The authors report no conflict of interest or relevant financial relationships.
Experiences of Obstetric Nurses Who Are Present for a Perinatal Loss
Article first published online: 17 MAY 2013
© 2013 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses
Journal of Obstetric, Gynecologic, & Neonatal Nursing
Volume 42, Issue 3, pages 321–331, May/June 2013
How to Cite
Puia, D. M., Lewis, L. and Beck, C. T. (2013), Experiences of Obstetric Nurses Who Are Present for a Perinatal Loss. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 321–331. doi: 10.1111/1552-6909.12040
- Issue published online: 17 MAY 2013
- Article first published online: 17 MAY 2013
- Manuscript Accepted: FEB 2013
- fetal death;
- infant death;
- obstetric nurses;
- perinatal loss;
- secondary analysis
To discover the impact of perinatal loss on obstetric nurses.
In the parent study, obstetric nurses were provided with an open-ended statement asking them to describe in writing the experience of being present during a traumatic childbirth. For this study, a secondary qualitative analysis was performed on those cases in which a perinatal loss was described as traumatic to answer new research questions.
A total of 464 cases were included in the parent study; 150 cases included either fetal or infant death. Of those, 91 cases had rich descriptions that we analyzed for this study.
The data were analyzed using Krippendorff's (2013) method for qualitative content analysis. Responses were clustered to allow themes to emerge. Nurses’ experiences of fetal and infant loss were analyzed individually and then compared and contrasted for overarching themes.
Six themes emerged from the fetal and infant loss experiences, with the final overarching themes from perinatal loss including getting through the shift, symptoms of pain and loss, frustrations with inadequate care, showing genuine care, recovering from traumatic experience, and never forgetting.
Perinatal loss can have a lasting effect on nurses, and thus continued support may be needed.
Each year more than four million infants are born in the United States (Martin et al., 2011). For most parents childbirth is a time of joy and happiness, but for some the birth can be devastating as they mourn the loss of their child. A fetal death, which is sometimes referred to as a stillbirth, takes place during pregnancy at 20 weeks gestation or more (American College of Obstetrician and Gynecologists [ACOG], 2009). In the United States 25,894 fetal deaths were reported in 2005 (MacDorman & Kirkmeyer, 2009). An infant death is the birth of a child before the first birthday and occurs at an almost equal rate of 29,153 (Mathews & MacDorman, 2011). Fetal deaths and the death of an infant fewer than 28 days old may also be referred to as a perinatal death or loss. Although the incidence of perinatal loss is small, the effect is profound. Such a tragic delivery affects not only the parents, but also the health care providers.
Although physicians are present at the delivery, nurses are with the patient throughout labor and are there to provide postmortem care to the infant and support the parents as they begin the grieving process. Parents often view nurses as the most helpful health care providers during this traumatic time (Gold, 2007). Yet though the nurses are providing physical care and emotional support to the family, they must cope with their own emotions and deal with personal stress as they try to maintain professionalism. In a recent study of secondary traumatic stress among labor and delivery nurses (Beck & Gable, 2012), nurses reported fetal/infant death reported as the most traumatic birth experience.
Many researchers have described the parental experience of a stillbirth or fetal death (Cacciatore, 2010; Nowak & Stevens, 2011; Trulsson & Radestad, 2004; Widger & Picot, 2008). Others have examined what care should be provided to the grieving families (Gensch & Midland, 2000; Hutti, 2006; Saflund, Sjogren, & Wredling, 2004). Despite the important role of nurses in the delivery and grieving process, there has been very little research conducted to explore nurses’ perspectives of providing care to families with a perinatal loss. The purpose of this secondary analysis was to describe the experiences of obstetric nurses caring for families with a perinatal loss.
Nurses play an important role in providing care to families with a perinatal loss, yet little research has been conducted to explore nurses’ perspectives.
