SCHIP is to provide
health insurance coverage for children through 18 years of age who are
uninsured or ineligible for Medicaid. More than $40 billion in federal grants
will be allocated to states over a 10-year period. States must contribute a
defined share of funds to obtain federal matching grants (
The success of SCHIP will depend heavily on getting
caregivers to enroll their children in the program. Nurses must assume
responsibility for helping to facilitate access to health care for families
with children. First, they need to be aware of their state health insurance
coverage's eligibility requirements and procedures for enrollment. Nurses
should work with community agencies in developing mechanisms for identifying
children eligible for federal and state programs. Then, they must refer
families to available resources and intervene if necessary to help them
navigate through the system.
Beyond the barriers created by lack of health
insurance, there are other factors involved in access to and use of care.
Demographic factors such as family income, race/ethnicity, place of residence,
and type of insurance have been identified as barriers to access of care (Sochalski & Villarruel,
1999). Institutional factors such as gate keeping by health plans, distance
from families' homes to health site, availability of transportation, and
waiting times are other factors. Nurses need to assess barriers for families in
accessing health care beyond their insurance status in order to ensure that
children will receive needed health care.
PERSPECTIVES ON PEDIATRIC NURSING
Family-Centered Care
All health care professionals recognize that quality
health care of children must extend to the entire family. Thus, the focus of
pediatric nursing must be on the child as well as the family. The term family-centered
care describes a philosophy of care that recognizes the centrality of the
family in the child's life and inclusion of the family's contribution and
involvement in the plan for care and its delivery. It is a health care delivery
model that seeks to fully involve families in the care of children.
Family-centered care evolved in response to the critical need to maintain the
relationship between hospitalized children and their families. Previously this
relationship had been neglected or disrupted because of forced separation by
the health care system.
In 1987, a revolutionary document that defined the elements
of family-centered care was published by the Association for the Care of
Children's Health (ACCH). Family-centered care was defined by this group as
including eight equally important elements (
The elements of family-centered care are based on principles
that are designed to promote greater family self-determination, decision-making
capabilities, control, and self-efficacy. Collectively, these attributes
are said to reflect a sense of empowerment. In contrast, the medical model
directs health care professionals to assume the roles of evaluator and controller of
treatment interventions. This approach results in child and caregiver
dependence on the health care providers (Dunst & Trivette, 1996). This position is in direct conflict with
the conditions necessary for more active involvement of caregivers in the care
of their health-impaired children.
Many health care providers respect and support the
idea of family-centered care; however, the practice of this type of care has
not been fully actualized (Ahmann, 1994). This discrepancy
between their support and actual practice of family-centered care may be
attributed in part to the model they employ (family empowerment versus medical
approach). Additionally, professionals often inadvertently foster family
dependency, alienation, and helplessness by taking control and administering
care without family input for the convenience and expediency of the staff and
the institution. However, in order to facilitate family-centered care, health
care providers must seek caregiver input, suggestions, and advice; incorporate
this information into the plan of
care; and teach the family the appropriate health care interventions. By providing education and
knowledge to the family, caregivers can be empowered to make informed decisions
about their child's care (Dunst & Trivette, 1996). Other strategies that enhance
family-centered care include no limits on the ages or number of visitors
(unless directed otherwise by the family); adequate sleeping facilities for
caregivers in the child's room; meals or discounts in cafeterias for
caregivers; free parking or a discount for caregivers; and family attendance at
interdisciplinary conferences regarding the child's care.
Atraumatic Care
Atraumatic care is a philosophy of providing care that minimizes or
eliminates physical and psychological distress for children and their families
in the health care environment. In pediatric care, many interventions are
traumatic, stressful, and painful; therefore, it is important for nurses to be
cognizant of these situations and provide care that minimizes distress. Three
principles provide the basis for atraumatic care: (1) identifying stressors for
the child and family, (2) minimizing separation of the child from caregivers, and (3) minimizing or
preventing pain (Furdon, Pfell,
& Snow,
1998). Examples of atraumatic interventions include:
•
Preparing
the child prior to every procedure using age-appropriate explanations
•
For
the child scheduled for surgery, preparing her or him prior to hospital
admission (encourage child and caregivers to visit the hospital, allow the
child to play with equipment and items such as a stethoscope, blood pressure
cuff, IV equipment, masks and gowns)
•
Allowing
caregivers to be involved and physically present as much as possible to provide
support and comfort for the child
•
Controlling
pain by administering analgesics freely
•
Using
a euteric mixture of local anesthetics (EMLA) cream
at least 1 hour prior to blood draws, insertion of IV needles, and injections
STANDARDS OF CARE AND STANDARDS OF
PROFESSIONAL PERFORMANCE
Professional nurses, as well as all health care
professionals, are being held more accountable for their actions. This change
is translating into more emphasis on adherence to standards of care. The standard
of care is the accepted action expected of an individual of a certain skill
or knowledge level. It is considered the minimal level of functioning and what
a reasonable and prudent person would do in a similar situation. Standards are
a tool for determining if the litigation as a legal yardstick to determine if
care can be considered acceptable nursing practice.
