|
 
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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 12
| Issue : 1 | Page : 31-37 |
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Describing the lived experiences of nurses and midwives in caring for mothers and families during a fetal loss
Rabab Bazaraah1, Howieda Fouly2, Jennifer De Beer3
1 College of Nursing, King Saud Bin Abdul-Aziz for Health Sciences, Jeddah, Saudi Arabia
2 Higher Colleges of Technology, UAE, Assuit University, Egypt
3 King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| Date of Submission | 09-Nov-2022 |
| Date of Decision | 13-Dec-2022 |
| Date of Acceptance | 21-Dec-2022 |
| Date of Web Publication | 15-Mar-2023 |
Correspondence Address:
Jennifer De Beer
King Faisal Specialist Hospital and Research Center, Jeddah
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjhs.sjhs_137_22
Background: Pregnancy is often anticipated as a positive experience for women with the expectation of having a healthy infant in the end. However, some pregnancies end in fetal loss, which can have profound effects on parents and families and is characterized by shock, anger, emptiness, helplessness, and loneliness. Aims: The study aimed to describe the lived experiences of nurses and midwives regarding care provided for mothers and families during the fetal loss at King Abdul-Aziz Medical City, Western region. Setting and Design: The study setting was the labor and delivery units at King Abdul-Aziz Medical City, Western region, Saudi Arabia. Husserl's phenomenological approach was used. Materials and Methods: Purposive sampling included 11 nurses and midwives were included. Data were collected through in-depth interviews that were audio reordered and then transcribed verbatim. Statistical Analysis: Thematic analysis using Giorgi's data analysis steps was used. Results: Two themes emerged regarding the experiences of nurses in caring for mothers and families who experience fetal loss, namely emotional turmoil with subthemes, heavy heart, feeling helpless, lack of self-control, feeling guilty, feeling extreme sadness, feeling isolation; and barriers with subthemes culture, lack of nursing care, and limited skill. Conclusion: Two major themes emerged from the study that highlighted that nurses found caring for patients and families after a fetal loss a challenging experience and, at times, were unable to manage their own emotions.
Keywords: Fetal death, fetal demise, fetal loss
How to cite this article:
Bazaraah R, Fouly H, Beer JD. Describing the lived experiences of nurses and midwives in caring for mothers and families during a fetal loss. Saudi J Health Sci 2023;12:31-7 |
How to cite this URL:
Bazaraah R, Fouly H, Beer JD. Describing the lived experiences of nurses and midwives in caring for mothers and families during a fetal loss. Saudi J Health Sci [serial online] 2023 [cited 2023 Mar 20];12:31-7. Available from: https://www.saudijhealthsci.org/text.asp?2023/12/1/31/371706 |
| Introduction | |  |
Pregnancy is often anticipated as a positive experience for women with the expectation of having a healthy infant in the end. During pregnancy, women undergo many changes that are physical, psychological, and social. Changes are also related to the self-concept of women as they take on the role of mother while also becoming emotionally attached to their unborn child.[1] However, some pregnancies end in fetal loss, which can have profound negative effects on parents and families and is characteristic by shock, anger, emptiness, helplessness, and loneliness.[2]
The loss of a pregnancy or child is a physiological, emotional, and social event that can have devastating consequences regardless of the gestational age of the fetus.[3] Early and late fetal death, including miscarriage and stillbirth, occurs in 25% of all pregnant women, with approximately 2% of pregnancies occurring in stillbirth.[4] Further, Tiruneh and Asegid[5] reported that there are an estimated 2.6 million stillbirths worldwide every year, half of which occur during labor and birth. According to the World Health Organization,[6] more than two and a half million stillbirths are reported globally, with an estimated rate of around 7178 deaths/day. Notably, most of the reported stillbirths occurred in developing countries.