Databases such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and PsycInfo were searched using the key words perinatal death, perinatal loss, infant death, infant loss, fetal death, fetal loss, nurses, and attitudes. In a quantitative study, Chan and Arthur (2009) conducted a survey of 185 nurses and midwives to evaluate their attitudes toward perinatal bereavement care. A regression analysis of data from questionnaires completed by obstetric nurses revealed that they were more likely to have positive attitudes toward perinatal bereavement care if they had religious beliefs or if they had positive attitudes toward hospital policies and training in bereavement care. Overall, nurses reported that they desired increased bereavement training and peer support.
Several studies focused on the experiences of nurses caring for families with a perinatal loss (Jonas-Simpson, McMahon, Watson, & Andrews, 2010; McCreight, 2005; Roehrs, Masterson, Alles, Witt, & Rutt, 2008; Wallbank & Robertson, 2008). Roehrs et al. (2008) conducted a qualitative descriptive study to assess the comfort level of nurses caring for families who had experienced a perinatal loss. Online surveys and follow-up interviews were conducted with 10 labor nurses. Content analysis resulted in six themes indicating the nurses’ desired ongoing education regarding bereavement care and increased managerial support such as not having a multiple patient assignment while caring for a family with a loss. Overall the nurses felt comfortable providing care but discussed how difficult it was to care for these families. In order to cope, the nurses would focus on the care they were providing, find support during administration of the care, and allow time to recover afterwards (Roehrs et al.). McCreight conducted a narrative analysis of the experiences of 14 nurses with perinatal loss and its emotional impact. The results signify the importance of the personal relationship between the nurse and the grieving family and the need for nurses to acknowledge their personal grief. Jonas-Simpson et al. conducted a qualitative study utilizing structured interview questions with nine nurses. Thematic analysis resulted in four themes: an honor filled with difficulty, responsibility, and opportunity to learn and grow; need for support, time to reflect, share, and regain strength; connecting with families while connecting families with their infants provides comfort amid the unbearable loss; and imagining how mothers will live with their loss while preparing them for the future. Although the work of caring for grieving families is difficult, the nurses found it to be a very meaningful experience and one that they never forget (Jonas-Simpson et al.). Such intensity of emotion requires support from peers and time for reflection.
The adverse personal impact of perinatal loss on nurses was further depicted in a metasynthesis (Wallbank & Robertson, 2008). Three themes emerged from the analysis of nine qualitative studies. The themes related to the impact on the staff, the professional behavior, and the coping mechanisms of the nurses. The nurses suffered from physical, emotional, and psychological symptoms. Inadequate education and personal emotions left the nurses feeling unprepared to counsel the grieving families. Overall, the results point toward negative immediate impact as well as long term sequelae (Wallbank & Robertson, 2008).
Relatively few researchers have explored the overall impact of perinatal loss on nurses. Previous authors have focused on particular aspects of perinatal loss such as nurses’ attitudes toward or level of comfort with providing bereavement care, emotional aspects of loss, or coping mechanisms (Chan & Arthur, 2009; McCreight, 2005; Roehrs et al., 2008). A better understanding of the entire experience of nurses caring for families with a perinatal loss may help them take better care of themselves and thus be better able to provide care for families. The purpose of this secondary qualitative analysis was to explore the experiences of nurses caring for families with a perinatal loss. The specific research questions were as follows:
- What is the experience of caring for a patient during a fetal death?
- What is the experience of caring for a patient during an infant death?
- What are the similarities and differences in nurses’ experiences in caring for a patient during a fetal death versus an infant death?
This study was designed as a secondary analysis of qualitative data. Traditionally qualitative research is based on primary data, such as interviews and observations. Yet these rich forms of data are often not used beyond the original research (Thorne, 1998). There are various types of secondary analysis. The use of the original database to answer new research questions, as was done in this study, is called analytic expansion (Thorne, 1994). The chance of under using a data set is decreased by asking additional research questions. Further benefits of secondary analysis include generation of new knowledge, new hypotheses, and support for existing theories (Hinds, Vogel, & Clarke-Steffen, 1997).
