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Keywords:

  • grief;
  • perinatal nursing;
  • secondary trauma;
  • stress

Abstract

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

The work of perinatal nurses sometimes includes emergencies involving death, or near death, which can leave health care providers with feelings of stress and grief. After experiencing a particularly stressful period, nurses at our organization identified processes to help themselves recover and to support each other. The result of this work is a written plan to facilitate the support of perinatal nurses after critical events. This article describes the development and implementation of this plan.

Nurses have always been in the position of caring for patients and families in crisis or when experiencing loss. In a birth center, however, the emphasis is on promoting a healthy, normal birth process. Many nurses choose this setting because they enjoy supporting and caring for laboring/birthing women, their newborns and their families that are receiving a new member. The death of a newborn or its mother is a human tragedy; families anticipate taking home a healthy newborn after a good, safe delivery, and they grieve intensely when the outcome involves loss. It can be particularly difficult for perinatal nurses to cope with loss (Beck & Gable, 2012; Dietz, 2009; Puia, Lewis, & Beck, 2013). Birth is not an illness process, but rather a normal event occurring thousands of times every day around the world. We recognize that emergencies occur, and families depend on us to intervene in such cases. Perinatal nurses train for emergencies, with, among other things, training in cardiopulmonary resuscitation, neonatal resuscitation and advance cardiac life support for obstetrics, along with a myriad of simulations and drills. In short, we are prepared.

But who cares for health care providers when unexpected tragedies occur? This article describes how a plan was developed and implemented to help perinatal nurses cope with the stress of critical events and death.

The Challenge

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

Our facility is a hospital-based, level one family birth center with 23 labor-delivery-­recovery-postpartum rooms where we provide family-centered care. We designed this unit from a more traditional setting more than 20 years ago and cross-trained all the staff to be perinatal nurses, caring for women and newborns in all phases of childbearing with the benefit of shared skills, and with a nurturing environment for our families and each other.

The signs of stress became apparent as nurses commented about their fatigue, grief and anxiety about assignments that might bring higher risk

In one recent 4-month period we had an unusual number of emergencies, including massive transfusion codes, a ruptured uterus of a primigravida during a vaginal delivery, several placental abruptions, unexpected vaso-previas and the sad loss of more than one newborn. One of our massive transfusion codes was for a woman having a normal, repeat cesarean surgical delivery who developed disseminated intravascular coagulation and required more than 100 units of blood products.

The nurses became quite skilled at emergency cesarean deliveries, neonatal transfusion, adult massive transfusion protocol, transferring patients to higher levels of care and supporting families with loss. The signs of stress became apparent as nurses commented about their fatigue, grief and anxiety about assignments that might bring higher risk.

The recommended routine after such emergencies is to invite all participants, including physicians and nurses, to a debrief meeting within a week (Dietz, 2009). In our department, a clinical nurse educator leads the clinical debriefing session, which is designed to review the woman's record and sequential description of events by health care providers. The objective is to see what went well and to identify opportunities for improvement. The staff looks forward to this event, but by design it doesn't address immediate emotional needs of staff (Dietz, 2009). Staff identified a need to debrief in the immediate time frame before leaving the hospital when a significant event had occurred.

Developing the Tool

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

A small process improvement team was formed to address staff concerns. An e-mail was sent to all nurses, inviting them to participate in developing a plan to help staff cope with emergencies. It was important that all stakeholders and management be involved. The chaplain's office, social services and the nurse manager were invited. Ultimately the team included three to four nurses from each shift, a chaplain, the social service coordinator assigned to our floor and our supervisor. We planned a meeting to look at the issues and possible solutions.

The meeting started with an opportunity to express personal experiences and define desired goals. Several nurses shared tears while recounting events, describing how challenged they felt and verbalizing feelings of being overwhelmed and unacknowledged at the end of the event. Many felt it was difficult to return to work, and expressed need for time to recover and do self-care. Team members also expressed concerns about their assigned patient load while assisting in the emergency; they needed reassurance that other staff members had covered their assignments. Finally, we narrowed down what we hoped to achieve in caring for each other, and the events that would trigger implementation of our plan.

Addressing Stressors

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

The most common characteristics that nurses found most stressful were as follows: (1) the events were unexpected, (2) events required additional resources from outside the department, (3) patients required transfer to a higher level of care, such as ICU or transport to a NICU. In addition, nurses expressed concern about the care of the patients that each was responsible for, and the need to know that someone else had been assigned to care for them. The patients had always been cared for, but there was not a formal process in place. Having reassurance that their patients were in fact being cared for would allow nurses to give full focus to assisting in the emergency. A formal plan, including a report, was designed to change patient assignments as necessary and keep staff updated.

Another concern expressed by nurses was the difficulty to organize and finish tasks of documentation, billing charges and a risk management report after the emergency. It's now a priority that a second nurse assists with these tasks.

A “Safe” Place to Share

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

The biggest concern was related to the difficulty of going home after an event involving loss, possibly returning the next day, and not having an opportunity to express grief or have time for discussing the event (Blacklock, 2012). We all realize that sharing at home is inappropriate (as well as limited by HIPAA), but we agonized over how to cope with emotions when we left the hospital with no opportunity to talk to someone. We desired a “safe” place to talk with peers, decompress and verbalize grief.

