- Email: [email protected]
Early Pregnancy Loss and Bereavement in the Emergency Department: Staff and Patient Satisfaction With an Early Fetal Bereavement Program
EVIDENCE-BASED PRACTICE
EARLY PREGNANCY LOSS AND BEREAVEMENT IN THE EMERGENCY DEPARTMENT: STAFF AND PATIENT SATISFACTION WITH AN EARLY FETAL BEREAVEMENT PROGRAM Authors: Kathleen Evanovich Zavotsky, MS, RN, CCRN, CEN, ACNS-BC, Kathy Mahoney, RN, APN, Donna Keeler, RN, and Robert Eisenstein, MD, FACEP, New Brunswick, NJ Section Editor: Nancy McGowan, RN, PhD
aginal bleeding is a common complaint that brings women of childbearing age to the emergency department. One of the most common causes of bleeding during early pregnancy is spontaneous abortions. A spontaneous abortion is defined as loss of pregnancy before 20 weeks or loss of a fetus weighing <500 g.1,2 An estimate of pregnancies that abort spontaneously may range from 25% to 50%. Approximately 75% of spontaneous abortions occur before completion of the first trimester.3,4 The standard medical or surgical treatment for patients with a diagnosis of spontaneous abortion can vary from uterine evacuation with an admission or discharge home with specific instructions.5 Discharge instructions often are focused on identifying the physical symptoms of complications such as avoiding intercourse, bed rest, pain management, and appropriate follow-up with a gynecologist and inadvertently may overlook the psychological
V
Kathleen Evanovich Zavotsky, Member, West Central Jersey Chapter, is Clinical Nurse Specialist, Emergency Department, Robert Wood Johnson University Hospital, New Brunswick, NJ. Kathy Mahoney is Perinatal Clinical Nurse Specialist, Robert Wood Johnson University Hospital, New Brunswick, NJ. Donna Keeler is Head Nurse, Emergency Department, Robert Wood Johnson University Hospital, New Brunswick, NJ. Robert Eisenstein is Associate Professor and Interim Chair, Department of Emergency Medicine, UMDNJ-Robert Wood Johnson Medical School, Chief Ambulatory Service, Division of Emergency Care, Robert Wood Johnson University Hospital, New Brunswick, NJ. For correspondence, write: Kathleen Evanovich Zavotsky, MS, RN, CCRN, CEN, ACNS-BC, Emergency Department, Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08903; E-mail: [email protected]. J Emerg Nurs 2013;39:158-61. Available online 23 October 2012. 0099-1767/$36.00 Copyright © 2013 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2012.08.006
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JOURNAL OF EMERGENCY NURSING
distress and grief that the patient and significant other can be feeling. Review of the Literature
Perinatal loss includes early fetal loss (at less than 20 weeks of gestation), stillbirth (at greater than 20 weeks of gestation or when the fetus weighs more than 350 g) and death in the first 28 days of the neonatal period.6 Families who experience early fetal loss often move through the same stages of the grief process as persons experiencing the death of a loved one. This process is accompanied by loss at a time when hopes for the future take an unexpected turn.7 Families and specifically mothers experiencing early fetal loss report a high level of anxiety, and more than 75% of women surveyed identified the loss as “…a pregnancy, baby, baby with a name, (etc).”8 The ability of these families to articulate their own bereavement needs may be limited, and they depend on health care providers to offer clear instructions and communication that is supportive, informative, and culturally appropriate.9-11 The education of the health care team regarding these communication strategies for parents experiencing fetal loss is recognized as a valuable tool.12 Very limited information is available on communication strategies and comprehensive bereavement for families experiencing fetal loss who are evaluated in the emergency department. The Problem
It is difficult for staff to help the patient and family deal with the profound psychological trauma that accompanies early fetal demise for a multitude of reasons. ED staff members in general are used to dealing with rapidly changing life-and-death situations. A mother who is hemodynamically stable may not be evaluated as a priority. Some staff may not recognize that a very early loss could create any type of grief. At times like these, the appropriate communication proves to be challenging to health care providers in many emergency departments.
