with parents and nurses
Résumé
Cette étude avait pour but d’approfondir l’expérience des parents aux services d’urgence lors d’une fausse couche selon la perspective des parents, des infirmières et des infirmières-gestionnaires. Une approche qualitative, descriptive et exploratoire, appuyée sur des entretiens semi-structurés auprès de 26 participants, a été utilisée. Les cadres de référence utilisés étaient le modèle logique d’approche théorique de la W.K. Kellogg Foundation (2004) et la théorie de la transition de Meleis (2015). Trois catégories de besoins ont été identifiées : physique, cognitif et émotionnel. Les parents ont rapporté plusieurs besoins non comblés ayant contribué à une insatisfaction quant aux soins reçus. Des contraintes organisationnelles ont nui à l’offre de soins de qualité optimale. Les infirmières ont un rôle important à jouer dans l’amélioration de l’expérience de soins, que ce soit en connaissant davantage les besoins des parents ou en s’engageant dans l’établissement de lignes directrices pour guider les pratiques de soins.
Abstract
Aims and objectives
This study aimed to understand how parents experienced miscarriage in an emergency department (ED) setting. Objectives were to identify parents’ needs, isolate factors that influenced their experience, and provide recommendations to improve care from the perspective of women, their partners, nurses, and nurse managers.
Background
Miscarriage is the most prevalent complication encountered during pregnancy. It subjects parents to a multitude of emotions and may have significant consequences on mental health. ED visits are frequently the only opportunity for parents to receive formal support during a miscarriage; it is thus crucial to understand the experiences of parents in this setting.
Design
The study employed a descriptive, exploratory, qualitative approach with semi- structured interviews.
Methods
The study was founded on the W.K. Kellogg Foundation’s Logic Model Development Guide (2004) and Meleis’ Transitions Theory (2015). A total of 26 participants were interviewed (17 parents, 7 ED nurses, and 2 ED nurse managers). Consolidated criteria for reporting qualitative research (COREQ) was used to report results.
Results
Three categories of needs were identified: physical health, cognitive, and emotional. For instance, parents expressed a need to receive more information during their visit to the ED (i.e. a cognitive need), whether about the diagnostic tests results or how to ensure a better recovery. Parents also reported a desire for professionals to address their emotional concerns. Nurses were aware of the emotional impact of
miscarriage but felt that they were not adequately trained in providing optimal care to parents in this situation.
Conclusions
Parents who visited the ED for miscarriage reported several unfulfilled needs that generated dissatisfaction with care. ED organizational constraints hindered optimal nursing care practices.
Relevance to clinical practice
Nurses have an important role to play in improving parents’ experience. They can do so by understanding the needs of parents and by being involved in developing new guidelines.
Keywords
Spontaneous abortion; Miscarriage; Early pregnancy loss; Bereavement; Hospital emergency service; Emergency department; Nurses; Nursing; Qualitative research
Introduction
Miscarriage, also known as “spontaneous abortion,” is defined as “the spontaneous loss of an intra-uterine pregnancy prior to 22 completed weeks of gestational age” (Zegers-Hochschild et al., 2017, p. 405), though the upper limit of the definition may vary between countries and studies (MacWilliams et al., 2016; Meaney et al., 2017). It is the most common pregnancy-related complication (Kersting & Wagner, 2012). In most cases, miscarriage does not require hospitalization and is not recorded. Though this makes any estimation of its frequency difficult, many studies and guidelines report that around 20% of recognized pregnancies end in miscarriage (Engel & Rempel, 2016; National Institute for Health and Care Excellence, 2012).
Miscarriage is a transition that may create a period of disequilibrium for parents by disrupting their expectations and their life goals (Meleis & Trangenstein, 1994; Murphy & Merrell, 2009). Experiencing a miscarriage can have a significant impact on the mental health of both women and their partners, though the latter are rarely
the focus of studies (Cholette, 2012). It is often a crisis characterised by sadness, pain, and distress and may be remembered by parents for years after the event (Murphy & Merrell, 2009). The emotional impacts of miscarriage are most often symptoms of depression, anxiety, and grief, which affect 10–50% of women (De Montigny, Verdon, Meunier, et al., 2017; Lok & Neugebauer, 2007). Families facing a miscarriage are likely to experience grief comparable to the loss of a loved one (Zavotsky et al., 2013).