Due to the nature of the relationship between the midwife and women, midwives play a significant role in providing emotional support to women and families following a fetal loss.[6] Hence, fetal loss maybe traumatic for nurses as well.[7] Sheen et al.,[8] who conducted a study on midwives in the United Kingdom following fetal death reported that one-third of (N = 429) midwives reported clinically significant levels of post-traumatic stress disorder. Despite this stress, midwives have to try to maintain professionalism.[9]
Some studies have shown that nurses may experience a variety of symptoms including, crying, sadness, sorrow, nightmares, guilt, grief, and fear.[10],[11],[12] Nurses having to deal with fetal loss may have unresolved grief issues themselves, yet they are expected to support women and families, whilst coping with their emotional response to a fetal loss.[13] Caring for women and families is challenging and requires a high level of skill, often requiring specialized training.[7] A midwives' sole purpose is to offer support, care, advice, and education to pregnant women throughout the range of pregnancy, labor, birth, and the postnatal period.[13] Moreover, much of the midwives' care for the grieving mother comprises helping her to make some sense of the incomprehensible experience. The mother may need help to recognize that she has given birth, even though she no longer has that baby. Integral to this is assisting her realization that she is a mother, which is achieved through midwifery care. The mother may start to make sense of her loss by talking about it. Although opening up may sound simple, it may present challenges for the mother.[14]
In addition some midwives may attempt to protect themselves emotionally from the effects of the perinatal loss through poor coping strategies.[15] This can lead to secondary traumatic stress, and vicarious traumatization, which are terms also used to describe the cost of caring which can often lead to compassion fatigue.[16] In a study by Fenwick et al.,[17] midwives described being emotionally overwhelmed and, as a result, tried to separate themselves from the situation emotionally. This can be seen as a self-protective mechanism for the midwife to deal with her feelings of shock and disbelief.[18] Within this backdrop, the researchers aimed to explore nurses' experiences in caring for patients and families who experience fetal loss within a Saudi Arabian context. There is a dearth of research around fetal loss within this context and, more specifically, the involvement and care of family members during a fetal loss.
| Materials and Methods | | |
This study followed a descriptive phenomenological approach and was conducted at the Ministry of National Guard Health Affairs-Jeddah, which is a 600-bedded hospital. The current study was conducted in a total of nine labor and delivery units, and the maternal fetal medicate units (MFMU) with a total of seven beds. Furthermore, there were 3161 birth deliveries in 2021 and 21 of these deliveries were fetal loss. The population included nurses and midwives working in labor and delivery and MFMU. During the study, there were six midwives and 29 nurses working in the units.
Data collection included in-depth interviews, which were conducted in the natural setting of the participants so that their views were not separated from their context within the hospital. A quiet office in the labor and delivery ward of the hospital was used for the interviews. No one had access to this office during the interviews, as a “please do not disturb” sign was hung outside the door. The venue was free from disturbances and was a place within the hospital, in which the participants felt comfortable.[19] Interviews were audio recorded with the permission of participants. The researcher started the interviews with the primary question: “Describe your experiences in caring for mothers and families during a fetal loss?” followed by probes such as: “What was facilitating in caring for them?” and “What was challenging in caring for them?”. Interviews were transcribed verbatim from the audio recorded format and were analyzed using Giorgi's approach.[20] Data collection and analysis were iterative.
Academic rigor included the principle of trustworthiness namely dependability, conformability, credibility, and transferability. Dependability was ensured by a dependability audit that involved using an expert qualitative researcher to review the tapes, transcripts, filed notes, and reflexive journals that the researchers used during this study. The researcher also employed the use of bracketing, which is characteristic of descriptive phenomenology. A conformability trail was also established by the researchers recording the research activities over time so that others can follow the research process undertaken. Member checking was also used to establish the credibility of the data.[21] This involved the researcher providing feedback about the emerging data and interpretations to participants to ensure it was a true reflection of their reactions. Transferability was ensured by the researcher providing sufficient thick descriptions by providing detailed descriptions of the research settings, participants, data collection methods, and period of data collection.
