NURS 368: Adolescent Pregnancy + The Childbearing and Child-Rearing Family + Midwives

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What is Family-Centered Care

An innovative approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals

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How is family structure changing in U.S

•Families headed by married couples are declining.
•Single-parent families are increasing.
•Changing roles within the family

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What are the Types of Families

Traditional/nuclear families
•Single-income
•Dual-income
oTwo-income families are most common.
•View parenting as the major priority

Nontraditional Families
•Single-parent
•Blended
•Adoptive
•Multigenerational (extended)
•LGBTQ+ Parents
• Communal

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What are Characteristics of Healthy Families

•Communicate openly
•Flexible in their roles
•Agree on principles of parenting
•Adaptable to life changes
•Volunteer Assistance Without Asking
•Spend time together
•Seek appropriate resources
•Transmit cultural values

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What are considered High-Risk Families

•Marital conflict and divorce
•Adolescent parenting
•Violence
•Substance abuse
•Child with special needs

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What are coping strategies

•Assist families to identify strengths and resources
•Internal strategies
•External strategies

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What is Culture?

The sum of the beliefs and values transmitted from generation to generation

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What is Ethnocentrism

Belief that one's cultural values are superior to those of other groups

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What are the Layers of Culture

Top: behaviors

Bellow: history, values, beliefs, and religion

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What are the Implications of Cultural Diversity for Nurses

Providing effective care
•Culture influences parenthood, health, illness, and aging
•Dissonance in beliefs and practices among generations
•Many health care workers have limited knowledge about other cultures

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What are things we are assessing in culture assessment?

•Ethnic affiliation
•Values, practices, customs, and beliefs
•Language barriers
•Child-rearing practices
•Religious and spiritual beliefs
•Nutrition and food patterns
•Ethnic health care practices

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Nursing Process and the Family

•Family assessment
§Affective function
§Socialization function
§Reproductive function
§Economic function
§Health care function
•Nursing diagnosis and planning
•Intervention and evaluation

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What is the incidence of Adolescent Pregnancy

•Lowest rate ever recorded
•Nearly double for African-American and Hispanic teens

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What is sex education

•Helps the teen determine his or her core values
•STDs

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What are the socioeconomic implications of Adolescent Pregnancy

•$9 to $10 billion per year
Developmental tasks of of adolescence are interrupted

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What are the options when adolescent pregnancy occurs

•Terminate the pregnancy.
•Place the infant for adoption.
•Keep the infant.

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•Implications for maternal health: adolescent pregnancy

•Increased risk for anemia, dystocia, preeclampsia, and preterm birth

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•The teenage expectant father

•Most teen fathers are not ready for parenthood.

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The impact adolescent pregnancy has on parenting

•At risk of being a non-nurturing parent

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Nursing care of the pregnant teenager

•Physical Assessment
§Iron deficiency
§Pre-eclampsia
§STI's

•Cognitive Development
§Egocentrism
§Present-future orientation
§Abstract thinking

•Behavioral Assessment
§Poor nutrition
§Smoking
§Alcohol
§Drug use
§Unprotected sex
§Screen for physical or sexual abuse

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•According to the World Health Organization (WHO) and expert professional organizations, childbirth is:

•Spontaneous in onset and progression
• Powered by the innate human capacity of the woman and fetus
• Normal physiologic phenomenon for the vast majority of women

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Integrating Midwifery Led Care

Research by Vedam and colleagues suggests that integrating midwives into pregnancy and birth care leads to:
• Access to a full range of birth settings
• Higher rates of physiologic birth, breastfeeding and vaginal births after cesarean
• Decreased rates of obstetrical interventions
• Fewer neonatal harms such as preterm birth, low birth weight, and neonatal death. (Vedam et al., 2018)

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Evidence & Shared Decision Making: Midwives

•Interventions should be based on the best available clinical evidence
• Shared decision making between the provider and patient should be used throughout labor to support the physiological and emotional needs of the laboring person

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The art and science of midwifery are characterized by :