This study was a qualitative exploration of the traumatic experiences of obstetric nurses present at a perinatal death. A content analysis was conducted on data from a mixed methods study on the nurses’ experiences of traumatic childbirth and manifestations of secondary traumatic stress (Beck & Gable, 2012). The parent study involved administration of the Secondary Traumatic Stress Scale (Bride, Robinson, Yegidis, & Figley, 2004) and an open-ended statement asking nurses to describe experiences of being present during traumatic childbirth of any kind, not limited to perinatal death. In the initial study, a definition of a traumatic experience was not provided to the participants as the researcher did not want to influence the nurses’ stories. The only requirement was that the nurse perceived the childbirth as traumatic. Participants were recruited from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) via mail. For this study, the sample was derived from those cases in which the traumatic event described by participants was a perinatal loss. Cases were sorted into categories of fetal death and infant death based on the nurse's self-report of the situation to be compared and contrasted as separate phenomena, then analyzed collectively to explore the overall experience of perinatal death.
Krippendorff's (2013) method for qualitative content analysis was used to analyze data. In this method, three researchers conducted close readings of written responses of each phenomenon. Responses were formulated into clusters, or themes, in which closely related data were grouped together. Clustering was conducted for all data using dendrograms, or tree-like diagrams, to allow overarching themes to emerge from the data. Figure 1 depicts an example of a dendrogram for one of the emerging themes. The dendrograms for fetal and infant death were initially developed separately by each researcher. The dendrograms were then reviewed by all three researchers in order to ensure consistency of data interpretation.
The parent study included a total of 464 cases. Of those, 70 cases included the experience of being present in a delivery in which there was a fetal death. Another 85 included the experience of being present in a delivery in which there was an infant death, resulting in a total sample size of 155 cases. Of those, 64 cases included a mention of being present for a perinatal loss, but no description of the experience was provided. The other 91 cases had a rich description and were able to be analyzed. Table 1 summarizes the demographic characteristics of each of these samples.
|Variables||Fetal deathb||Infant deathb||Overalla|
|Total (% out of 464 cases)||85||18.3||70||15.1||140||30.2|
|Mean Age (years)||48.5||48||48.2|
|Years as RN|
|Primary Clinical Focus|
Table 2 shows the themes that emerged for each phenomenon, fetal death and infant death and the overarching themes that are shared by the two phenomena in the collective category of perinatal death. The individual themes that emerged from the cases on fetal death revealed differences from those that emerged from the cases on infant death. Nurses discussed the challenges of focusing on the tasks of the labor despite the trauma as they tried to get through the shift. They felt deeply affected by the loss, which was made worse by frustration with the physician, other nurses, or the system that had led to the trauma in the first place. Nurses did what they could to compensate for what they perceived as inadequate care by going above and beyond to bring relief to patients. Although nurses described many coping strategies, they unanimously expressed the feeling that they could never forget the trauma that they had witnessed.
|Fetal death||Infant death||Overarching theme|
|Getting through the shift||Flight mode: Getting through the shift||Getting through the shift|
|Responses to the loss: Shaken to the core||Emotional trauma: Feeling the loss||Symptoms of pain and loss|
|Frustrations with care: Adding to the trauma||Placing the blame: Blending anger and regret||Frustrations with inadequate care|
|Providing the best care: Putting your heart into it||Giving of self: Going above and beyond||Showing genuine care|
|Recovery: A time to heal and make sense||Attempting recovery: Moving forward||Recovering from traumatic experience|
|Never forget: Holding onto grief||Never forget: Living with the trauma||Never forget|
Some noticeable differences exist between nurses’ reactions to fetal and infant loss.
The results depict the intense emotion and immense impact a fetal loss has on labor and delivery nurses. Six themes emerged from the data representing nurses’ responses to caring for a woman with a fetal death.