The ethical principles of anonymity, confidentiality, and freedom to participate were followed, and informed consent was obtained. The necessary ethical approval was obtained from the Research Unit at the College of Nursing, Nursing Management at the Ministry of National Guard Health Affairs-Jeddah and then finally the Institutional Review Board at the National Guard Health Affairs-Jeddah office–protocol number SP 19/268/J.
| Results | | |
[Table 1] shows sample realization.
[Table 2] shows summary of findings.
Theme 1: Enduring emotional turmoil
The first theme that emerged was that of enduring emotional turmoil. Participants described the experiences of caring for mothers and families who had experienced a fetal loss as being an emotionally charged experience, which was characterized by an array of negative emotions. Subthemes included heavy heart, feeling helpless, lacking self-control, feeling guilty, feeling extreme sadness, and feeling isolated.
Heavy heart
Caring for mothers and families during a fetal loss was expressed as a very touching experience, especially in situations where the baby was expected to be born alive, and when the baby dies, it becomes a very emotional situation
It's very painful and touching especially when you know that we… we midwives are expecting a live baby (Laura).
I felt very sad and shocked when I received the baby not active, not crying, and …I am in shock … the baby … how I can take a dead baby…really touching. You feel it in your heart… (Elizabeth).
Feeling helpless
Most participants expressed that caring for mothers and families during a fetal loss made them feel helpless. Feelings of helplessness were related to the nurse not being fully equipped to support the mother and families with such a loss.
I did not know how to deal with the mother, because I don't know what to do. I remained silent, I could only watch the mother… (Sofia).
I don't know what to do for her, I tried my best, I feel I did what I can do and I can't do more than that … based on my experience I can't do anything more than this … (Lily).
Lacking self-control
Participants verbalized that the experiences of supporting mothers and families within the context of a fetal loss most often resulted in them not being able to control and contain their own emotions. Participants expressed that the experience sometimes resulted in them crying with mothers and families
I can't control myself I am always crying with the patient…when the patient cries I also cry, it is very hard for me to control myself and not cry in front of them (Sofia).
I don't know … sometimes we do cry with the patient …we're the first person to be with the patient that's why we are crying with the patient …because you lost your baby that you're excepting. carrying this baby for nine months… it's very difficult (Laura).
The following participants further expressed that sometimes avoiding crying with the patient is impossible: I cry, I know some time is not appropriate… yeah sometimes, you know you feel that lump at the time you try to be strong but the time you see the patient crying you cry (Mary).
The following participant expressed that crying is something that cannot be avoided but she finds ways to avoid showing this emotion
I cry even the pediatrician she also cries while she knows the diagnosis… because I'm covering my face it's easy to hide and have tears, nobody can recognize but I'm trying to avoid not to talk because I'll have like crying voice. …but I am still crying (Elizabeth).
I cry I know sometime is not appropriate… yeah sometime, you know you feel that lump at time you try to be strong but the time you see the patient crying you cry (Mary).
Feeling guilty
Participants expressed that, in some instances, they felt guilty. Feelings of guilt were attributed to participants feeling that the fetal loss could be a result of the healthcare providers not doing what they should have done timely.
I felt guilty like what happen suddenly led to the death so you're wondering … for many days…what happened what could be the cause then you think maybe it's my fault... am I late in doing things… (Rose).
We asked ourselves what went wrong what was that we didn't see maybe we missed something that made the baby die… whatever (crying voice)… when you attend to the patient … it leaves you feeling as if you didn't do your… work appropriately (Laura).
I can sit and reflect on what I did…I did this and this … I wish I did this better and maybe it would have happened like this… I wish it ended successfully, this delivery, I wish she enjoyed her baby (Kate).
Feeling extreme sadness
Almost all of the participants expressed that the experiences of supporting mothers and families during a fetal loss led to feelings of extreme sadness. Feelings of sadness were linked to participants being witnesses to mothers and families anticipating a new life and an addition to the family, only to end up dealing with the death and grief around this loss.