In many countries, women experiencing a miscarriage and their partners go to the emergency department (ED) for treatment (MacWilliams et al., 2016; Warner et al., 2012). An ED visit is often the only opportunity parents will have to receive emotional and informational support from healthcare professionals. Yet studies have shown that parents report dissatisfaction with the ED care they received, and they are particularly disappointed by the lack of emotional support (Baird et al., 2018; Meaney et al., 2017). In this context, it is important to understand the experiences of parents who have presented to the ED for a miscarriage in order to identify their needs, determine the factors that influenced their experience, and to learn about their recommendations to improve care.
Background
Many studies have focused on women’ experiences following a miscarriage. However, a systematic search in five major electronic databases (CINAHL, Medline, PsychArticles, PsycINFO, Social work abstracts) reveals that only six studies seem to have addressed the specific experiences of parents who visit the ED during a miscarriage. These qualitative studies were carried out in Australia (Edwards et al., 2018; McLean & Flynn, 2012; Warner et al., 2012), Canada (MacWilliams et al., 2016), and the United States (Baird et al., 2018; Koziol-McLain et al., 1992). The participating women reported multiple shortcomings in the care they received. Indeed, the behaviour and attitude displayed by professionals betrayed a lack of compassion as well as a tendency to minimize, even disregard, the women’s loss (Edwards et al., 2018; MacWilliams et al., 2016; McLean & Flynn, 2012; Warner et
al., 2012). The noisy environment of the ED was harmful to the sense of dignity of the women (Baird et al., 2018; Warner et al., 2012), who also strongly criticized the lack of information provided to them on diagnostic test results, physical and emotional impacts, and available resources (Baird et al., 2018; Edwards et al., 2018; MacWilliams et al., 2016; McLean & Flynn, 2012; Warner et al., 2012). Certain participants condemned the fact that the care provided did not take their partners into account (Edwards et al., 2018), and others mentioned a long wait time, as miscarriage is considered a nonemergency (Edwards et al., 2018; McLean & Flynn, 2012; Warner et al., 2012). Finally, some women found it regrettable that no follow- up appointment was scheduled (Baird et al., 2018, Warner et al., 2012).
Although these studies shed light on women’s experiences in the ED, further studies are required to develop effective ED interventions. Firstly, there is limited information available about partners’ perceptions of care; partners were included in only one of the six studies mentioned above (Edwards et al., 2018). This is a significant limitation given that national guidelines, such as those of the Public Health Agency of Canada (2017), the United Kingdom’s National Institute for Health and Care Excellence (2012), or the United States’ National Perinatal Association (2017), usually recommend that the partner or family be involved in miscarriage care. No published study has focused on the perspectives of ED nurses or healthcare professionals on parents’ needs or the interventions to prioritize during visits to the ED for a miscarriage. It is therefore difficult to conclusively determine the main needs of women and their partners who visit the ED during a miscarriage or the interventions that should be provided to improve their experience. Understanding these needs is an essential first step in developing clinical interventions (W.K. Kellogg Foundation, 2004; Sidani & Braden, 2011).
Four studies have developed (Bacidore et al., 2009) or evaluated (Zavotsky et al., 2013; Kong et al., 2014; Johnson & Langford, 2015) ED-based nursing interventions meant to provide effective support to women experiencing miscarriage. These multifaceted interventions include a physical exam, active listening, oral (Bacidore et al., 2009) and written information (Zavotsky et al., 2013), individual counselling,
and a follow-up call one to two weeks after the visit (Kong et al., 2014, Johnson & Langford, 2015). The interventions showed promising results in three areas: greater satisfaction for healthcare professionals with the care they provided (Zavotsky et al., 2013), lower overall levels of grief for women (Johnson & Langford, 2015), and greater emotional well-being for women who had initially registered high levels of emotional distress and depressive symptoms (Kong et al., 2014). It should be noted that the development of these interventions was primarily informed by the perspectives of women who have miscarried and not by their partners’ experiences or those of healthcare professionals, which may impact the acceptability and applicability of these interventions.
As parents who have experienced a miscarriage in the ED have been the subject of very few studies, only one of which has explored the perceptions of partners, the objective of the present study was to provide deeper insight into parents’ experiences in the ED. More specifically, the objectives were to identify the needs of both parents, the factors that influence their experience, and recommendations to improve care from the perspective of women, their partners, ED nurses, and ED nurse managers.