Theme 1. Getting through the shift
Many of the nurses discussed the difficulty of maintaining professionalism while simultaneously trying to cope with their own grief and provide care to the families, “I feel like an actress sometimes, acting calm and matter of fact, when I just want to scream out, ‘Oh my god!’” Some nurses tried to distance themselves in order to provide care, “I went through the motions but at some point I had to cut off my emotions to just get through it.” Other nurses expressed the sentiment of holding it together until later. “I was able to stay professional in the patient's presence but fell apart on my own.” Another nurse recalled, “I remember the chaplain trying to comfort me in the hall … and telling her, ‘if I cry now, I won't be able to stop, I'll cry at the end of my shift.’ And that's what's expected of us as nurses!”
Some nurses felt comfortable grieving in front of others, sometimes with their peers, “I … found the OB physician in the med room crying. I went to her and put my arms around her. I do not know who was supporting whom as we stood there and cried together.” Other nurses grieved with the family, “We all cried together … He [the father] sobbed and grieved for many minutes with my arm around his shoulders.” Other nurses would mourn in private, “I meanwhile sat in an empty DR and cried.” Grief was not the only response to the death.
Theme 2. Responses to the loss: Shaken to the core
The nurses experienced physical symptoms and the emotional toll of the loss. Physically the nurses reported feeling stressed, muscle tension, headache, and pressure. Other nurses described difficulties eating and sleeping, “I couldn't sleep all day - kept waking up hearing her scream” and “I have dreams about saving the baby.” Other nurses had consuming thoughts while awake, “I constantly played it back in my head.… For a while I had a hard time fully engaging or being present when doing things with my family because I was always replaying work situations.” Another nurse explained, “The stories/hopes of the parents flood my thoughts distracting me.”
The response may be further exacerbated when discovering the fetal loss:
I could not locate the baby's heart rate. I started to feel numb. I felt hot and cold at the same time. I literally heard my own heart beat slowing down. It was loud and pounding ever sooo slowly, I could hear it. We got a stat ultrasound which showed no cardiac activity. Even though the place was hot I was sweating and feeling cold. I could not work for the rest of the day.
Another nurse simply stated, “Telling a patient her baby's heart has stopped beating is the hardest thing to do.” The difficulties continue for the nurses as “…you have to put them through the paces of labor and delivery with no baby at the end.”
Many nurses used words such as angry, sad, painful, difficult, helpless, and alone to describe the situation, but there was also intensity to their emotions. Words like extremely emotional, emotionally draining, overwhelming, and profound sadness conveyed the depth of the nurses’ emotions. One nurse summarized the response when she said, “it shook me to my core!” In addition to their sadness many nurses were plagued with self-doubt. Nurses questioned their care of the family, “Was I empathetic, caring enough?” These feelings of self-doubt further lead to feelings of guilt, “for not being able to protect the baby.” Feelings of doubt and guilt were enhanced when the nurse felt the patient did not receive the best care possible.
Theme 3. Frustrations with care: Adding to the trauma
Many of the nurses reported disagreements in provision of care among the healthcare providers. One nurse described a woman who was having her first infant on Mother's Day:
…she presented in active labor. I could not find heart tones. A sonogram confirmed an IUFD. She did not progress quickly enough for her OB who said to get her ready for a c/s. There was a bit of arguing amongst the staff with the doctor. Ultimately, the patient had a delivery of a dead baby by c/s.
Another nurses explained, “The MD discouraged the patient from pushing and it took hours to deliver the preterm fetus. The patient just wanted it over and I thought it was awful that they wouldn't just let her push.”
Sometimes the frustration with the care was a result of language barriers. One nurse recalled a situation in which the translator would not come into the room because “it made her sad.”