VOLUME 39 • ISSUE 2 March 2013
Zavotsky et al/EVIDENCE-BASED PRACTICE
TABLE 1
TABLE 2
Options given for an early fetal bereavement packet
Contents of the ED early fetal bereavement packet
• Acknowledgement of the patient's and significant other's loss • Contact information for the emergency department • A personalized letter • Web sites for additional information • A poem
• A personalized letter of condolence • Contact information for the ED staff • Web sites for additional information about fetal bereavement • A poem written by one of the staff members • Information about a support group offered at the hospital for fetal bereavement (English only)
When patients experience the loss of a fetus that is older than 20 weeks, they often are admitted to an obstetrical unit, where specially trained nurses and other resources are available to help provide the patient and family with the support that is needed. Therefore the ED staff often is responsible for managing patients with early fetal loss during the first and second trimester. Providing patients with a comprehensive bereavement plan in the emergency department may be difficult. ED staff members may or may not have access to the appropriate tools to help them provide emotional support and education to the patient and family. ED nurses are generalists and have a very broad physiological knowledge base. Provision of thoughtful and compassionate education and consultation, as well as ensuring safe discharge, will pose some additional challenges. These challenges may involve being able to give the patient hope for the future and finding the right consoling words. This situation faced the ED staff where the study took place. The study site is an urban academic level I trauma center located in the northeastern part of the United States with an emergency department that has 75,000 visits per year. The staff had discharge instructions that emphasized physical care only; no mention was made of the psychological needs of the patient and family. The staff was accustomed to having bereavement material that they provided to families when a pediatric or adult death occurred, and thus a group of staff members approached the clinical nurse specialist in the emergency department about developing material that would help address this need for appropriate communication in the fetal loss population. The hospital at which the study occurred uses a nursing conceptual model that helps guide nursing practice and diagnosis.13 Five interdependent components of care are identified: growth and development, basic needs, protection, management of health, and coping. Being able to help patients and families cope is a fundamental part of nursing practice, and it was the staff’s understanding of this model that led the ED staff to request tools to help them develop a comprehensive bereavement plan in the emergency department and better meet the needs of patient and their families.
March 2013
VOLUME 39 • ISSUE 2
The purpose of this project was twofold. The first purpose was to determine and validate whether the ED nursing and medical staff felt satisfied with the current early fetal loss program, which included discharge information that addressed only the patient’s physical needs. The second part of the project took place after the implementation of a new fetal loss program that addressed both the physical and psychological needs, and its purpose was to assess patient and staff satisfaction. Phase I of the project involved a satisfaction survey for the nursing and medical staff. The survey used a Likert scale (0 to 10, with 0 being not satisfied and 10 being most satisfied). The staff also was asked if an early fetal bereavement program was important to them; if they answered yes, they ranked its importance (0 to 10, with 0 being not important and 10 being extremely important). They also were provided with a selection of options (Table 1) that could be included in a fetal bereavement packet and were asked to choose what they would have like to see included in the packet. Phase II of the project involved implementation of an early fetal bereavement packet that was developed by the authors (Table 2). The nursing and medical staff received a 1-hour education program about how to deal with early fetal bereavement. The staff was able to view the bereavement packet before it was distributed to patients and families. The fetal bereavement packet was approved by the hospital’s Multidisciplinary Patient Education Committee before it was used. The hospital’s Multidisciplinary Patient Education Committee is made up of members from every discipline in the hospital, including the hospital chaplain. The packet was available in both Spanish and English. The education program that was provided to the staff is based on a framework for managing pregnancy loss by Bacidore et al14 (Table 3). The authors used this framework to develop the educational offering. Use of this framework provided the staff with a simple and concise model that they could easily apply to their practice. It was introduced as a starting point in the utilization of the fetal
WWW.JENONLINE.ORG
159
EVIDENCE-BASED PRACTICE/Zavotsky et al
TABLE 3
Fetal loss: a collaborative framework F E T A L L O S S
Focused physical examination Early information TLC Anniversary Let out feelings Link to social worker Outpatient care Social support Sustained follow-up
Confirm the loss early in the process in language they can understand Provide comfort and empathy Warn the patient and family about increasing depression around the anniversary date Counsel the patient on the need to communicate feelings Social worker evaluation may need to accompany ED care Identify the process for follow-up Indicate social services and community resources that are available Encourage the patient to communicate concerns at follow-up visits
TABLE 4
Survey questions after implementation of the program • How satisfied are you with the current fetal demise education that is being provided to patients in the emergency department? • Is having a fetal demise bereavement packet available to provide to patients important to you? • Have you provided any patient with the fetal bereavement packet? If yes, how beneficial do you think it will be to the patient? • What information would you like to see deleted from the current fetal demise bereavement packet? • What information would you like to see added to the packet?