Methods
DesignThis descriptive, exploratory, qualitative research study was conducted with parents who have presented to the ED for a miscarriage as well as ED nurses and nurse managers. A qualitative approach was chosen to gain an in-depth understanding of the experience of parents who visit the ED for miscarriage treatment. These experiences were explored with the ultimate goal of improving them as part of a future study. An exploratory descriptive methodology was chosen so that parents’ experiences could be described in the specific context of the ED, through the stories of those involved (Polit & Beck, 2004). Multi-perspective qualitative interviews, as defined by Kendall et al. (2009), were chosen; these consist of interviews with both patients and their care providers with the aim of exploring their complex,
complementary, and contradictory perspectives about experiences and needs. Multi- perspective interviews generate a richer understanding than the single perspective interviews commonly used in qualitative studies. They are especially recommended for studies that aim to improve healthcare practices. In this study, interviews with parents helped uncover high-quality information about their experiences in visiting the ED for miscarriage treatment. Interviews were conducted with the woman and her partner together, as including the perspective of the partner was a priority of this study. If the partner did not wish to participate, the interview was conducted with the woman alone. Interviews with nurses and nurse managers allowed for a better understanding of their perceptions of the experiences of parents and of the care context. Exploring nurse managers’ perceptions was important because they have a key role to play in planning, implementing, and monitoring clinical practice guidelines and interventions.
Conceptual framework
Two conceptual frameworks were used to develop the interview guides, as well as for data analysis and interpretation. First, the Kellogg Foundation’s (2004) theory approach logic model for intervention development was utilized from the outset. It was chosen as the present study is part of a larger research project, the ultimate goal of which is to develop an intervention that optimizes parents’ experience in the ED during a miscarriage. This logic model includes six steps: (a) conceptualization of the problem, (b) needs assessment, (c) desired results, (d) influential factors, (e) strategies, and (f) assumptions. This study focused on the second step of the logic model – the identification of parents’ needs. It also helped gather information about the first step, the conceptualization of the problem.
Second, Meleis’ Transitions Theory (2015) was chosen to gain a deeper understanding of the experiences of parents at the ED. This theory allowed the experience of miscarriage to be conceptualized as a transition that affects the expectations and roles of parents. Transitions Theory focuses on the person or family experiencing a transition and the context that can influence the transition. Whatever a person’s reaction to miscarriage, it will entail a transition that denotes
changes in needs (Meleis, 2012). Key concepts of Meleis’ Transitions Theory were used as a “conceptual lens” (Creswell & Poth, 2018) to understand miscarriage experience at the ED. Because the transition associated with miscarriage goes beyond the ED visit, three key concepts of Meleis’ Transitions Theory were of particular interest for this study: conditions of change, patterns of responses, and nursing therapeutics. Conditions of change are factors that influence the way a person moves through transition, and these may facilitate or hinder the transition process and influence patterns of responses. Patterns of responses are personal reactions to the change event. They include process patterns, which move the person towards either health or vulnerability, and outcome indicators, which reflect the end of the transition process. Processes of transition related to miscarriage experiences continue beyond the ED visit, and process patterns were therefore of greater interest to this study. Meleis et al. (2000) have suggested that outcome indicators should not be evaluated too early in the transition process at the risk of being associated with irrelevant information. Finally, nursing therapeutics are nursing interventions that facilitate and inspire healthy processes and outcome responses (Meleis et al., 2000, Meleis, 2015).
Setting and sample
This study was carried out in the province of New Brunswick, Canada, at the ED of the Edmundston Regional Hospital. The 169-bed hospital serves a population of about 47 800 and offers different types of acute care.
The inclusion criteria were as follows: parent participants had to be (a) adults aged 18 or older who had (b) experienced a miscarriage (≤ 20 weeks gestation) in the preceding three years and visited the ED for this reason. The period of three years was deemed suitable as miscarriage may be a traumatic event remembered several years after the loss (Gerber-Epstein et al., 2008). Participants’ stories were found to be detailed in previous studies on the topic using time frames of up to six years (MacWilliams et al., 2016; Meaney et al., 2017). The exclusion criterion for parents was to have been a nurse in this ED setting. The inclusion criteria for nurses were as follows: participants had to (a) be nurses in the ED who (b) have provided care
for parents who have experienced a miscarriage. For nurse managers, the inclusion criterion was to be an ED nurse manager.