As an act of desperation I grabbed the cyra phone [translation phone] and used it as a tool to answer this poor woman's questions and also to find out what her final wishes were for the infant. I was mortified at having to deal with such a sensitive subject with a stranger over the phone.
Another nurse described her frustration when a non-English speaking patient was diagnosed with a fetal demise and then sent home and told to return on Monday for follow-up. The patient returned several times over the weekend to be seen for increased pain and bleeding and finally arrived in the emergency room:
Pt had blood soaked pants, underwear and snow jacket fixed around waist to conceal vaginal bleeding in public setting. I helped her to undress and baby, placenta and afterbirth products all inside underwear.
Pt bleeding. Amazing that NO One took the time or helped this woman at multiple points in medical system. Because with language barrier she had no voice. Unbelievable.
For many nurses, not being able to provide compassionate care increased the emotional impact.
Theme 4. Providing the best possible care: Putting your heart into it
For most nurses, they felt providing excellent care to the patient was a way to make the situation more bearable. One nurse explained, “Being present at the labor and delivery of a full term patient with a fetal demise makes me sad but determined to give the patient the best care in a horrible situation. I usually feel protective of the patient.” The nurses would put a great deal of care into bathing, dressing, and photographing the infants. “I always handled the babies with care, wrapping them and holding them like the babies they were, which the parents appreciated.” Being present at such a tragic moment often created a special bond between the nurse and the patient. “I believe then and still believe that during that emotional time she was not just another patient to me and she knew that.” The nurses recognized the delicate emotional state of the parents and tried to provide support. “The patient still needed attention and support above the average.” Another nurse described, “My place … was beside my patient and her husband who were both sobbing and frantic.… There had been no sound from this beautiful baby. I supported this family during the long minutes when the team was not there.” Although helping the families grieve made the nurses work more meaningful, for many nurses it was not enough.
Theme 5. Recovery: A time to heal and make sense
After such an emotional experience the nurses needed time to regroup and make sense of the situation. Communication and faith were the two big factors that helped nurses to recover. Nurses expressed a need to discuss the event, but often this was difficult to do with people outside the profession. One nurse explained:
I tried to … discuss all of this with my husband, but he really couldn't Relate, and did not want to hear about it, and couldn't understand why I let it get to me or perhaps that I'm too sensitive and should toughen up!
Many nurses mentioned debriefing as a helpful way to communicate. Another nurse suggested a less formal approach:
I believe the best help for nursing staff would be to have open sessions after such tragedies and let them express themselves and their feelings and allow their peers to comfort them and express ways that they have found to cope. This not only builds nursing bonds among our own, it helps us know that while our folks at home may not understand, our birthing community does.
Prayer while caring for the patient and afterwards provided comfort for many nurses: “I prayed for the parents and their babies, for myself and other care providers.” One nurse recalled, “After Mom recovered, the delivery nurse, MD, and I were trying to cope and the MD thanked me for the prayers - I was unaware but evidently I was audibly praying during the procedure.” Although nurses are able to find meaning and come to terms with the tragedy they witnessed, caring for families with a fetal death left a lasting impression.
Theme 6. Never forget: Holding onto grief
The nurses all noted that they could still vividly remember the fetal deaths: “I recall the room and the entire family holding the baby, even though it is now even 10 years later”; “the overwhelming despair on her face and her strength in spite of it will stick with me forever”; “The event occurred about 15 years ago but I will never forget this couple and how such a traumatic event could happen to such nice people.” But it is not just the memory of the situation; it is also the intense emotion that remains with the nurse: “Sometimes the anguish heard in their cries goes deep into my bones and I can reflect back on it and feel it like it's happening currently.” Another nurse recalled, “I once saw a Native American medicine man who told me I was holding onto grief. He had no idea what I did for a living. How can a person just let it go?” These nurses continue to hold a piece of sorrow for the bereaved families and their infants and are changed forever by these experiences.
The cases related to infant death included those in which the infant died in the delivery room, in the neonatal intensive care unit after delivery, or at home. Six themes emerged from the data.