§Recognition, promotion, and advocacy of menarche, pregnancy, birth, and menopause as normal physiologic and developmental processes
§Advocacy of non-intervention in physiologic processes in the absence of complicationsIncorporation of evidence-based care into clinical practice
§Promotion of person-centered care for all, which respects and is inclusive of diverse histories, backgrounds, and identities
§Empowerment of women and persons seeking midwifery care as partners in health care
§Facilitation of healthy family and interpersonal relationships
§Promotion of continuity of care
§Utilization of health promotion, disease prevention, and health education

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,Other then Afghanitan and Sudan, who has the a rising maternal mortality rate

USA

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Who has the highest maternal mortality rate of any high resource country in the world

USA

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Arizona Maternal Mortality

•Overall maternal mortality rate is 25.1 deaths per 100,000 live births.
•The rate for Hispanic and Latina women is 22.4/100,000
•Black, Asian and Pacific Islander women have a combined rate of 44/100,000
•Native American and indigenous women 70.8./100,000
•White non-Hispanic women, 17.4/100,000

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Women's Health: A Final Comment

•Social determinants of health are central to the work of nurses: our health is shaped by the environment we live in
•Race and ethnicity shapes health: differing outcomes means we must keep looking for better ways to be healthy and achieve health equality as a nation.
•Violence against women: with intimate partner violence being the leading cause of injury to women in the United States, screen everyone and have resources available to respond.
•The health of women and female-bodied people is the best indicator of the health of the nation.

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What is Ethics?

· The systematic study of right and wrong, good and bad. And an active process used to make theory-based, logical, and thoughtful arguments to justify your position (instead of based on feelings or what others around you might think or believe.

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What are types of ethics?

· Descriptive
· Meta
· Normative

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What is Descriptive Ethics?

· Describes what people think about morality or describe how people actually behave

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What is Meta-Ethics?

· The study of the language of ethics and morality, including defining and describing the concepts, principles, and theories

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What is normative ethics?

· Tries to answer the question - What is right? What is wrong? What is good? What is bad? Is prescriptive...
· "Should", "should not," "ought," "obligation," "duty to..."

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What exactly is a "norm"?

· Standards, morals, principles, values, "rules that define acceptable and appropriate actions in a society or group"

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What are Morals also considered?

· standards/principles/norms/values/ethics

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Where do we see normative ethics?

· EVERYWHERE
· Bioethical issues/dilemmas - societal and at an individual level
· Professional/workplace issues/dilemmas
· Personal ethics (moral character) versus professional ethics
· Societal issues
· Business ethics - insider trading, conflict of interest, discrimination
· Social media and freedoms of speech
· Legal decisions (rules and laws) intersect as a society decides what it will and will not allow

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What are most of are decisions defined by?

· Morals

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How are normative ethics used?

· Ethical decision-making tools (models, theories, approaches, frameworks). Typically determined after much discussion and debate. Used on an individual basis as well.

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What is required for something to be a dilemma?

· 2 justifiable sides
· Something cannot have 1 'correct' answer for it to be a dilemma

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What are Moral Actions?

· Norms or duties defining right actions

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What are examples of Moral Actions?

· Do not kill (murder)
· Do not cause pain or suffering to others
· Prevent evil or harm from occurring
· Tell the truth
· Nurture the young and dependent
· Do not steal
· Do not punish the innocent

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What are examples of moral character traits?

· Honesty
· Integrity (wholeness of character, lacking duplicity)
· Fairness
· Beneficence (a "heart" for good) & Nonmaleficence (do no harm)
· Trustworthiness
· Fidelity (keep promises)
· Veracity (tell the truth)
· Kindness

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What is common moral principles?

· Set of norms, set by all people committed to morality, applicable to all person in all places, and we rightfully judge human conduct by these standards.

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What are types of moral principles?