bereavement packet and provided an evidence-based model that was easy to remember. The education of the nursing and medical staff took place over a 2-month period. The members of the study team delivered a scripted education program. After provision of the education program, the new fetal bereavement packets were made available by the department, and a satisfaction survey was included for families to complete and return in a self-addressed stamped envelope. One month after implementation, the nursing and medical staff was surveyed again. The survey questions are listed in Table 4. Staff and Patient Satisfaction
A total of 7 physicians and 38 nurses agreed to participate in the pre-survey. Overall, neither the physicians nor the nurses were satisfied with the early fetal bereavement program as it existed before the intervention. The mean score was 3.6. A total of 95% of the participants reported that
160
JOURNAL OF EMERGENCY NURSING
having a fetal bereavement packet available to them was important, and they rated the level of importance as high; the mean score was 8.5. The participants responded to what they believed should be included in the early fetal bereavement packet; 76% wanted to include an acknowledgement letter to the parent, 51% wanted to include information about how to contact the emergency department if necessary, and 64% wanted to include Web sites that would provide additional information. The post-survey was completed within 60 days of the completion of the educational offering and the initiation of the new early fetal bereavement packet. A total of 5 physicians and 28 nurses participated in the second survey. The overall satisfaction score with the new early fetal bereavement program rose to 7.8. When the staff was asked if they would want any information removed from the early fetal bereavement packet, overall 82% responded “nothing.” The survey also asked if they had used the packet within the last 30 days; 45% of respondents indicated “yes,” and they rated the perceived benefit to the patient as high. Three patients returned the survey; 1 was English speaking and 2 were Spanish speaking. All of the subjects (100%) rated satisfaction with the early fetal bereavement packet as high. When the subjects were asked if anything could have been added to the packet, all responded no. Implications for Practice
We found that before the implementation of the early fetal bereavement packet, the ED staff was not satisfied with the way they were providing education and support to patients who experience early fetal loss. Their responses suggested that it was important to them to have information available to provide to patients. These results suggest that when caregivers don’t have the tools to provide care to patients, they are not satisfied and may feel they are not delivering quality care.
VOLUME 39 • ISSUE 2 March 2013
Zavotsky et al/EVIDENCE-BASED PRACTICE
After the educational offering, the nursing staff indicated that they were more satisfied with the program than were the physicians. Each discipline received the same education. This finding simply suggests that although the nurses and physicians both received the same education and were involved in the program, the nurses subsequently were more satisfied with the improvements than were the physicians. Only 3 patients responses were received from 25 patient surveys that were distributed; this response rate does not allow for any advanced statistical analysis. However, the information gleaned from those three subjects certainly suggests that the packet has the strong potential to help patients cope with their loss and the grieving process. Possible reasons for the low return rate were that patients may not have reviewed the packet, they might have believed that the packet was too painful to review and reflect on, or they simply may not have been interested in returning the survey. The ED staff can use a simple fetal bereavement packet as a guide for patient education around the grief and grieving process and to assist them in meeting the bereavement needs of the family. Such tools can be used as an adjunct to physical care to help the patient and family cope with the early pregnancy loss. Conclusion
Dealing with early fetal loss is a common occurrence in emergency nursing practice. Often times it does not require lifesaving interventions, and frequently patients are discharged home. It may be difficult for nurses and physicians alike to find the right words to say to offer condolences and provide patients with the emotional support they need to help them deal with this profound loss. A simple tool such as an early fetal bereavement packet that staff can provide to patients may prove to be a very valuable educational tool and can help satisfy the needs of patients and ED staff.