Specific standards of care and professional performance
have been developed for pediatric clinical nursing practice by the American
Nurses Association (ANA) and the Society of Pediatric Nurses (SPN) (
|
BOX 1-6 ANA-SPN standards of care and standards of
professional performance for pediatric nurses Standards of care for the pediatric nurse: ·
Collects
health data ·
Analyzes
the assessment data in determining ·
Identifies
expected outcomes individualized to the ·
Develops
a plan of care that prescribes interven ·
Implements
the interventions identified in the plan ·
Evaluates
the child's and family's progress toward Standards of professional performance for the
pediatric nurse: ·
Systematically
evaluates the quality and effective ·
Evaluates
her or his own nursing practice in relation to professional practice standards
and relevant statutes and regulations ·
Acquires
and maintains current knowledge in pediatric nursing practice ·
Contributes
to the professional development of ·
Makes
decisions and takes actions on behalf of children and their families that are
determined in an ethical manner ·
Collaborates
with the child, family, and health care providers in providing client care ·
Uses
research findings in practice ·
Considers
factors related to safety, effectiveness, and cost in planning and delivering
care American Nurses Association and the Society of
Pediatric Nurses. (1996). Statement on the scope and standards of
pediatric clinical practice. |
Professional standards are derived from regulatory
agencies, nursing practice acts, professional nursing organizations, and state
or federal laws. Additionally, they come from scientific literature, which is typically
research-based or evidence-based, and from health care institutions'
policies and procedures. Standards are used not only to evaluate the
effectiveness of nursing care provided, but also are used in litigation as a
legal yardstick to determine if care can be considered acceptable nursing practice.
Specific standards of care and professional
performance have been developed for pediatric clinical nursing practice by the
American Nurses Association (ANA) and the Society of Pediatric Nurses (SPN) (
STANDARDS AND GUIDELINES FOR PRELICENSURE AND EARLY
PROFESSIONAL EDUCATION
Caring for children and their families has always been
challenging, but has become increasingly more complex as technology advances.
This complexity has resulted in challenges for nursing educators, one of which
is an expanded and more complex amount of knowledge in pediatric nursing. Also,
with increased attention to family-centered and community-based care, all
nurses will care for children and their families at some point during their
nursing career. Thus, the Standards and Guidelines for Prelicensure
and Professional Education for the Nursing Care of Children and Their Families
were developed to support the education of prelicensure
students and the professional development of new graduates for the
nursing of children and their families (
The intent is that the goals will be implemented
across all settings where prelicense and early
professional education occur. Resources and circumstances unique to each
education situation will influence how the goals are implemented, how
teaching-learning processes are chosen and applied, and the outcomes that are
selected as the main aims of the education. Additionally, it is expected that
the standards and guidelines will be integrated throughout the entire
curriculum rather than only in
one course.
MEETING THE CHALLENGES OF THE 21ST
CENTURY
Child health care has changed considerably over the
past 20 years. Health care systems were previously focused on the treatment of
disease. Health care personnel placed a greater emphasis on treating disease
while neglecting early detection and treatment of illness as well as health
promotion and maintenance. Disease treatment usually involved invasive
procedures through medical technology in acute care settings, a costly approach. Financing
and reorganization of services has changed to a managed care system. With
managed care, the traditional physician-oriented focus has shifted to a
payer-oriented focus emphasizing health promotion, disease prevention, and cost
containment. Cost cutting in health care institutions is currently pervasive in
the market-driven system of the
•
Children
in inpatient facilities having conditions that
are more acute
•
Shorter
length of stay in these facilities
•
Increased
incidence of chronic illnesses
•
Constraints
on delivery of care, including reduced
human and material resources
•
Advances
in telecommunications and information
technology
|
BOX
1-7 Standards and guidelines for prelicensure and
early professional education for the nursing care of children and their
families I. Child,
family, and societal factors 1. Concept:
Anatomic structures and physiologic and psychologic
processes in neonates, infants, children, and adolescents Goal The nurse will integrate knowledge of the unique anatomic structures,
physiologic and psychologic processes of children
from birth through adolescence to make assessments, plan, implement, and
evaluate care. 2. Concept:
Health behaviors Goal: The nurse will use opportunities to positively
influence the health behaviors of children and their families. 3. Concept:
Separation, loss, and bereavement Goal: The nurse will provide supportive care for children and families experiencing
separation, loss, and/or death. 4. Concept:
Economic, social, and political influences Goal: The nurse will use knowledge of how the larger environment influences
the child's health and development and the family's care to (a) make
assessments, plan strategies, and implement approaches that are in accord
with the family's economic and social situation and available resources, and
(b) work with others in the community to make and implement plans for the
health care needs of children. II. Clinical
problems or areas: 1. Concept:
Safety and injury prevention Goal: The nurse will provide and promote safety in
order to prevent injuries and support the development of the child. 2. Concept:
Children with chronic conditions or disabilities and their families Goal: The nurse will make assessments, plan
strategies of care, and intervene in ways that promote the growth and
development of the child with a chronic condition or disability.
