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Introduction of TOPIC
Sensitive, caring and skilled nursing care for women experiencing miscarriage plays a crucial role in their long-term emotional recovery. For some women, miscarriage is a traumatic life event and may even be regarded as the most painful form of bereavement. However, miscarriage is often not viewed by society as a bereavement. The emotional effects are often overlooked by researchers and healthcare providers, who focus primarily on the physical aspects of miscarriage. Nurses who work in gynaecology and early pregnancy units should endeavour to provide sensitive and supportive care while managing their own emotions. Some nurses may cope well with care in these specialised units, while others may become emotionally overwhelmed. The stressful nature of providing care for women experiencing miscarriage should therefore be validated and recognised by those in nursing management and education.
Rachel Evans Staff nurse, intensive therapy unit, Morriston Hospital, Swansea. Correspondence to: [email protected]
Bereavement, emotional care, grief, miscarriage, women’s health
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Miscarriage occurs in around 10-20% of clinical pregnancies and accounts for 50,000 inpatient admissions to hospitals in the uK annually (royal college of obstetricians and gynaecologists (rcog) 2006). Miscarriage is defined as ‘the unintended end of a pregnancy before a fetus can survive outside of the mother, which is recognised as being before the 20th week of gestation’ (rcog 2006). Physical recovery from miscarriage is usually uncomplicated and uneventful, and nursing staff may regard it as a relatively minor and commonplace complication (adolfsson et al 2004, Murphy and Merrell 2009). However, the emotional effect of miscarriage is often extremely distressing, and may include depression and feelings of guilt for women and their families (rcog 2006, Brier 2008, Bacidore et al 2009).
The relationship between the attitudes of nursing staff and the successful physical and emotional recovery of women whose pregnancy has failed is well documented (corbett-owen and Kruger 2001, adolfsson et al 2004, chan and arthur 2009, Murphy and Philpin 2010). The intense feelings of grief some women experience may also affect those caring for them. nurses may find themselves simultaneously providing physical and emotional care for the woman, while having to deal with their own emotional responses to the situation (McQueen 1997, Bolton 2000, Mccreight 2005, roehrs et al 2008, Watts 2009). This article explores the emotional experience of miscarriage in the hospital setting, from the perspective of the patient and nurse. a literature review was conducted indentifying two recurring themes: the nurse’s role in the emotional care of women during miscarriage and the emotional effects experienced by nurses june 20 :: vol 26 no 42 :: 2012 35
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Art & science literature review providing care. in line with clinical governance, and based on the theories discussed in the articles reviewed, evidence-based practice will be used to inform recommendations for further research, education and training in this area of practice. implementation of these recommendations may then lead to changes in the way miscarriage is managed on gynaecology wards, to ensure patients receive sensitive care.
Nurses’ role in caring for women after miscarriage increasing research into the care of women experiencing miscarriage has highlighted the importance of the nurses’ role (chan et al 2008). Miscarriage may be a traumatic life event for some women, requiring sensitive management from nursing staff.
Miscarriage may be regarded as the most painful form of bereavement for women, because it is often unexpected and almost always unexplained, and may never be forgotten (adolfsson et al 2004, chan et al 2005, st John et al 2006, schott et al 2007, Bacidore et al 2009). society may not view miscarriage as a bereavement, and it is often overlooked by researchers and healthcare providers (sands 2012). a pregnancy loss at six weeks may be as emotionally significant as a loss at 40 weeks. For many parents, a fetus is considered a person at an early stage of gestation, a fact that is sometimes overlooked by nursing staff, who may focus primarily on the physical aspects of miscarriage (Jacobs and Harvey 2000, Bryant 2008, Webster-Bain 2011).
Search methodology in May 2011, an electronic search was conducted of the cumulative index to nursing and allied Health Literature (cinaHL), PubMed, cochrane Library, British nursing index, MeDLine, MiDirs and PsycinFo databases for articles published between January 1961 and october 2011. This was undertaken using keyword searches and Boolean operators. The initial search used the keywords miscarriage, nursing, care, early pregnancy loss and spontaneous abortion. This produced a large number of articles, but to refine the search to meet the criteria, namely the emotional care of women who experience miscarriage, the additional keywords burnout, coping, empathy and detachment were included.
This resulted in a total of 44 articles, which were included in the first manual sift of the literature. abstracts of these articles were separated into headings that were considered relevant to the review. Three manual sifts of the literature were conducted, which resulted in a total of 36 articles to be critiqued: 26 from primary sources and ten from secondary sources. Most of the research studies included in the literature review are qualitative. as the purpose of qualitative research is not to produce a mass of numerical data, but rather to understand meanings and generate knowledge, the numbers of participants in some of the studies was small because the focus was on homogeneous groups.