March 2013
VOLUME 39 • ISSUE 2
REFERENCES 1. Callister LC. Perinatal loss: a family perspective. J Perinat Neonatal Nurs. 2006;20(3):227-34. 2. Ventura SJ, Abma JC, Mosher WD, Henshaw SK. Estimated pregnancy rates by outcome for the United States, 1990-2004. Natl Vital Stat Rep. 2008;56(15):1-26. 3. Simpson J, Jauniaux E, et al. Pregnancy loss. In: Gabbe S, ed. Obstetrics: Normal and Problem Pregnancies. Philadelphia, PA: Churchill Livingstone; 2007:629-49. 4. Coppola PT, Coppola M. Vaginal bleeding the first 20 weeks of pregnancy. Emerg Clin North Am. 2003;21:667-77. 5. Morrison L, Spence J. Obstetrics and gynecology. In: Tintinalli J, ed. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw Hill; 2007:665-730. 6. American College of Obstetricians and Gynecologists. Management of stillbirth (ACOG Practice Bulletin No. 102). Obstet Gynecol. 2009; 113:748-61. 7. Limbo R, Kobler K. The tie that binds: relationships in perinatal bereavement. MCN Am J Matern Child Nurs. 2010;35(6):316-21. 8. Limbo R, Kobler K, Levang E. Respectful disposition in early pregnancy loss. MCN Am J Matern Child Nurs. 2010;35(5):271-7. 9. Cacciatore J. Stilbirth: patient centered psychological care. Clin Obstet Gynecol. 2010;53(3):691-9. 10. Whitaker C, Kavanaugh K, Klima C, et al. Perinatal grief in Latino patients. MCN Am J Matern Child Nurs. 2010;35(6):341-5. 11. Moore T, Parrish H, Black BP, et al. Interconception care for couples after perinatal loss: a comprehensive review of the literature. J Perinatal Neonatal Nurs. 2011;25(1):44-51. 12. Gold KJ, Dalton VK, Schwenk TL. Hospital care for parents after perinatal death. Obstet Gynecol. 2007;109(5):1156-66. 13. Krenz M, Karlik B, Kiniry S. A nursing diagnosis based model: guiding nursing practice. J Nurs Admin. 1989;19(5):32-6. 14. Bacidore V, Warren N, Chaput C, Keough VA. A collaborative framework for managing pregnancy loss in the emergency department. J Obstet Gynecol Neonatal Nurs. 2009;38(6):730-8.
Submissions to this column are encouraged and may be sent to Nancy McGowan, RN, PhD [email protected]
WWW.JENONLINE.ORG
161
EARLY PREGNANCY LOSS AND BEREAVEMENT IN THE EMERGENCY DEPARTMENT: STAFF AND PATIENT SATISFACTION WITH AN EARLY FETAL BEREAVEMENT PROGRAM Authors: Kathleen Evanovich Zavotsky, MS, RN, CCRN, CEN, ACNS-BC, Kathy Mahoney, RN, APN, Donna Keeler, RN, and Robert Eisenstein, MD, FACEP, New Brunswick, NJ Section Editor: Nancy McGowan, RN, PhD
aginal bleeding is a common complaint that brings women of childbearing age to the emergency department. One of the most common causes of bleeding during early pregnancy is spontaneous abortions. A spontaneous abortion is defined as loss of pregnancy before 20 weeks or loss of a fetus weighing <500 g.1,2 An estimate of pregnancies that abort spontaneously may range from 25% to 50%. Approximately 75% of spontaneous abortions occur before completion of the first trimester.3,4 The standard medical or surgical treatment for patients with a diagnosis of spontaneous abortion can vary from uterine evacuation with an admission or discharge home with specific instructions.5 Discharge instructions often are focused on identifying the physical symptoms of complications such as avoiding intercourse, bed rest, pain management, and appropriate follow-up with a gynecologist and inadvertently may overlook the psychological
V
Kathleen Evanovich Zavotsky, Member, West Central Jersey Chapter, is Clinical Nurse Specialist, Emergency Department, Robert Wood Johnson University Hospital, New Brunswick, NJ. Kathy Mahoney is Perinatal Clinical Nurse Specialist, Robert Wood Johnson University Hospital, New Brunswick, NJ. Donna Keeler is Head Nurse, Emergency Department, Robert Wood Johnson University Hospital, New Brunswick, NJ. Robert Eisenstein is Associate Professor and Interim Chair, Department of Emergency Medicine, UMDNJ-Robert Wood Johnson Medical School, Chief Ambulatory Service, Division of Emergency Care, Robert Wood Johnson University Hospital, New Brunswick, NJ. For correspondence, write: Kathleen Evanovich Zavotsky, MS, RN, CCRN, CEN, ACNS-BC, Emergency Department, Robert Wood Johnson University Hospital, 1 Robert Wood Johnson Pl, New Brunswick, NJ 08903; E-mail: [email protected]. J Emerg Nurs 2013;39:158-61. Available online 23 October 2012. 0099-1767/$36.00 Copyright © 2013 Published by Elsevier Inc. on behalf of Emergency Nurses Association. http://dx.doi.org/10.1016/j.jen.2012.08.006
158
JOURNAL OF EMERGENCY NURSING
distress and grief that the patient and significant other can be feeling. Review of the Literature