Theme 1. Flight mode: Getting through the shift
Like in cases of fetal death, nurses described their grief in dealing with the loss of the infant. Nurses described crying with family members: “The patient and her mother hugged and cried with me,” and with other staff, “Other members of the staff and I cried afterwards,” while others cried alone.
Although this grief was profoundly present, nurses indicated that grief often came only after a period of numbness, shock, and being “kicked into flight mode.” One nurse said she simply, “did what I had to do as a nurse.” Another explained, “I felt very detached during the resuscitations and focused on performance. It was very hard to D/C efforts even when they were obviously futile.” Sense of time was also distorted during the delivery, “Time stood still.” One nurse said, “It was like watching a bad movie. I remember the head delivering and the body of the infant seemed to take forever. We tried everything we could. It was all slow motion.” Nurses wrote that the whole thing felt unreal and many described feeling extremely helpless. Afterwards, they described feeling spent and mentally and physically drained.
Theme 2. Emotional trauma: Feeling the loss
Beyond the trauma of the shift itself, nurses described the severity of the physical and emotional impact as they coped with what had happened after the shift. Some described “coming home and crying for hours on the couch” and others “cried constantly.” Physical symptoms also included anxiety attacks, rapid heartbeat, butterflies in stomach, and insomnia. One nurse said, “I was so very depressed.”
As in fetal death, nurses also described intense and overwhelming emotion, using words such as extreme sadness, emotionally devastated, emotional turmoil, and hopelessness. As one nurse wrote, “You feel the loss as much as the family.” Emotions were also exacerbated by stress over a potential lawsuit. Nurses discussed cases with their managers and risk management and stressed over the potential repercussions of the case, only adding to their sense of loss.
Theme 3. Placing the blame: Blending anger and regret
For nurses dealing with infant death, figuring out how and why the infant did not survive was an integral part of the grieving process. Nurses began to doubt the physicians, other nurses, and even the patients but most often questioned themselves.
Even when nurses felt as though they had done their best, many felt shame, guilt, and failure:
Although I do not feel that any actions were inappropriate on part of medical or nursing staff the incident made me question every action and wonder if it would be interpreted differently. Made me feel uncertain about my actions/interventions with other patients and question my confidence.
Many nurses described reviewing and replaying the case: “[I would] go over the events in my mind over and over, wondering what I could have done differently or better”; “[I] continued to ruminate on the scene and question my competence”; “You review in your mind if you did anything wrong. What could I have done to prevent this? Could I have worked faster? Many questions were reviewed in my head with no solid answers.” When no answers were found, nurses described feeling more anxious in future cases.
In other cases, nurses felt extreme guilt because they felt they should have stepped up when they felt uneasy about the course of action taken by the physician. One nurse described a case in which she felt strongly that a cesarean was necessary, but the obstetrician decided to attempt a vaginal delivery:
I do not doubt we could have saved her … I know God has forgiven me, but whether I will be able to forgive myself is the question … In heaven, I hope to tell the child who died how very sorry I am that she didn't make it. I know I didn't cause the death, but I might have prevented it if I cared more about what was right and less about being a good employee.
Some nurses were able to come to understand that they had done what they could but recognized that “not everything is in our hands or control.” One nurse said, “We are human after all… We feel we need to be perfect. We feel we need to have perfect outcomes all the time, even when it's out of our hands.”
Nurses also had to deal with anger, bitterness, and resentment that they felt towards physicians, nurses, and the healthcare system when they did not believe that others had taken appropriate actions. This only added to the guilt they felt for not speaking up sooner. As one nurse said, “I wanted to scream, ‘This is my patient and she trusts me to take care of her baby,’ but I did not.” Another said, “I wanted to push [the physician's] hands away during the delivery and do it myself.” Inappropriate actions also led to the nurse “questioning the MD's competence” in future deliveries. Targets of anger ranged from lack of resources to lack of caring, with nurses expressing frustrations with the hospital for not requiring an OR crew in house, with the previous shift nurse for not giving a thorough report, or even with the patient for not receiving prenatal care.