However, this method explores the lived experience and perceptions of the nurses and patients interviewed (McQueen 1997, Bolton 2000, Mccreight 2005). The three quantitative studies focused primarily on the ‘medicalised’ aspects of miscarriage and did not explore the more complex emotional responses that women may experience. Because of their age, some of the studies included in the review may be considered historic and therefore not in line with contemporary nursing practice, however the relevance of their content justifies their inclusion. The critique guideline iMraD was implemented for reviewing these articles (university of Tampere 2012). 36 june 20 :: vol 26 no 42 :: 2012
Theoretical perspectives some women choose to miscarry in the privacy of their home, but for most women in the uK, miscarriage necessitates some form of hospital admission, usually to a gynaecology unit. Treatment may involve evacuation of retained products of conception under general anaesthesia or medical management. Prostaglandin is used to bring about uterine contractions without anaesthesia. Medical management may prove psychologically distressing, as the woman may come into contact with the fetus and has to undergo the labour process. However, rcog (2006) guidelines state that medical evacuation has economic benefits for the nHs, with a potential saving of up to £50 per case. usually the nursing management of miscarriage is a short process, and takes place on surgical units.
These clinical areas may also be dealing with additional stresses of caring for other patients undergoing major surgery and emergency admissions. This may result in the emotional and psychological needs of women being viewed as a lower priority, and nurses having little time to develop therapeutic relationships with these patients (Jacobs and Harvey 2000, chan et al 2008, Murphy and Merrell 2009). a qualitative, ethnographic study was carried out by Murphy and Merrell (2009) in a gynaecology unit in the uK. it identified the difference between how nurses would ideally like to practise and what occurs in reality. nurses who participated in the study reported understanding the emotional effect of miscarriage on women, but expressed frustration at the confines in which they could care for these patients, citing perceived time and financial constraints, colleagues’ attitudes and lack of knowledge as issues. other factors that may influence the nursing care of women experiencing miscarriage have been identified. roehrs et al (2008) conducted a study of ten nurses in a hospital birthing unit in the united states, including an online survey and further follow-up interviews.
The study described the support needs and comfort level of nurses caring for families experiencing perinatal loss. nurses found it difficult to provide perinatal bereavement care. Developing clinical expertise was identified as necessary to be comfortable enough and have the skills to care for these women and their families. initial and continuing education was identified as a means to support nurses in the emotional challenge of providing high quality perinatal bereavement care. roehrs et al (2008) also noted that nurses who received appropriate training in perinatal bereavement care and had access to peer support were more confident and felt more comfortable providing appropriate care to parents than colleagues who had not received training.
The nurses in roehrs et al’s (2008) study said they wanted to be calm and accessible, and to have the ability to answer questions openly and honestly. However, they also expressed discomfort when talking openly with women in their care, for fear of saying or doing the wrong thing. They felt that this may affect their ability to provide individualised care for patients. a correlational survey by chan et al (2005) in two gynaecological units in Hong Kong concluded that, when dealing with miscarriage, nurses perceived that communication and empathy were the most important components of nursing management. They also suggested that the attitude of nursing staff may directly influence a woman’s recovery following loss of a pregnancy.
Communication in research conducted by chan and arthur (2009) and chan et al (2008), nurse and midwife participants said that bereaved parents wanted the healthcare professionals caring for them to be well informed. This view was shared by Brier (2008) in a comprehensive review of the literature surrounding grief following miscarriage. clear policies on bereavement management should be available to assist nurses in helping parents to make plans and decisions.
in a qualitative study of 50 women who had experienced miscarriage in the hospital setting in south africa, corbett-owen and Kruger (2001) noted that women had better outcomes in terms of feelings of guilt and self-blame if they were given clear explanations of what had happened to them, and had the opportunity to discuss the implications of various options. This was especiall
y apparent when healthcare professionals emphasised that nothing could have been done to prevent the
They said that being treated like an object was disempowering and resulted in them keeping their thoughts to themselves. grieving parents should be afforded dignity and respect, and need to be given time to come to terms with what has happened to them (adolfsson et al 2004, chan and arthur 2009). The advice or support offered by nursing staff may not always be welcomed – there may be issues that parents do not wish to address in the immediate aftermath of a miscarriage (schott et al 2007). corbett-owen and Kruger (2001) discussed the need for women and their families affected by miscarriage to feel safe and in control rather than feeling obliged to share their experience openly with staff. swanson (1999) noted that patients who were offered a choice in how their miscarriage was managed experienced better psychological outcomes, including reduced emotional disturbance, anger and depression.