· Cultural norms/Family norms
· Religious codes - Bible, Ten Commandments, Koran, etc.
· Professional codes - ANA's Code of Ethics for Nurses and Scope and Standards of Practice, AMAs Medical Code of Ethics.
· Organizations (i.e. hospitals) have own codes of conduct or ethics

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Norms from ANA's Code of Ethics for Nurses

· Care / Compassion
· Advocacy
· Courage
· Respect
· Collaboration
· Confidentiality
· Privacy
· Competency
· Wholeness of character
· Integration of personal and professional identities (free of duplicity)
· Sound ethical decision making
· Continual professional growth
· Critical self-reflection

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What is an Ethical/Moral Dilemma?*

· A decision where both sides are equal in some sense and you need to chose
· The ethics of right verses right OR the ethics of wring verses wrong

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What are types of Ethical Dilemmas?

· Covid-19
§ Mask mandates
§ Vaccination mandates
§ Other public restrictions
· Abortion - women's rights versus restrictions r/t fetal rights
· Genetics - gene editing, sex-selection, etc
· Legalization of marijuana

· Central issues in society at large (in forming laws, rules, codes, and policies)

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What is Deontological?

· Right or wrong based on duty/obligation
· Does not look at consequences of action
· Individual has clear direction in how to act in all situations

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What is Teleological?

· Humanistic origins
· Outcome focused/Ends justify the means

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What is Principlism?

· Based on the "Common" principles of autonomy, beneficence, non-maleficence, and justice

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What is Utilitarianism/Consequentialism?

· What is best for the most people
· Main emphasis is on the outcome/consequences

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What is Feminist Ethics/Ethics of Care?

· Requires context of the situation
· Takes into account variances in culture/societal norms
· What is right for 1 group may not be right for another

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What is situational [Theories of Ethical Thinking]?

· Each situation creates own rules and principles
· Emphasizes the uniqueness of the situation and respect for person in that situation

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What is casuistry?

· Case-based reasoning
· Does not focus on rules or theories, but practical decision making
· May be combined with other models/theories

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What is Ethical Principlism?

· Prima facie - "on the face of things"
§ On the surface levels, the principles should be follow
· Based on the common moral principles

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Bioethical Theories/Frameworks Used: [2]

· Four Principle Approach
· Four Topics Method

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Central Ethical Dilemmas (in society at large)

· PAD/PAS
· Euthanasia
· Abortion
· Parental rights to make decisions for their minors
· Legalization of Marijuana
· Genetics

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Individual Patient Related

· Should the patient be taken off the ventilator?
· Is it right for this patient to have an abortion?
· Should this teenager be allowed to make his own decisions?
· Should this patient with no health insurance be provided with an organ transplant?

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What are the Four Topics Method steps?

1. Gather the facts
2. Define the central ethical dilemma using the four-principle approach
· Principle(s) involved on both sides of the debate are identified and analyzed. Then the analyzer determines which principle(s) should rank as of higher or lesser value/importance.
3. Explore the specifics for the clinical case - medical indications, patient preferences, QOL considerations, contextual consideration
4. Discuss and come to resolution/recommendations

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What are the Four Principle "Clusters"?

· Respect for Autonomy
· Beneficence
· Nonmaleficence
· Justice

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What is Respect for Autonomy?

· Refers to the freedom one should have to make their own decisions regarding treatment options
· Patient's autonomy should be respected as long as in doing so it does not pose a greater harm to others
· May be suspended if a client is incapable of self-rule such as infants and suicidal clients
· Autonomy does not obligate providers to provide futile or pointless treatments
· Professional autonomy
§ Informed Consent
§ Privacy and Confidentiality

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What is Beneficence?

· Preventing or removing harm, promoting good; "doing good"
· Advocacy - nurse is obligated to be the pt's voice when needed
· Nurses are obligated to implement actions that benefit the patient while not ignoring his wishes
· Beneficense is usually overridden by respect for autonomy
§ Compassion
§ Fidelity
§ Veracity

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What is Nonmaleficence?*

· Duty to "Do no Harm" or to prevent harm
· Obligation to not cause intentional harm
· Values
§ Avoiding Futile or pointless treatments
§ Rule of double effect

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What is Justice?