Additionally, the nurse will support the child's and family's management of
care and promote a healthy family lifestyle. Evaluation of nursing care is a
part of this process. 3. Concept:
Children with acute illness or injuries and their families Goal: When providing care to children with acute illness or injuries and
their families, the nurse will make assessments, plan strategies of care, and
intervene in ways that promote the growth, development, and safety of the
child. Evaluation of nursing care is a part of this process. III. Care
delivery 1. Concept:
Family-centered care Goal: A The nurse will use the family-centered approach to:
(a) assess needs, plan and implement interventions, and evaluate outcomes
relevant to the health care needs of children in partnership with them and
their families; (b) work with other health care providers and the family to
promote coordinated service delivery; and (c) advocate for family-centered
care of children. Goal: B The nurse will participate in developing and working
within service delivery systems to support practice that is consistent with
principles of a family-centered approach. 2. Concept:
Cultural competence Goal: The nurse will acknowledge and integrate into health care the beliefs,
practices, and values of cultural groups defined by geography, race,
ethnicity, religion, or socioeconomic status. 3.
Concept: Communication Goal: The nurse will communicate effectively with the child, family, and
others who participate in the care and education of the child and family. 4. Concept: Values and moral and ethical
reasoning Goal: The nurse will respond to ethical, moral, or
legal health-related dilemmas in ways that promote the development of
families and children, assist them in making decisions, and support them in
implementing the decisions. Pridham, K., Broome, M., Woodring,
B., & Baroni, M. (1996). Education for the
nursing of children and their families. Standards and guidelines for
pre-licensure and early professional education. Journal of Pediatric
Nursing, 11, 273-280. |
These changes in the health care delivery system have
resulted in unprecedented challenges for nurses who care for children and their
families.
Telecommunications and the Internet have made available
vast amounts of health information for health care providers as well as the
consumer. The public is becoming so well informed about their health problems
that the mystique, and therefore, the power of medical providers are disappearing. Clients
are challenging clinicians with information obtained on the Internet,
and the increasing available health information is changing nurses' role from
health expert to information broker (
Key Concepts
Current societal trends affecting children, their
health, and their families include immigration, poverty, homelessness, migrant
farm work, and violence.
Healthy People 2010 sets forth national health goals and objectives for
adults and children, and focuses on disease prevention and health promotion.
The aggregate health status of infants, children, and
adolescents is determined statistically by keeping records of indicators such
as infant mortality rate, low birth rate, and immunization rate.
The infant mortality rate is the lowest ever recorded
in the
The leading cause of death in children 1-19 years of
age is unintentional injuries, with the majority of deaths resulting from motor
vehicle occupant injury.
Family-centered care is based on principles that are
designed to promote greater family self-determination, decision-making
capabilities, control, and self-efficacy.
The primary roles of pediatric nurses include
caregiver, advocate, educator, researcher, and manager/leader.
Diversity of pediatric health care settings and a
shift in focus of health care from treatment of disease to promotion of health
have led to nurses functioning in advanced practice or expanded roles such as
pediatric nurse practitioners, clinical nurse specialists, and case managers.
Review Questions
1.
Describe how
poverty affects children.
2.
Define
infant mortality.
3.
What
can nurses do to prevent firearm-related injuries
and deaths in the home, school, and community?
4.
Which
of the following is the leading cause of death in
children under 19 years of age?
a. cancer
b. heart
disease
c. congenital
anomalies
d. injuries
5. What major health protection measure has
reduced the incidence of poisoning from prescription drugs?
6. What
strategies can nurses include in their practice
that relate to family-centered care?
7.
Describe each of the roles that nurses take when interacting with children and
their families, and explain how they are connected to one another.
8. Define
differentiated practice, and describe why it was
developed.
9. Discuss
the differences between the pediatric nurse
practitioner and the pediatric clinical specialist.
1 O. Describe
case management, and discuss why it was developed.
LEGAL AND ETHICAL ISSUES
Pediatric nursing spans a broad developmental spectrum
within a arrow age range. This developmental spectrum presents a challenge
for pediatric nurses not only in the delivery of health care, but also in legal
and ethical decision making. Whether or not a minor can consent to confidential
health care is one of the many legal issues faced by pediatric nurses.
Nurses are confronted every day with situations in
which difficult decisions must be made based on the determination of right and
wrong. Technological advances have created unprecedented choices not only for
society at large, but specifically for nurses and their clients. Nurses caring
for children in critical care areas encounter ethical dilemmas such as whether
or not to resuscitate a dying child whose quality of life may be bleak or which
treatment option will provide the most benefit and do the least harm for a
child. Therefore, it is important for nurses to have a basic understanding of
the laws that affect their practice and the ethical guidelines that can be
used to resolve dilemmas. This
chapter explores pediatric legal topics, along with the concept of ethics,
ethical theories and principles, and the process of ethical decision making.
LEGAL CONSIDERATIONS
It is essential for nurses to understand that the same
legal problem may be solved differently in different states. Health care is
often controlled by state laws and regulations. The answers to many questions
will vary from state to state, depending on both the specific laws of each
state and how the state courts interpret those laws. It is difficult for a textbook
to provide answers to specific legal questions. In dealing with actual legal
problems, it is important for the nurse always to consult with someone who is
familiar with the laws of the state where the individual is licensed.
Table 2-1 lists the different sources of law.