Perinatal loss includes early fetal loss (at less than 20 weeks of gestation), stillbirth (at greater than 20 weeks of gestation or when the fetus weighs more than 350 g) and death in the first 28 days of the neonatal period.6 Families who experience early fetal loss often move through the same stages of the grief process as persons experiencing the death of a loved one. This process is accompanied by loss at a time when hopes for the future take an unexpected turn.7 Families and specifically mothers experiencing early fetal loss report a high level of anxiety, and more than 75% of women surveyed identified the loss as “…a pregnancy, baby, baby with a name, (etc).”8 The ability of these families to articulate their own bereavement needs may be limited, and they depend on health care providers to offer clear instructions and communication that is supportive, informative, and culturally appropriate.9-11 The education of the health care team regarding these communication strategies for parents experiencing fetal loss is recognized as a valuable tool.12 Very limited information is available on communication strategies and comprehensive bereavement for families experiencing fetal loss who are evaluated in the emergency department. The Problem
It is difficult for staff to help the patient and family deal with the profound psychological trauma that accompanies early fetal demise for a multitude of reasons. ED staff members in general are used to dealing with rapidly changing life-and-death situations. A mother who is hemodynamically stable may not be evaluated as a priority. Some staff may not recognize that a very early loss could create any type of grief. At times like these, the appropriate communication proves to be challenging to health care providers in many emergency departments.
VOLUME 39 • ISSUE 2 March 2013
Zavotsky et al/EVIDENCE-BASED PRACTICE
TABLE 1
TABLE 2
Options given for an early fetal bereavement packet
Contents of the ED early fetal bereavement packet
• Acknowledgement of the patient's and significant other's loss • Contact information for the emergency department • A personalized letter • Web sites for additional information • A poem
• A personalized letter of condolence • Contact information for the ED staff • Web sites for additional information about fetal bereavement • A poem written by one of the staff members • Information about a support group offered at the hospital for fetal bereavement (English only)
When patients experience the loss of a fetus that is older than 20 weeks, they often are admitted to an obstetrical unit, where specially trained nurses and other resources are available to help provide the patient and family with the support that is needed. Therefore the ED staff often is responsible for managing patients with early fetal loss during the first and second trimester. Providing patients with a comprehensive bereavement plan in the emergency department may be difficult. ED staff members may or may not have access to the appropriate tools to help them provide emotional support and education to the patient and family. ED nurses are generalists and have a very broad physiological knowledge base. Provision of thoughtful and compassionate education and consultation, as well as ensuring safe discharge, will pose some additional challenges. These challenges may involve being able to give the patient hope for the future and finding the right consoling words. This situation faced the ED staff where the study took place. The study site is an urban academic level I trauma center located in the northeastern part of the United States with an emergency department that has 75,000 visits per year. The staff had discharge instructions that emphasized physical care only; no mention was made of the psychological needs of the patient and family. The staff was accustomed to having bereavement material that they provided to families when a pediatric or adult death occurred, and thus a group of staff members approached the clinical nurse specialist in the emergency department about developing material that would help address this need for appropriate communication in the fetal loss population. The hospital at which the study occurred uses a nursing conceptual model that helps guide nursing practice and diagnosis.13 Five interdependent components of care are identified: growth and development, basic needs, protection, management of health, and coping. Being able to help patients and families cope is a fundamental part of nursing practice, and it was the staff’s understanding of this model that led the ED staff to request tools to help them develop a comprehensive bereavement plan in the emergency department and better meet the needs of patient and their families.