Theme 4. Giving of self: Going above and beyond
Nurses taking care of patients during an infant death gave all that they could to help themselves and families cope with the trauma. Because the infant was often transferred to the neonatal intensive care unit, nurses discussed cases in which they arrived to their shifts early to visit the infant or to check on the mother. Others described staying late after their shift to be with the mother until the infant had passed. One nurse told a story of an infant with internal and external anomalies:
After making it through the night, I went in to her room after my shift to say goodbye to her. It was obvious by the agonized breathing that this infant was having that she would expire soon. The patient's husband had to attend to the other children, leaving her alone to deal with their baby. I stayed with her until her baby passed. As the heart rate decreased, we sat together on her bed and I just held both of them until it was over, and cried like a baby with the mom.… I was glad I was able to be there for her.
Nurses described taking time to photograph the infants and wrap them for the parents. In a case in which the parents did not want to see the infant, the nurse wrote, “I kept her warm, held her, sang to her, put her under the warmer to assess” until the family was ready to hold their infant. Other nurses attended funerals and even sent cards to the family on the anniversary of the infant's birth/death.
Theme 5. Attempting recovery: Moving forward
Again, being there for the patient was not enough to allow the nurse to recover from the event. As in fetal death, nurses found debriefing and counseling with coworkers to be a helpful tool that “gave some of us closure.” Prayer was also important for many of these nurses: “I have found comfort in asking God for a safe delivery prior to every birth.”
Several coping skills were unique to infant death. For example, nurses described the need to take time away from work, ranging from days to years, and some thought about leaving nursing altogether. As one nurse said, “This event initially left me with wanting to leave the practice of nursing. Can we ever be prepared enough?” Others described a feeling of becoming numb as a way of coping. “I do not want to become numb to these experiences, but I think my mind and body are choosing to become this way to protect me from mental trauma.”
Lastly, some nurses described coping by changing their own attitudes and practice. They described the event as a “valuable learning experience,” an opportunity to “learn from our mistakes,” to “teach and continue to learn and to become a better nurse.” Several nurses said this situation helped them learn how to speak up: “I no longer hesitate on being more assertive in situations I feel uncomfortable in,” and “I always speak up now!” Nurses also said that these tragic losses, “make me appreciate having successful, healthy pregnancies.”
Theme 6. Never forget: Living with the trauma
Just as with fetal death, all of the nurses suffered from vivid memories of the tragic events, even when they may have occurred decades ago: “I feel like I will never get these sounds/images out of my head.” “Sometimes I flash to the wailing of a mother when we were coding her baby.… I can't get her screaming/crying/wailing out of my head.” “I remember it like it was yesterday, though it occurred 10 years ago.” “I can see particular rooms, or faces, or hear cries still echoing in my mind.” Nurses described flashbacks, sometimes triggered by patients with similar risk factors, working with the same staff members, or being in the same room: “This situation haunted me for years and still I get nervous if any scenario resembles this situation.” “When you get a bad case it brings them all back, puts you right back in them as if it was happening right now.” Another nurse said, “I still shake every time I hear the call bell, it's been a year and a half.” “40+ years later I remember that beautiful girl with long eye lashes – willing her to cry.” “I will never, ever, be able to forget this trauma.” As with fetal death, these nurses were forever changed by the trauma they have witnessed and endured.
Debriefing sessions can be an important part in the recovery process for nurses who have cared for families experiencing perinatal loss.