INFORMED CONSENT AND ASSENT FOR
HEALTH CARE
In 1914, Justice Benjamin Cardozo
stated, "Every human being of adult years and sound mind has a right to
determine what shall be done with his own body ..." Schloendorff
v. Society ofN.Y. Hospital (1914). This famous court
case created the legal foundation for requiring informed consent prior to
medical treatment. Informed consent is the duty of a health care provider to discuss the risks and
benefits of a treatment or procedure with a client prior to giving care. Informed
consent must include the following: the nature of the procedure, the risks and hazards of the procedure, the
alternatives to the procedure, and the benefits of the procedure (
For example, a 10-year-old boy comes into the office
to have stitches placed in his right hand. The health care provider asks the
child's parent for informed consent after the parent has been provided
information about the risks and benefits of local anesthesia and the placement
of sutures. Alternatives to suturing and the risks of leaving the wound open
are discussed. Once the parent provides informed consent, the boy is asked to
assent to the procedure. The boy is told that a tiny needle will be used to put
a little numbing medication in the skin. When the skin is numb, the health care
provider will place some stitches to close the cut. If the child agrees to having stitches, he has
given assent to the procedure. While assent is not legally required, it is
always better to have the cooperation of the child prior to giving care (Pieranunzi & Freitas, 1992).
Assent from the child may maximize success of the procedure and minimize trauma
to the child.
TABLE 2-1 Sources of Law
|
1.A statement that the study involves research. 2.An exploration of the purpose of the research,
delineating the expected duration of the subject's participation. 3.A description of the procedures to be followed and
identification of any procedures that are experimental. 4.A description of any reasonably foreseeable risks or
discomforts to the subject. 5.A description of any benefits to the subject or to
others that may reasonably be expected from the research. 6.A disclosure of appropriate alternative procedures
or courses of treatment, if any, that might be advantageous to 7.A statement describing the extent to which anonymity
and confidentiality of the records identifying the subjects 8.For research involving more than minimal risk, an
explanation as to whether any medical treatments are available if 9.An explanation about who to contact for answers to
questions about the research and subject's rights, and who to From: Code of Federal Regulations: Protection of
human subjects, 45 CFR, 46, OPPR Reports. Revised March 8, 1983. |
When Informed Consent Is Not
Required
Figure 2-1 Sexual Abuse Examination
Most health care facilities will provide care to a
minor or an adult in an emergency situation if they cannot obtain prior
informed consent. A minor is defined as a person who has not yet
obtained the age at which she or he is considered to have the rights and
responsibilities of an adult. When consent is not obtained for an adult
client, it is usually because the individual is unconscious or physically
unable to consent. The care given under these circumstances is usually an
emergency lifesaving procedure. Health care providers may provide emergency
care to a child if they have made a reasonable attempt to contact the child's
parent or legal guardian. When that person cannot be located, especially in the
case of an adolescent, it is prudent to obtain informed consent from the child
(Abbott, 1996). Many states allow the evaluation and treatment of a child for
suspected physical or sexual abuse without the informed consent of a parent or
guardian. In
Legally, it may not be necessary to obtain parental
consent prior to performing a sexual assault or other forensic examination,
but it is important to have the assent of the child or adolescent prior to
starting an examination. A forensic
examination is performed for the purpose of collecting medical evidence
when the health care provider suspects the client may be the victim of a
crime. In cases of sexual assault or abuse, a child should never be forcibly
restrained for a genital or rectal examination (Wissow,
1990). Forcing a child to participate in a forensic examination may damage the
child's ability to testify in a criminal case, especially if the child
perceives the medical examination as another episode of abuse (Figure 2-1).
When a Minor Can Consent for Care
In all but three states, a minor is a person under the
age of
Some states allow minors to make medical decisions if,
under the laws of the state, the minor is considered to be emancipated. Emancipation is the legal recognition
that a minor lives independently and is legally responsible for his or her own
support and decision making. Emancipation can occur through an official court proceeding. During the
proceeding, the judge will establish whether the minor is living on his or her
own and no longer requires the financial support of parents. In some states, a
minor may become automatically emancipated by marrying, joining the military,
or becoming a parent before the age of
majority (the age, determined by state law, at which a person is
considered to have all the legal rights and responsibilities of an adult).
Emancipation laws vary from state to state, and some states do not officially
recognize any form of emancipation.
A minor who has not achieved emancipation may be able
to consent to medical care in some states following the mature minor
doctrine, under which a minor can consent to care as long as the individual
demonstrates the maturity to understand the risks and benefits of the treatment
(Nixon, 1992). The mature minor doctrine is another example of how the courts
create laws through decisions made by judges. Unless the definition of a mature
minor is defined by a law or statute, appellate courts in each state have the
ability to define the legal requirements for a mature minor. This definition
can be created only when a case that disputes the ability of a child to make a
health care decision is brought to court. In
Parental Consent after Divorce
After divorce, the ability to consent for medical care
rests with the parent who has been granted legal custody by the divorce
decree (the legal document approved by the court that grants divorce, divides
marital property, and specifies child custody). In order to serve the best
interests of the child, the court will often grant both parents legal custody
of the child. This means that both parents will be able to give consent for
medical care. Even when one parent has legal custody, the parent who has
physical custody of the child maybe able to give informed consent for emergency
care (Veilleux, 1989). For example, if a child is
visiting the parent who does not have legal custody, the one who is physically
present with the child may be able to consent for emergency care. If parents
have joint legal custody and disagree on whether or not a child needs medical
care, it may be necessary to obtain a court order before providing care.