Data collection
Purposeful sampling was used to recruit participants with maximum variation in their characteristics (Patton, 1990). Parents were invited to participate through advertisements placed on local and social media as well as in different locations frequented by adults in their twenties and thirties (shopping centers, fitness centers, hospital). Parents expressed interest in participating in the research study by contacting the first author by email or telephone. Parents were selected with an emphasis on ensuring a range of characteristics (eg. age, miscarriage history, etc). Some partners did not wish to participate in the research study. Women whose partners did not wish to participate were also included as these women could also bring rich information about their experience, and women may consult the ED alone. Potential participants had no contact with the research team prior to their participation in this study. To recruit nurses and nurse managers, the first author met with the two ED nurse managers of the hospital to explain the terms and nature of the study. One of the nurse managers in turn sent research information sheets to all ED nurses by email. Nurses were invited to contact the researcher by email or telephone to express their interest. Nurse managers were not provided any information about the names of nurses who participated in the study. As the first four nurses who agreed to participate in the study have several years of experience at the ED, the first author asked one nurse manager to resend the invitation to participate in the study to nurses with less experience. The interviews with nurse managers were conducted last to reduce any potential for coercion. All participants were provided detailed oral and written information (information sheets and consent forms) about the study from the first author shortly after they expressed interest in participating. They were also informed of the occupation of the first author and the fact that this research was part of her doctoral dissertation in nursing sciences. Considering the unique contributions of each group of informants, specific interview guides were developed for parents, nurses, and nurse managers based on the
literature review and the two conceptual frameworks. Interviews with parents focused on their experience, their needs, and the factors that influenced their experience when visiting the ED for miscarriage treatment. Interviews with nurses and nurse managers focused on their perceptions of parents’ experiences and needs when visiting the ED for miscarriage treatment and of the professional role of nurses in the situation. Each of the interview guides also focused on recommendations to improve care. Example interview questions are presented in Table 1. Each interview guide was pretested on two people who had experienced a miscarriage more than three years ago. These initial interviews were therefore not included in the final sample.
Semi-structured in-person interviews were carried out by the first author, who is female and has previous nursing experience in ED and perinatal care. She is an assistant professor in nursing and a PhD candidate (trained in nursing sciences). Interviews lasted an average of 50 minutes. They took place in a setting chosen by the participant (home, hospital, university) and were audio recorded and fully transcribed. A list of community resources, including counseling services, was provided to the parents at the end of each interview in recognition of the sensitive nature of the topic. Field notes were systematically taken during and following each interview. These notes were mostly reflective in nature; the personal reflections and interpretations of the researcher were used to enrich subsequent interviews and facilitate data analysis. Participants were continually recruited until no new elements were reported in the final two interviews conducted with parents and nurses. All interviews were conducted in French, except one (with Elena). The quotations were translated by a professional translator and revised by the authors and another independent researcher. All participants are referred to by pseudonyms throughout this article.
Data analysis
A category analysis was conducted to provide a description of parents’ needs (Loiselle et al., 2011). Transcribed interviews and field notes were re-read in their entirety several times to identify emerging ideas and potential codes. Initial codes
for the first three interviews were derived from key concepts of Meleis’s theory while remaining open to codes emerging from the corpus. The codes included information about conditions that facilitated or hindered parents’ experience (conditions of change), parents’ reactions to these conditions (patterns of responses), and participants’ recommendations regarding nursing interventions. Transcripts associated with each code were subsequently analyzed in order to establish separate categories and subcategories based on parents’ needs, as recommended by the Kellogg logic model. These needs were identified from the conditions of change that had most influenced parents’ responses. Each need category and subcategory included information about conditions that facilitated or hindered parents’ experiences, parents’ reactions to these conditions, and participants’ recommendations. A cross-analysis based on participants’ characteristics (e.g. miscarriage history, age) was performed; as it did not provide any additional insights, it is not reported here. This analysis was carried out by the principal researcher in collaboration with the two coauthors, both of whom are female; one researcher is an expert in perinatal bereavement and is a Canada Research Chair (educational background in nursing sciences) and the other researcher has expertise in patient education and counseling (educational background in education sciences).
Several validation strategies were used to ensure scientific rigor (Creswell & Poth, 2018). To optimize data accuracy, the first author conducted the interviews, validated the transcripts, compared the transcripts with the field notes, and led data analysis