· Often referred to as an obligation to treat all people fairly, and for appropriate and equitable distribution of benefits (resources) and burdens.

· Cost versus benefits issues
· Providing "ordinary" versus "extraordinary" care
· Rationing of healthcare - fair allocation of limited resources
· Values
§ Fairness
§ Equitable distribution of benefits and burdens

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What is Professional autonomy?

· HCP is not obligated to violate their own values

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What are the Derivative Principles of Autonomy?

· Privacy and Confidentiality
· Advocacy - nurse must make sure pt knows enough to make informed decision
· Informed Consent - Consists of the patient:
§ Understanding the nature of the procedure
§ Understanding alternatives to the intervention
§ Understanding the risks, benefits, and uncertainties
§ Being alert and cognitively able to understand
§ Understanding he has the right to accept, decline, or terminate an intervention or procedure
§ Accepting the procedure

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What are the Derivative Principles of Beneficence?

§ Compassion - Duty to care
§ Fidelity - Obligation to be faithful to agreements and promises, loyal to patients. Promise keeper.
§ Veracity - Honesty or truthfulness
§ Altruism - Deeds of mercy, kindness, charity

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Derivative Principle of both Beneficence and Autonomy

§ Paternalism - Healthcare professional's exercise of unilateral authority over a patient to make decisions, usually out of a perceived obligation of beneficence
§ "I know you need to get out of bed and I am going to be a little pushing to get you to get up, regardless of what you want, because this is best for you in the long run"

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Other Principles Related to Nonmaleficence:

§ Due Diligence - Care that a reasonable person exercises in a given situation to ensure that he/she does not harm another person.
§ Rule of Double Effect - Causing harm for a greater good
§ Futile or Pointless Treatments [Weighing risks, cost, versus benefit]
§ "Slippery Slope" arguments

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Derivative Principles of Justice:

· Respect for others - Principle that all persons are of equal value and importance
· Equality, impartiality
· "Veil of ignorance" - to help make justice-based decisions without bias

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Who is responsible for making ethical decisions?

· No one profession/discipline is responsible for ethical decisions

· Medical/Healthcare providers and experts [Hospital ethic's committees]
· Public health experts
· Government decision-makers
· Bioethicists

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What do ethics committees do?

· Write guidelines and policies for organization
· Provide education, counseling, and support on ethical issues
· Provide guidance to a competent client, an incompetent client's family, or health care providers when ethical issues arise.
· Ensure that relevant facts of a case are brought out
· Forum in which diverse views can be expressed
· Provide support for caregivers
· Can reduce the institution's legal risks

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What are the steps to analyzing a Central Ethical Dilemma?

1. What is your ethical question?
· Is it ethical to mandate vaccines for school aged children?
· Is abortion ethical?
· Should physician assisted suicide (PAS) be legal?
2. Who is on each side of the debate? - Individual, an advocacy group, groups within society at large...
3. How might each side argue their case?
· There will be compelling arguments on each side! (otherwise there would not be much of a debate) - like in a courtroom
4. What ethical principle(s) is represented in each argument?
5. Which argument do you think is most compelling or "right"?

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Strategies to Enhance Ethical Decisions and Practice

· Be aware of your own values and the ethical aspects of nursing
· Encourage patients' expressions of desires
· Identify others who impact and are impacted
· Review medical literature
· Be familiar with nursing code of ethics
· Discuss and share

· Respect the values, opinions, responsibilities of other health care professionals
· Strive for collaborative practice
· Participate in ethics rounds
· Serve on ethics committees
· Evaluate decisions

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Nurse role in ethics?

· Develop sensitivity to the ethical dimensions and principles of healthcare practice
· Begin to look at ethical issues in a systematic and logical manner: Learn to analyze, articulate, and argue both sides of the issue
· Examine your own norms/values and those of your patient
· Understand how norms/values influence patients decisions