Refusal of Medical Care by Parent or Child
What are the rights of the child when a parent refuses
health care that could benefit the child? In most situations, a parent will
seek appropriate medical care for an ill child. However, there are cases in
which an individual refuses to give consent for potentially lifesaving medical
care when it conflicts with her
or his religious beliefs. If a parent refuses to act in the best interests of
the child, the state may step in and make legal decisions for the child. Under
the theory of parens patrie,
the state has an overriding interest in the health and welfare of a child. Parens patrie is a
legal rule that allows the state
to make decisions in place of parents when they are unable or unwilling to provide for the
best interests of the child.
In certain situations, adolescents have been able to
refuse medical care without notifying or obtaining consent from their parents.
Using the mature minor doctrine, some courts have allowed older adolescents to
refuse lifesaving medical treatment or to refuse medical care that prolongs a
terminal illness (Wadlington, 1994).
Some states use child abuse statutes that make medical
neglect a form of abuse as legal justification to take custody of a child who
needs medical care. While many of these abuse statutes include an exemption for
religious practices, the court will still take custody of an endangered child.
The religious exemption clause only prevents the parents from being prosecuted
for medical neglect. However, religious exemptions do not protect parents when
medical neglect has resulted in the death of a child (Wadlington,
1994). The ability of the state to take legal custody or guardianship of a
child is usually limited to circumstances in which the life of a child is
endangered.
OBTAINING INFORMED CONSENT UNDER SPECIAL ClRCUMSTANCES
Advances in medical and nursing science create both
new opportunities and new legal conflicts. Often the legal implications of new
technologies are not anticipated until a conflict occurs. Legislation is often
created after a problem is given a legal interpretation by the courts.
Consent for Donation of Tissue or
Organs
The improved availability of transplant technology has
increased the demand for suitable donors of tissue and organs. An organ or
tissue from a living child may
be the only hope of survival for a terminally ill sibling or other family
member. When a child is too young to give informed consent for organ or tissue
donation, the parent or legal guardian may consent for the child. Usually, a
court hearing will be required to establish whether the individual providing
consent is acting in the best interests of the child who is donating the tissue
or organ. In the case of Curran v. Bosze (1990),
the Supreme Court of Illinois decided that for a minor child to donate tissue,
three requirements must be met. First, the parent who is consenting must be
aware of the risks and benefits. Second, the child's primary caregiver must be
able to provide emotional support for the child. Third, there must be a close relationship
between the donor and the recipient (Dufault, 1991).
It is important to realize that other state courts may require different
standards to be met before allowing a minor to participate in tissue or organ
donation.
Consent for Genetic Testing
Another dilemma created by new technology is genetic
testing of children. While a parent or guardian can consent to genetic testing
for the child, as in the case of all diagnostic tests, the benefits and the
risks should be discussed with the child when appropriate. Since most genetic
testing requires only a blood sample, there is usually no physical risk to the
child. At the same time, there can be psychological risks to the child that
include decreased sense of self-worth, anxiety, and disruption of family bonds
(Lessick & Faux, 1998).
Overall, the best interests of the child should be
evaluated before any genetic testing is ordered. A health care facility that
offers genetic testing should be able to provide appropriate counseling both
before testing and after results are received. The facility should also
establish policies for advocating for the best interests of the child. When possible, informed consent should be
obtained from both the parent and the child. Finally, there needs to be a
process by which a mature adolescent can receive test results without the
con-sent or notification of the parent (Lessick
& Faux, 1998).
Children and Medical
Experimentation
Medical research is an important part of improving
health care. Since there are many diseases
and physical conditions that have an impact on the lives of children, there is
often a need for them to participate in research studies. Many researchers
believe that children should not be used as research subjects unless there is a
benefit to the child participating in the study or to children in general
(Rowell & Zlotkin, 1997). All research facilities
that receive federal funds must comply with federal regulations that require
review of all experimental protocols by an Institutional Review Board (IRB)
(Code of Federal Regulations, 1983). An IRB is a group of professionals that
reviews research proposals for an institution to make sure that the research
does not cause undue harm to subjects. The IRB also makes sure that all state
and federal regulations are followed by researchers at the institution. Federal
regulations require the consent of one or both parents and the assent of the
child, depending on the amount of the potential risk and benefit associated
with the treatment or procedure (Glantz, 1998). As
client advocates, nurses who are involved in pediatric experimental protocols
should make sure that all efforts are made to acquire appropriate consent and
assent from study participants. Further discussion of children and medical
experimentation can be found in the ethical section of this chapter.
CONFIDENTIALITY
The right to confidential health care is protected by
the U.S. Constitution, federal and state laws, and the ethical codes of health
care professionals. Confidentiality is an essential part of the relationship
between client and health care provider. If clients do not feel secure about
divulging their medical information to a provider, their care becomes
restricted. Most nurse practice acts define a nurses duty of confidentiality.