For some parents it may be difficult to absorb the large volume of information given to them. Written information should be available where possible, and language and cultural barriers should also be taken into consideration where appropriate (chan and arthur 2009). Questions asked by parents should be answered as accurately as possible; the honesty of nursing staff may be appreciated, even if it is painful (adolfsson et al 2004, schott et al 2007). adolfsson et al (2004) carried out interviews with women attending an emergency clinic in sweden to explore their experience of miscarriage. They considered how the nurse can support parents during the grieving process and aid subsequent emotional recovery. Debriefing following miscarriage, in which a woman’s questions are june 20 :: vol 26 no 42 :: 2012 37
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Art & science literature review answered and emotional support given, is essential. adolfsson et al (2004) also proposed that further studies are necessary to evaluate whether debriefing and empathy help women to grieve and reduce feelings of abandonment. it is important to recognise that the experience of miscarriage is not the same for all women (corbett-owen and Kruger 2001, Maker and ogden 2003, adolfsson et al 2004, schott et al 2007, Murphy and Merrell 2009). a gap in the literature on women who are not negatively affected by pregnancy loss was identified by corbett-owen and Kruger (2001). This could be attributable to societal expectations that pregnancy is a joyful experience, and that any miscarriage will always be viewed negatively. regardless of how women feel about miscarriage, most need to have their unique experiences validated by healthcare professionals (corbett-owen and Kruger 2001, adolfsson et al 2004, Brier 2008).
However, corbett-owen and Kruger (2001) pointed out that even when nursing and medical staff were perceived as listening, their responses were hindered by personal beliefs and assumptions. st John et al (2006) commented that many nurses participating in such discussions respond by staying silent. commonly held beliefs, such as ‘it is nature’s way’ and ‘there is always the next time’, trivialise loss and the grief that women feel, further increasing their feelings of isolation (Jacobs and Harvey 2000). Murphy and Merrell (2009) found that participants in their study – including women who had experienced miscarriage and healthcare professionals – agreed that not all instances of miscarriage should be interpreted as bereavement, but rather as transitional and complex life events. care for women experiencing miscarriage. Mccreight (2005) also emphasised that the ward sister should be a role model and source of training for other nurses. increased education and mentorship of nurses is essential to improve emotional care for women experiencing miscarriage. as this may ultimately contribute to improved psychological outcomes for the patient, education and mentorship deserve further validation and recognition by nurse managers and educators, as well as by nurses’ employers.
The work of a nurse has often been described as upsetting and stressful. Menzies (1970) stated that nurses are ‘at considerable risk of being flooded by intense and unmanageable anxiety’ because of the nature of their work. Traditionally, nurses were discouraged from displaying emotion in the professional arena and from forming caring relationships with patients, in the belief that this may afford them some degree of protection from becoming too emotionally involved (May 1991). However, nursing theorists have suggested that a one-to-one partnership with the patient is central to nursing practice (rogers 1951, Leininger 1978, Peplau 1988, Watson 1988, Benner and Wrubel 1989). This close relationship may make it difficult for nurses to manage their own emotions.
Caring and coping
caring for women who experience miscarriage can be particularly challenging for healthcare professionals. nurses should endeavour to provide sensitive and supportive care while coping with their own emotions (Mccreight 2005, chan et al 2008, roehrs et al 2008). Mccreight (2005) explored how nurses develop and construct ‘meanings’ for a pregnancy loss. The study emphasised the importance of professional engagement with patients’ emotional processes. This includes listening, empathising and spending time with them.
Providing care for women who experience miscarriage can be demanding. some nurses may become overwhelmed and emotionally exhausted, which means they are unable to provide appropriate care (roehrs et al 2008, chan and arthur 2009). McQueen (1997) emphasised the emotional component in caring relationships and the emotional work involved in caring for those in gynaecology units. nurses working in such units may come into contact with fetuses almost daily and experience feelings of loss for each one (Mccreight 2005,
Many of the studies in the literature review reflect the need for formal education in grief counselling. chan and arthur (2009) identified that nurses and midwives felt it was important to be given the opportunity to enrol on a training programme focused on bereavement care. However, the homogeneity of the sample in this study may have produced biased results because most of those included were educated to diploma level or below. roehrs et al (2008) also recognised that novice clinicians should be mentored by more experienced staff to develop their practice and guide the communication of other members of the multidisciplinary team who may come into contact with women experiencing miscarriage. Mccreight (2005) found that older, more experienced nurses provided the most appropriate 38 june 20 :: vol 26 no 42 :: 2012
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Murphy and Philpin 2010). gynaecology nurses in Bolton’s (2000) qualitative study, carried out between 1994 and 1998 in the gynaecology unit of one large nHs hospital in the north of england, emphasised the emotional complexity of nursing work. Bolton (2000) stressed the importance of understanding that nurses consider caring to be a central value of their professional work. The nurses in the study discussed experiencing grief while handling the dead fetus, and described it as one of the more stressful aspects of their work. However, they felt that their emotional involvement was an important part of their role and if they had to be ‘uninvolved’ they would consider leaving the profession. Bolton (2000) termed this nurse behaviour as ‘the gift of emotion work’ and defined it as ‘emotional labour’. it was also identified that gynaecology nurses must present the ‘detached face’ of a professional carer while still providing an appropriate level of sensitive care for their patients (Bolton 2000).