The infant death and fetal death themes had similarities and differences. The nurses’ descriptions of their grief and the physical and emotional impact were similar for both types of perinatal loss and were reflected in the overarching themes of getting through the shift and symptoms of pain and loss. Similarly, nurses present for a traumatic birth resulting in a perinatal loss reported never forgetting the experience. The individual differences were present in the overarching themes of frustrations with inadequate care, showing genuine care, and recovering from traumatic experience. Unlike in the cases of fetal loss, the nurses present for an infant loss felt compelled to find a cause for the death, often questioning others’ performance and even blaming themselves. In the case of infant loss, nurses often described the need to provide additional supportive care outside of their normal job description. Finally in contrast to fetal loss, nurses present for an infant loss reported needing extended time away from the unit and even from the profession in an effort to recover.
The results of this secondary analysis support findings from prior research. The physical and emotional symptoms discussed are similar to previous reports (Wallbank & Robertson, 2008). The importance of the emotional connection with the families was also supported (Jonas-Simpson et al., 2010; McCreight, 2005). The need for emotional support and a time to recover also emerged in a similar study (Jonas-Simpson et al.). However, the results from this study provide a more comprehensive view of the impact of perinatal loss on nurses.
Earlier studies focused on specific aspects of perinatal loss, such as attitudes and comfort level of providing bereavement care (Chan & Arthur, 2009; Roehrs et al., 2008). We focused on the overall experience of nurses with perinatal loss: beginning with the initiation of care of the woman, continuing through the actual delivery and postpartum care, and concluding with the nurses’ emotional impact and coping mechanisms. In addition, we also detailed the long-term consequences of the loss for the nurse. The results of this study are significant because the large sample size of 91 nurses from various institutions across the country adds to the volume of data and the generalizability of this study. Future researchers may investigate the experience of perinatal death among a more culturally diverse population or the experience of the obstetric nurse present at other types of traumatic childbirth. Trial interventions may be developed to decrease secondary traumatic stress among obstetric nurses.
In comparing fetal death to infant death, nurses tended to experience similar reactions to the trauma of the event. The individual themes reflect slight but important differences, though the process of being present and subsequent grieving is much the same. One significant difference was the need for the nurse of the patient with infant death to place blame, whether it was on self, physician, patient, or other staff member. In fetal death, the nurse experienced self-doubt and frustration with care, but the nurse in infant death went beyond questioning and truly felt responsible or blamed others for the death of the infant. In fetal death, nurses believed that these patients deserved extra attention in dealing with their loss and were frustrated when patients did not receive optimal care. In infant death, many nurses believed that the patient did not receive the best care, that the patients did not receive safe care, and that this neglect may have even led to the tragic outcome. Another difference was in the coping of these nurses, in which nurses of infant death often experienced numbing or required time away that did not emerge as consequences of fetal death.
Being present for the traumatic delivery of a perinatal loss may have long term consequences for some nurses. Secondary exposure to a traumatic birth can result in the nurse experiencing similar post-traumatic stress symptoms as the woman giving birth (Beck & Gable, 2012). When dealing with such tragedy and trauma nurses must recognize their own susceptibility to secondary traumatic stress so that they may be proactive in obtaining necessary support and treatment. Theme 5 for fetal and infant loss reveal the importance of nurses sharing their stories with their peers, as only other nurses can truly understand the emotional impact. Debriefing sessions for all healthcare workers involved with the perinatal loss should be conducted as soon as possible. Debriefing sessions are most effective when conducted within the first 72 hours after the traumatic event (Bateman, Dixon, & Trozzi, 2012). Debriefing is a specific stress management technique used to aid in coping with a traumatic event (Maloney, 2012). Such sessions allow for review of the situation, discussion of thoughts and emotions, and reflection on its impact. In addition to debriefing sessions nursing managers and supervisors must accommodate the emotional needs and staffing needs of these nurses when caring for patients who have experienced a perinatal loss by relieving them of their other assignments as soon as possible (Hill, 2012). Finally, the findings of this study indicate that perinatal death can have a long term effect on nurses, and continued support is needed in helping them deal with the consequences of such a trauma.
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