If a nurse breaches confidentiality, she or he can be held sible
for any damages that result. The nurse may also be disciplined by both the
employer and the state board of nursing.
When a Minor Can Receive
Confidential Care
As stated earlier, some states allow children to
access confidential care for contraception, treatment of sexually transmitted
diseases, drug and alcohol treatment, and mental health care. Some states also
provide access to confidential human immunodeficiency virus (HIV) testing. It
is important for nurses to be familiar with the laws and regulations
concerning confidentiality in the state where they practice.
When a Health Care Provider Can
Breach Confidentiality
There are four recognized exceptions when a provider
can breach client confidentiality. The first is mandatory reporting laws for
child abuse. All 50 states have these laws. If a health care provider fails to report suspected abuse, the individual
may be liable for criminal charges. Most mandatory reporting laws carry the
possibility of both fines and a term of imprisonment for failure to make a
report. If a child receives additional injuries after the health care provider
should have reported suspected abuse, the provider may be liable for civil
damages to compensate the child.
The second exception is mandatory injury reporting
laws that apply to all clients who are injured by a weapon or criminal act. If
a client is given care for a gunshot or stab wound, the provider may be
required to breach confidentiality and report that information to law
enforcement.
A provider may also be required to follow public
health laws that require reporting infectious diseases to the local health
department. Many states require providers to report cases of tuberculosis, HIV,
hepatitis, and sexually transmitted diseases. Some states also require
reporting of poisonings by pesticides or other agricultural products.
Finally, providers may be required to breach confidentiality
when there is a duty to warn third parties. In the case of Tarosoff
v. The Regents of the
There is new case law that may extend the duty to warn
to persons who may have a genetically inherited disease risk.
In the case of Safer v. Estate of Pack (1996),
a physician failed to warn the child of a client that she could have a higher
risk of colon cancer and should receive early and frequent screening. When
colon cancer developed in the daughter, the physician was sued for failure to
warn.
Role of Nurses in Maintaining
Confidentiality
Nurses play an important role in maintaining client
confidentiality. They are legally and ethically responsible for keeping
medical records and other types of client communications confidential. They
need to be especially cautious about giving client information over the phone
or releasing information to the news media. Prior to releasing any confidential
health information, the nurse should always receive written permission from the
client.
Nurses also need to be aware of the need to keep electronic
medical records confidential and secure. Proper use of passwords and screen
savers can prevent unauthorized access to computerized medical records. As more
medical records and client interactions are transmitted electronically, nurses
will need to develop strategies for maintaining privacy in this rapidly
changing area of health care.
MALPRACTICE IN THE PEDIATRIC SETTING
Anyone who works in the field of health care is
constantly faced with the issue of negligence or malpractice. Negligence is
defined as an occasion when a person owes a duty to another and, through
failure to fulfill that duty, causes harm. Malpractice is professional
negligence. It is important to understand that a bad outcome for a client in
the hospital or clinic setting is not automatically malpractice. Even when a
nurse or physician makes a mistake while providing care to client, a
malpractice lawsuit may not be a possibility. For a court to recognize a claim
of malpractice or negligence, four legal elements must be present.
1.
There
must be a duty owed to the client by the nurse.
2.
The
nurse must breach that duty.
3.
The
breach of duty must be the cause of the damage.
4.
There
must be actual damage to the client.
When a claim of malpractice is made, the person making
the claim (client) is the plaintiff. The nurse who is being accused of causing
the injury is the defendant. Using the example of a medication error, let us
look at the four elements required to prove a case of malpractice.
Duty
Duty is
the special relationship created when a person agrees to provide care to a
client. The amount of time the duty is owed to the client will depend on the
setting in which the care is given. When a nurse accepts an assignment of
clients at the beginning of the morning shift, under the laws of negligence,
the nurse is considered to have a legal duty to provide care for those clients.
After the shift is completed and the evening shift nurse accepts the assignment
of those clients, the first nurse is relieved of his or her duty to them. If
the evening shift nurse gives a child gentamicin
instead of the ampicillin that was ordered and the
child suffers an anaphylactic reaction, the duty of the morning nurse is not
extended to the actions of the evening nurse. The nurse from the morning shift
will not be held responsible for this medication error because that individual
no longer owed a duty of providing the child with medication after the shift
was completed.
Breach of Duty
When a nurse fails to meet the standard of care, he or
she has breached the duty to the client. In medical administration the
standard of care is the right client, the right medication, the right dosage,
the right time, by the right route. By giving the wrong medication in the
example above, the nurse breached the standard of care. Most malpractice cases
require testimony from a nurse who is familiar with the particular area of
nursing in question to determine whether the standard of care was breached. In
other words, a labor and delivery nurse would not be able to testify about the
standard of care for a pediatric client unless the individual could show prior
experience in that area of nursing. Both the plaintiff and the defendant may
each have a nurse testify about what is considered to be the standard of care.
Causation
The injury to the client must be the result of the
breach of the standard of care. If the child actually died because of
respiratory failure that was unrelated to the medication error, malpractice did
not occur. Causation is sometimes a difficult element to prove in a malpractice
case. It may be impossible to determine whether the injury was the result of
care given or if the client had a preexisting problem that caused the injury.
Often medical expert testimony is required to establish causation.