As part of our new plan, the charge nurse will be tasked with identifying a space that can be used by staff, away from patients and visitors, to have an initial opportunity to debrief, cry, talk—whatever is needed. The primary nurses will have someone assigned to check in with them after work to see how they are doing, offering any additional support if desired. If needed, rearrangement of the work schedule to accommodate need for rest will be arranged. We noted that special care should be taken for nurses experiencing loss for the first time, as this may be particularly traumatizing.

The biggest concern was related to the difficulty of going home after an event involving loss, possibly returning the next day, and not having an opportunity to express grief or have time for discussing the event

At the end of one of our later emergencies, a chaplain came to inquire about staff well-­being. Several nurses had been the recipient of this effort and found it to be very helpful, so we decided that chaplain involvement would also be part of our plan. An opportunity to speak with the chaplains at one of their staff meetings ­presented itself, and the chaplain team was very receptive to the request for staff support. Compliments were offered for their wonderful response to our emergencies and support of our families; we appreciate them as part of our team. The chaplains agreed to be a support team for our staff, and now have in place a plan to notify a second chaplain to come for the staff if it is desired or needed.

The Tools

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

Several tools were designed to help organize and manage critical events for the staff, including checklists of responsibilities (see Boxes 1 and 2). Our social services coordinator designed a Self Care Packet and copies are kept in a cabinet available for staff to take home. This packet includes a handout on normal grief responses from normal stress to posttraumatic stress disorder, as well as a list of suggestions for self-care including relaxation, exercise and nutrition. There is also a list of counselors in the community who have a special interest in perinatal loss and are available to any staff member desiring to talk to someone outside of the hospital. Any staff member, whenever desired, may take the packet at any time.

Box 1. Critical Event Responsibilities of Charge Nurse

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Box 2. Responsibilities of Manager After Critical Event

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Sharing the Plan

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

Once the plan was designed, sharing it with the staff for input and acceptance was important. We first took it to the Self-Governance Committee for review, and then presented it at staff meetings. Finally, it was presented to the hospital-wide Nursing Standards and Practice Committee, where it was lauded as a model that can be adapted by all units.

Implementation and Evaluation

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

Shortly after presenting the plan to the staff, we had a tragedy on the unit involving a full code and loss of a newborn. The plan was implemented and then evaluated for effectiveness.

We were pleased with the ability of the staff to respond to the emergency, and the remaining staff's eagerness to pick up and provide primary care for additional patients. A second nurse assisted with the documentation, which was deemed enormously helpful. The primary nurse preferred to continue caring for the mother who experienced the loss, and her other patients were reassigned to other nurses for the rest of the shift.

Opportunity to talk behind closed doors was utilized by the staff, but we found that the designated “safe room” was too far from the desk and, therefore, was not used. Instead, as no patients were in the nursery, the door was closed and that space was more useful at that time. A need to specify a more convenient room was identified.

Finally, it was arranged for the primary nurse to be able to take the next shift off. When she returned to work, she thanked the team for the opportunity to grieve at home. She had not slept well, and a day to herself to process was welcomed and helpful. The chaplain checked in with her several times over the next few weeks, and made sure she knew she could call at any time. She commented that having people checking in several times over the days was helpful and very appreciated.

Feedback and Future Steps

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

Feedback on the use of the Critical Event Plan has been positive. There have been a couple of suggestions that are now included in the process. Nurses have been informed that in a critical event they can expect the following:

  1. Any nurse involved in an emergency will formally have their patients reassigned, allowing them to fully engage with the emergency.
  2. The staff directly involved can count on a “partner” to help with tasks such as documentation, cleanup, completing risk management reports, etc. The partner will also be available for any emotional support or debriefing that the nurse desires.
  3. The nurse involved in the critical event will be checked on over the next few days to see how she is coping and if she has other needs that need to be tasked to the partner or possibly another person preferred by the nurse.
  4. The nurse involved in the critical event will have her work schedule modified if she needs time to recover from the events. Unless she prefers otherwise, her patient assignment for the shift will be reassigned.
  5. The chaplain will be available and a second chaplain will be called just for the staff if needed.
  6. A self-care resource packet is available, as well as counseling, if desired.

An opportunity to speak with the chaplains at one of their staff meetings presented itself, and the chaplain team was very receptive to the request for staff support

Conclusion

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

It has been a little while since we have needed to implement this process; we are grateful for the recent good outcomes for our mothers and infants. Yet, it is also reassuring to think that we are better able to support each other as we go forward, knowing that there will always be another emergency in the future. NWH

References

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography

Biography

  1. Top of page
  2. Abstract
  3. The Challenge
  4. Developing the Tool
  5. Addressing Stressors
  6. A “Safe” Place to Share
  7. The Tools
  8. Sharing the Plan
  9. Implementation and Evaluation
  10. Feedback and Future Steps
  11. Conclusion
  12. References
  13. Biography
  • Suzan Foreman, BSN, RNC, is a perinatal nurse and charge RN at the Wilcox Women's Pavilion at Legacy Good Samaritan Hospital in Portland, OR.