McQueen (1997) recognised that nurses shared the sadness and disappointment of their patients, but found it difficult to tell patients this. in these cases, nurses reported reverting to ‘professional’ or ‘learned’ empathy, rather than the more reflexive type of empathy described by Bolton (2000). The extent to which nurses should become involved with patients may be influenced by several factors. Dowling (2006) expressed the view that some nurses aspire to achieve intimacy in relationships with patients, but are cautious to do so because of the possible disruption to the social construct of the profession. Participants in May’s (1991) qualitative study of 22 scottish surgical nurses, reported that the most significant barriers to close nurse-patient relationships were the possibility of unequal distribution of nursing work and disruption to daily nursing tasks.
May (1991) also discussed what he perceived as the dangers of becoming too involved with patients. However, May (1991) emphasised that the extent to which the nurses interacted with patients was determined only by the nurses themselves. Participants in this study also discussed their apprehension at forming close bonds with patients, for fear of being criticised by their colleagues. These feelings of unease are reiterated in a study conducted by Dowling (2006), in which the intimacy between the nurse and patient is discussed from a sociological perspective. Dowling (2006) concluded that on the whole nurses do not welcome over-involved and intimate nurse-patient relationships, and warned that nurses who are deemed to participate in such relationships may be considered as deviating from the work patterns of their colleagues, leading to them being perceived as deviant and even threatening.
Detachment and burnout some nurses may need to withdraw and distance themselves emotionally from patients so that they are able to practise in a professional manner. This may result in nurses appearing disengaged, which means their patients feel depersonalised. several authors have explored the possible motives for this type of nursing behaviour (sheward et al 2005, glasberg et al 2007, Patrick and Lavery 2007), as well as the concept of burnout among nurses. Maslach et al (1996) defined burnout as ‘a syndrome of emotional exhaustion, depersonalisation and reduced personal accomplishment’. Burnout is considered to have negative implications for nurses and the organisations in which they work. it can contribute to increased staff sickness and have a negative influence on patients’ perception of the nursing care provided (glasberg et al 2007, Patrick and Lavery 2007).
The relationship between nurse-patient ratios and emotional exhaustion and job dissatisfaction was examined by sheward et al (2005). it was found that increasing numbers of patients in relation to nurses was associated with an increased risk of emotional exhaustion and job dissatisfaction. emotional exhaustion has been considered by many authors as a key factor in burnout and is characterised by feeling drained and depleted of emotional resources (Maslach et al 1996). Patrick and Lavery (2007) conducted a randomised survey of 574 australian nurses to assess them for burnout.
The survey found different levels of burnout among different groups of nurses, with emotional exhaustion more prevalent among newly qualified nurses than more experienced or senior staff. The study also demonstrated an association between emotional exhaustion and the age of the nurse and number of years in practice. nurses who had gained their nursing qualification at university had higher levels of emotional exhaustion and depersonalisation than colleagues whose training was hospital-based, indicating a possible imbalance between the two methods of training (Patrick and Lavery 2007). The nurses in Mccreight’s (2005) study revealed that most of their knowledge and learning surrounding miscarriage came from experienced nurses more adept at dealing with sensitive situations. Dowling (2006) found that more experienced nurses considered themselves to be as june 20 :: vol 26 no 42 :: 2012 39
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Art & science literature review caring as their junior colleagues, but did not have such intense reactions to emotive situations. nurses may use their experience as a resource to compensate for the absence of adequate training in dealing with women experiencing miscarriage. Patrick and Lavery (2007) commented that professional education cannot always provide graduate nurses with the appropriate skills to deal adequately with stresses associated with new workplace challenges. Bolton (2000) described nursing students on gynaecology placements as having to learn ‘a new set of feeling rules’ to enable them to maintain a professional demeanour and carry out the ‘dirty work’ of nursing; this was also described by Murphy and Philpin (2010). other authors have endorsed the need for increased education, enhanced communication skills and support from colleagues for nurses who may be experiencing emotional stress and other symptoms of burnout (schott et al 2007, roehrs et al 2008). chan and arthur (2009) explored factors associated with nurse and midwife attitudes to perinatal bereavement care.
They recommended education in bereavement counselling and preceptorship supervision to increase the confidence of newly qualified nurses. The nurses in their study also emphasised the need for increased training and support from colleagues in this area. although this study was carried out in a gynaecology unit in singapore, its relevence should be considered because the experience of miscarriage is similar everywhere. in an ethnographic study of nurses practising in a fertility unit, allan (2001) found that nurses associate the emotional cost of caring with exhaustion, but cannot see how clinical supervision would encourage a closer relationship with patients.
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