Damages
Unless there are damages when an error is made, there
is no malpractice. If the nurse gave the antibiotic 2 hours late but the child
had no adverse affects, the client would have no claim for malpractice. Damages
in a malpractice case may include lost wages, pain and suffering, and actual
medical expenses. When a child is injured by malpractice, the actual cost of
treating the injury is not the only money awarded. Costs will be awarded to pay
for any care that will be required in the future because of the malpractice
injury. An infant with severe brain damage will recover more money than an
80-year-old man because the cost of providing total care for the child will be
multiplied by the child's life expectancy. A child with a 40-year life
expectancy will be compensated more than an 80-year-old man with a 1-year life
expectancy.
Malpractice Prevention
Caring for pediatric clients can create situations
that increase the risk for allegations of malpractice or negligence.
Using the weight of a child to confirm a dosage can decrease edication errors, which are an area of special concern. Pediatrie medications come in several forms, including
elixir, pill, parenteral, and suspension; therefore, it is important to make sure
any medication is given by the correct route (Hamlin & Coplein, 1998). It is especially important to give accurate
amounts of intravenous solutions, since a small volume can create
significant problems in a child or infant.
Child safety is another area of concern when caring
for the pediatric client. It is important to keep side rails elevated to
prevent small children from falling out of bed. Children are also more susceptible
than adults to burns. Hot water bottles, heating pads, and heat lamps should be
avoided or used only with extreme caution. Children are considered to be a
vulnerable population; therefore, the nurse has a heightened duty of care with
pediatric clients (Hamlin & Coplein, 1998).
Medical Records
The client's chart is usually the most important
document in a malpractice case. Charting is the nurse's opportunity to document
the care given. This medical record will be the best evidence of both the chronology
of events and what actually happened during a critical event. Always chart legibly
and completely. When charting, avoid using judgmental terms—describe rather
than label behavior. An example would be to chart that the caregiver has not
performed the exercises that were prescribed by the physical therapist, rather
than saying a caregiver is not cooperating with physical therapy. Never alter
a medical record. In some states, altering a medical record is considered
unprofessional conduct and can result in a formal complaint against a nurse's
license. If you forget to chart an important
detail, date and time a late entry.
PEDIATRIC NURSES
Every nurse should read and understand the Nurse
Practice Act in the state where he or she is licensed to practice nursing. This
act describes the scope of nursing practice and defines both illegal and
unprofessional conduct for nurses. The state board of nursing is an excellent
resource for assisting nurses with the resolution of legal issues. The board of
nursing can provide valuable guidance if there is a particular legal concern
involving nursing practice in the state.
Nurses also need to be aware of other state laws that
affect nursing practice. Does your state have a Good Samaritan Act that
protects a nurse from liability when care is rendered voluntarily at the scene
of the accident? Nurses also need to know their duty under the mandatory reporting laws of the state. All states require
reporting child abuse. Your state may also require reporting of other types of
abuse or injuries, including gunshot or stab wounds.
Find out if your hospital or health care facility
employs a risk manager. In many health care facilities, the risk manager is a
nurse with specialized training or a nurse who is also an attorney. The risk
manager is responsible for making sure the facility conforms to state and
federal laws. A risk manager should also review policies and procedures, which
affect both client care and the legal rights of clients. Your facility should
have policies and procedures dealing with informed consent, confidentiality,
refusal of care, and other important legal issues (Figure 2-2).
If you work at a large health care institution, your
hospital may have an ethics committee. The role of this committee is to
provide a team of both professionals and laypersons to discuss and provide guidance when an
ethical conflict arises. The ethics committee may also facilitate communication
between clients and health care providers when there is an ethical conflict. As
with other aspects of health care, nurses should update their knowledge of
legal issues on a regular basis. The law is constantly changing, and in order
to provide appropriate care, a nurse must keep up with the changes that affect
both nursing practice and the rights of clients.
Figure 2-2 Legal Resources
CONCEPTS OF ETHICS
Pediatric nursing practice today occurs in a multitude
of settings, including acute care facilities and community-based agencies.
Nurses are most often the primary care providers whatever the setting and are,
therefore, the first health care group to become aware of an ethical issue. In
addition to understanding the legal parameters of safe practice, the professional
nurse must ground her or his daily activities in a solid ethical foundation. It
is important, then, for the nurse to understand basic terms relevant to ethics.
Ethics is the study of the nature and justification of principles that
guide human behaviors and that are applied when moral problems arise. It is the
study of the Tightness of conduct. As children develop, they learn and
internalize standards of right and wrong. Religion, culture, and society all
influence the formation of morals (principles of right or wrong in
behavior).
Morality is
behavior in accordance with custom or tradition that usually reflects personal
or religious beliefs. An example of a moral belief is a persons desire to
maintain her or his right to die. Values are the constructs used to give
meaning to our lives. These are also influenced greatly by the religion,
family, and society into
which one is socialized. Values are motivational preferences. When one assesses
what is beautiful, it is considered an aesthetic value. Monetary preferences
reflect economic values. Judgments on what is good or bad, right or wrong
reflect our moral values (Omery, 1995). It is
important for nurses to assess their own values and prioritize them. A student
nurse in a pediatric clinical rotation might feel that the priority value for
the mother of a 4-year-old boy recovering from a vehicular accident is to be
at her child's bedside rather than to continue to work and see the child for a
limited time in the evening. He calls out for his mother continuously.