You want to be present when there is a new gift of life …coming … in your hand but it is sad …when you have this mother that you know has a regular follow-up and everything was fine and all of sudden … you have a dead baby in your hand (Kate).
I always feel so sad … especially when the patient comes and does not know she has a dead baby …it's sad especially if the mother is unbooked and she came and she gets the news for the first time that the baby she is carrying is already dead (Mary).
Feeling isolated
Participants expressed that, most often, they felt isolated. One participant expressed that she felt as though she was left alone to deal with the emotional after-effects of a fetal loss. She further verbalized that she felt as if no one cares for nurses who are left with the emotional challenges of such a situation
The support of nurses that are not done anywhere …no one takes care of the nurses after they attend to the mother who lost her baby … the nurses are left alone every time. We're are left …we're been left alone we are the one who deals with this patient who has IUFD but the nurses are not taken care of … (Laura).
Another participant verbalized that she was left to take care of herself in dealing with this loss and get on with the preparation for the next admission.
yeah nobody takes care …nobody considers you sad … no nobody… not even the in charge… she will not listen to your feedback … sometimes no one even comes… even to your room… alone yeah we have to treat ourselves, by ourselves for the next admission.(Elizabeth).
Participants also shared that nurses are often left to deal with the emotional scars of the experiences on their own and there is no follow-up for the nurse:
No one is following up … since this happened… how the nurse is feeling if there is anything that has been done for her or what… there are no follow-ups (Laura).
The nurses are always left behind …. We deal with some many patients and then when something happens to them, we take care of the patient but no one takes care of us after this loss (Elizabeth).
Theme 2: Obstacles to caring
A second theme that emerged was obstacles to caring, which consisted of the following subthemes: culture, language, policy, and lack of nursing support.
Culture
Some participants expressed it was sometimes challenging when caring for the patient and their families, as the cultural beliefs of patients and families made it difficult for nurses to provide support. Some women and families were more inclined to rely on cultural beliefs rather than medical information
Some patients consider their culture and the traditional way …this affects the midwives, especially when dealing with equipment… it's really difficult for them to understand… why is this medical equipment helping... what is the way it is guiding us we explain the situation to the patient to understand…when you try to explain to those who come for medical care but the problem when you tell them … they do not believe you (Kate).
There is a culture barrier… we have faith and belief that baby will be alive and maybe he/she will be cured… you know… (Elizabeth).
Another obstacle in terms of culture was that most participants in this study were expatriate nurses/midwives who were not necessarily from the Arab or Saudi cultural background. One participant expressed that is easier to care if the nurse caring for the mother is from the same culture as the mother as this could enable the nurse to better understand and care for the mother than a nurse who has a cultural background different from the patient and families.
It's easier for a nurse of the same culture … to support the patient it's much easier (Carol).
Language
Another major obstacle to caring for women and families during a fetal loss was language barriers. Participants expressed that not being able to speak and understand the native language of Arabic limited the support that was provided to women and families.
The mother usually they're very upset and … if it's like with us like there's a lot of non-Arabic speaking staff, this can be a challenge to comfort the mother (Carol).
In instances where the nurse was involved in grief counseling, the counseling ability became limited, which caused the nurse to become fearful.
My experience I am scared because I am not fluent in Arabic and like with my grief counseling in Arabic is limited … (Carol).
Another participant expressed that the language barrier did not allow her the opportunity to empathize with the patient.
I have a problem with the language barrier because … you cannot comfort the patient the way you want to talk to her …our barrier with the patient is a language barrier … like I said I can't communicate verbally and … empathize with the patient normally (Laura).
Another participant expressed the inability to speak to the patient was replaced by touch: We aren't Arabic speaking so how much can we talk to the patient? The most we can do is hug her (Rose).
Lack of direction referred to participants expressing concern regarding no existing policies and guidelines within the current institution that specifically guided healthcare professionals in caring for women and families experiencing fetal loss. In addition, there were no policies and guidelines that were available for healthcare professionals themselves for caring for women and families with fetal loss.