The student in this situation has given
"family" a higher priority than economic considerations and is
conveying her value judgment to the parent. Education in the nursing profession
and the effects of role modeling by significant others in our lives are also
key factors in the acquisition of values. Most of us, consciously or
unconsciously, make small daily decisions, as well as more monumental ones,
based on our values. The employment setting sought by new nurses entering the field reflects a value in
the sense that the setting is one that the individual prizes and chooses above
others.
Values and ethics have an obvious relationship, and
the intermingling of the two can complicate the nurse's role in an increasingly
complex health care system. Today's health care practitioners are faced with a
vast array of situations for which they have no past experience or tradition on
which to base a moral judgment or ethical choice. Moral values are evaluated in
terms of positive or negative effects. If the choice between good or bad
results is very clear, no confusion or ethical dilemma will ensue. If,
however, the good and bad effects are blended or the choice is between two
evils, the moral choices for the nurse and the health care team become more
difficult.
High-tech care of an infant born prematurely seems to
be an obviously good choice in that it saves the infant's life. The converse
side of that situation requires evaluation of the possible long-term negative
consequences to the infant and family, such as the development of cerebral
palsy. This result, with the accompanying lifelong disability, medical, social,
and emotional consequences, may become a burden to the family unit (Merenstein & Gardner, 1993).
Knowledge of the major ethical theories and principles
are of benefit to the nurse because they can be used to develop a theoretical
framework for nursing practice. The following section will present ethical
theories and principles relevant to contemporary practice.
ETHICAL THEORIES
Ways of thinking about ethical problems and issues are
represented in a variety of theoretical positions or frameworks. Each
framework has something to offer and should not be viewed as being in conflict
with the others. Normative ethics provides the standards to justify our
moral actions and choices. Ethical issues in health care generally involve
normative ethics. Descriptive ethics differs from normative in that it
"seeks to identify actual preferences or dispositions in ethical
situations as they occur" (Omery, 1995, p. viii).
Descriptive ethics looks at what is actually done in any given ethical
situation, whereas normative ethics looks at what "ought" to be done.
Most situations encountered by the nurse in practice
involve normative ethics. Four main groups of theory fall under the umbrella of
normative ethics: deontologic theory, teleologic theory, virtue theory, and care theory. These
guides are useful in providing meaning for moral experiences. They serve to
justify human actions, maybe right or wrong, and present obligations or
"ought to" statements (Bandman & Bandman, 1995).
Deontologic theory uses
principles or rules to guide the decision-making process. The Tightness or
wrongness of acts is clear-cut regardless of the consequences. Duty to others
is emphasized. This theory is regarded by some as the key theory to be used for
ethical decision making in health care (Loeb, 1992). The American Nurses
Association Code for Nurses (1985) can be classified as a document
based in deontologic theory, as it delineates rules
and standards of behavior for nurses (Ornery, 1995). This code is a guideline
for ethical conduct and delineates the nurse's obligation to clients.
Teleologic theory uses
the consequentialist approach to set criteria for justifying any moral action.
The desired outcome serves as the basis for the moral action rather than
examining what should be done. For example, rationing of health care may
deprive some vulnerable groups, such as developmentally disabled children, of
the full array of health care services, but it would serve the greater good by providing
health care to larger,
broader segments of the general population (Kjervik,
1996).
Virtue theory looks at the intent of the moral agent. Development of
traits of character such as excellence, truthfulness, gentleness, politeness,
and trustworthiness lead to appreciation of a situation and the resulting
appropriate decisions (Beauchamp, 1991). An example would be the general
public's response to nurses belonging to unions, asking for contracts, or going
on strike. It may be particularly offensive to some to think that nurses would
abandon pediatric clients to go on strike. This perspective is based on the
public's trust in nurses and its expectation that they will sublimate their
desires for a just wage to the children's needs for care.
Care theory incorporates advocacy or acting on the client's behalf
based on empathy and caring (Cameron, 1993). It tends to use the individual's
needs or concerns as the framework for ethical decision making and essentially
rejects objective-based rules or criteria for these decisions. An example of
care theory is when a nurse practitioner employed in a school setting advocates
for a teenage victim of sexual abuse to obtain counseling and
protection.
Frequently, the terms ethics and bioethics are
used interchangeably, but there is a distinction in meaning. Bioethics refers
to "the application of moral reasoning to the life sciences, medicine,
nursing, and health care" (Rachels & Callahan,
1995). Nurses are faced with a vast array of bioethical issues, including
allocation of health care resources, prolongation of life, euthanasia, genetic
engineering, abortion, and research involving fetal life. It is important to
remember that the personal perspectives of the nurse and other health care
professionals also enter into moral judgments because they all have biases that
color the way they view any given ethical situation (Devettere,
1995).
ETHICAL PRINCIPLES
Knowledge of the following key ethical principles can
assist the nurse when confronted with dilemmas of ethics: autonomy, justice,
beneficence, nonmaleficence, veracity, and fidelity.