But there is nothing … like how can I say formerly available… lack of policy… when you say this is a policy and how do you deal with fetal loss … (Carol).
There are no specific guidelines on how you talk to the mother…we don't have guidelines or policies for the management of IUFD, like how to support the mother. I don't know what we should do as nurses because there is no protocol about this … (Lily).
Lack of nursing support
This subtheme relates to a shortage of nurses. There are instances when nurses/midwives were vocal about not being able to manage a woman and family with a fetal loss; however, the nurse/midwife was left with no option but to care for the women and family as there was a shortage of staff.
There isn't a choice because of the shortage of staff I have to deal with this case…it is like if you're telling the nurse in charge that you can't do this… (Elizabeth).
The following participant expressed that the shortage of staff results in patient care being compromised, as she cannot provide quality care to the patient as there is no time to do so.
We have shortages… as a nurse, I'm the one who faces the relative I'm the one facing the audience…Sometimes we are new staff… we are feeling like we are circling ourselves when asking the in charge she will tell you I don't know how I'm busy I can't help you… we are not one-to-one nurses and patients…maybe one nurse we need to take over another patient so that means one-to-two ratios so sometimes we can't really … yeah you can't concentrate on our patients (Alice).
Limited skill
Limited skill in this regard referred to limited grief counseling skills. This skill involved utilizing the spoken word around grief and dealing with grief, yet some participants found themselves not being able to do so, resulting in them being silent in some instances.
Speaking I mean we are all not skilled in grief counseling where do you start and how do you go about it (Carol).
I don't know how to deal with it… only silence… even I couldn't support the patient (Sofia).
| Discussion | | |
Enduring emotional turmoil
Nurses and midwives in the current study experienced a wide variety of emotions, some of which included feeling sad, feeling guilty, feeling helpless, and feeling isolated. Hutti et al.[7] who reported in a study on experiences of nurses caring for women after a fetal loss, reiterate these findings. Nurses reported negative feelings such as intense sorrow, feeling overwhelmed, anger, being inconsolable, and even wanting to avoid patient care. A systematic review of healthcare professionals' experience of perinatal loss revealed that the most common emotions were guilt, frustration, a sense of personal failure, and helplessness.[22] Further to this, various studies have highlighted that nurses caring for women after fetal loss suffer a wide range of emotional responses, which include sadness, intense sorrow, guilt, grief, fear, crying, and nightmares.[10],[11],[23]
Although the findings of this study did not reveal any physical symptoms of emotional stress on nurses, some studies have well-documented the physical effects of stress because of fetal loss on nurses. Puia et al.[24] reported that nurses' responses to fetal loss included muscle tension, headaches, and difficulty eating and sleeping. This can be related to the cost of caring concept, where caring is the process of meeting the holistic needs of the patient through the physical and mental presence of the carer.[25] However, meeting the emotional needs of another person necessitates a health professional's emotional involvement, which can lead to emotional stress in healthcare professionals.[26] According to Figley,[27] healthcare professionals' mental health and ability to provide sensitive care to patients can be compromised after experiencing duty-related traumatic events. In the current study findings, nurses had to endure the emotional turmoil associated with fetal loss, which can be seen as a traumatic event for them. According to Katsantoni et al.,[16] who studied the prevalence of compassion fatigue, burn-out, and compassion satisfaction among maternity and gynecology care providers, highlighted that witnessing traumatic birth events impacts nurses and midwives psychological well-being to the extent of experiencing compassion fatigue. According to Beck et al.,[28] 36% of 473 maternity health-care professionals reported clinically significant trauma symptoms. Similarly, Sheen et al.[8] reported a 33% incidence of traumatic stress symptoms in 421, and more than two-thirds of Australian midwives (67%) reported witnessing a traumatic event, with 74% experiencing feelings of horror and 65% guilt.[29],[30] Further, the subtheme lacking self-control within this study shows that nurses and midwives were not always able to maintain professional boundaries and the intense emotions of the fetal loss often resulted in them crying. This can be related to the close-knit relationship between the midwife and the childbearing mother. Kirkham[31] suggested that the midwife-childbearing mother relationship is distinctive of midwifery practice, where midwives draw on satisfaction and job motivation from. However, midwifery practice is characterized by a high degree of empathy, which makes appropriate professional boundaries between patients and professionals difficult.[32] There is agreement from empirical evidence that empathy is key in the development of secondary trauma and compassion fatigue.[25],[27],[33] According to Thomas and Wilson,[34] the greater a professional's empathic identification with a client, the higher his or her risk of experiencing compassion fatigue or secondary traumatic stress. Within the context of these study findings, the nurses crying with the patients because of a fetal loss can be characterized by the high degree of empathy that existed between the mother and the nurse or midwife. From the study findings, nurses and midwives expressed concern about numerous obstacles to providing care to mothers and families during fetal loss. Obstacles included language barriers that prevented effective communication between the nurse and mother. In some instances, the nurse was not able to provide any words of comfort to the mother. According to Nair et al.[35] effective communication acts as a bridge to link information to health literacy, knowledge, and awareness for satisfaction and shared decision-making. Further to this, communication with mothers and families after a fetal loss should be compassionate, honest, and respectful, where there is clear, timely, sensitive information for collaborative decision-making.[36] According to Shakespeare et al.[37] language appropriate support at appropriate times helps in reducing anxiety, depression, and grief. Another obstacle to providing care was cultural barriers, where the culture of the patient conflicted with the practice of health care. In some instances, women were reluctant to accept medical facts; rather, they relied on cultural beliefs for the outcome of the baby. According to Roberts,[38] language, religion, and culture play a crucial role in patients' access and reaction to clinical services. He indicated that the provision of medical care conforming to families' culture, requires healthcare professionals' awareness and understanding of cultural and religious views toward life, birth, and death. Even though the issue of cultural stigmatization was not a finding in the current study, the researchers chose to include this discussion as it was thought to be relevant to the phenomenon of fetal loss. Some women may experience stigmatization and devaluation after a fetal loss because of cultural practices and beliefs. In some instances, the women or curses/spirits are blamed for the fetal loss with a tendency to suppress mourning, lack of acknowledgment of motherhood after stillbirth, or absence of burial traditions may lead to disenfranchised grief. Another barrier highlighted within the current study was related to lack of direction, which related to the lack of formal policies, and guidelines to deal with fetal loss. Wool and Caitlin[3] recommended the creation of standards, policies, and written information for parents after perinatal loss. Further to this, nurses and midwives within the current study felt unskilled at times in dealing with mothers and families who experienced fetal loss. According to Begley,[39] midwives who have not received adequate training and support in dealing with fetal loss may experience traumatic psychological symptoms. Midwives must gain training in the care of women with bereavement and management of fetal loss, as this is crucial to the health and welfare of midwives of the future.
| Conclusion | | |
This study highlighted that caring for patients and families who experience fetal loss is a challenging experience for nurses and midwives who, at times, are unable to manage their own emotions. This study also highlighted that there were no differences in the experiences of Saudi and expatriate nurses. The study included the nurses working within one hospital and only females. In addition, the audio recording was a major limitation as the nurses were worried that these records will be taken against them even after the principles of anonymity and confidentiality were explained. As this is the first study in the context of Saudi Arabia that explored the phenomenon of fetal loss by looking at the experiences of nurses, it is suggested that future research exploring the experiences of women and families be completed. It is also advisable to complete research that includes specifically fathers or men who experience fetal loss, especially around the issue of disenfranchised grief. Research using space triangulation and possibly a quantitative approach is also advised.
Acknowledgment
The authors would like to thank all the nurses and midwives caring for women and families that experience fetal loss, at King Abdul-Aziz Medical City, Western region.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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