March 2013
VOLUME 39 • ISSUE 2
The purpose of this project was twofold. The first purpose was to determine and validate whether the ED nursing and medical staff felt satisfied with the current early fetal loss program, which included discharge information that addressed only the patient’s physical needs. The second part of the project took place after the implementation of a new fetal loss program that addressed both the physical and psychological needs, and its purpose was to assess patient and staff satisfaction. Phase I of the project involved a satisfaction survey for the nursing and medical staff. The survey used a Likert scale (0 to 10, with 0 being not satisfied and 10 being most satisfied). The staff also was asked if an early fetal bereavement program was important to them; if they answered yes, they ranked its importance (0 to 10, with 0 being not important and 10 being extremely important). They also were provided with a selection of options (Table 1) that could be included in a fetal bereavement packet and were asked to choose what they would have like to see included in the packet. Phase II of the project involved implementation of an early fetal bereavement packet that was developed by the authors (Table 2). The nursing and medical staff received a 1-hour education program about how to deal with early fetal bereavement. The staff was able to view the bereavement packet before it was distributed to patients and families. The fetal bereavement packet was approved by the hospital’s Multidisciplinary Patient Education Committee before it was used. The hospital’s Multidisciplinary Patient Education Committee is made up of members from every discipline in the hospital, including the hospital chaplain. The packet was available in both Spanish and English. The education program that was provided to the staff is based on a framework for managing pregnancy loss by Bacidore et al14 (Table 3). The authors used this framework to develop the educational offering. Use of this framework provided the staff with a simple and concise model that they could easily apply to their practice. It was introduced as a starting point in the utilization of the fetal
WWW.JENONLINE.ORG
159
EVIDENCE-BASED PRACTICE/Zavotsky et al
TABLE 3
Fetal loss: a collaborative framework F E T A L L O S S
Focused physical examination Early information TLC Anniversary Let out feelings Link to social worker Outpatient care Social support Sustained follow-up
Confirm the loss early in the process in language they can understand Provide comfort and empathy Warn the patient and family about increasing depression around the anniversary date Counsel the patient on the need to communicate feelings Social worker evaluation may need to accompany ED care Identify the process for follow-up Indicate social services and community resources that are available Encourage the patient to communicate concerns at follow-up visits
TABLE 4
Survey questions after implementation of the program • How satisfied are you with the current fetal demise education that is being provided to patients in the emergency department? • Is having a fetal demise bereavement packet available to provide to patients important to you? • Have you provided any patient with the fetal bereavement packet? If yes, how beneficial do you think it will be to the patient? • What information would you like to see deleted from the current fetal demise bereavement packet? • What information would you like to see added to the packet?
bereavement packet and provided an evidence-based model that was easy to remember. The education of the nursing and medical staff took place over a 2-month period. The members of the study team delivered a scripted education program. After provision of the education program, the new fetal bereavement packets were made available by the department, and a satisfaction survey was included for families to complete and return in a self-addressed stamped envelope. One month after implementation, the nursing and medical staff was surveyed again. The survey questions are listed in Table 4. Staff and Patient Satisfaction
A total of 7 physicians and 38 nurses agreed to participate in the pre-survey. Overall, neither the physicians nor the nurses were satisfied with the early fetal bereavement program as it existed before the intervention. The mean score was 3.6. A total of 95% of the participants reported that
160
JOURNAL OF EMERGENCY NURSING
having a fetal bereavement packet available to them was important, and they rated the level of importance as high; the mean score was 8.5. The participants responded to what they believed should be included in the early fetal bereavement packet; 76% wanted to include an acknowledgement letter to the parent, 51% wanted to include information about how to contact the emergency department if necessary, and 64% wanted to include Web sites that would provide additional information. The post-survey was completed within 60 days of the completion of the educational offering and the initiation of the new early fetal bereavement packet. A total of 5 physicians and 28 nurses participated in the second survey. The overall satisfaction score with the new early fetal bereavement program rose to 7.8. When the staff was asked if they would want any information removed from the early fetal bereavement packet, overall 82% responded “nothing.” The survey also asked if they had used the packet within the last 30 days; 45% of respondents indicated “yes,” and they rated the perceived benefit to the patient as high. Three patients returned the survey; 1 was English speaking and 2 were Spanish speaking. All of the subjects (100%) rated satisfaction with the early fetal bereavement packet as high. When the subjects were asked if anything could have been added to the packet, all responded no. Implications for Practice
We found that before the implementation of the early fetal bereavement packet, the ED staff was not satisfied with the way they were providing education and support to patients who experience early fetal loss. Their responses suggested that it was important to them to have information available to provide to patients. These results suggest that when caregivers don’t have the tools to provide care to patients, they are not satisfied and may feel they are not delivering quality care.
VOLUME 39 • ISSUE 2 March 2013
Zavotsky et al/EVIDENCE-BASED PRACTICE
After the educational offering, the nursing staff indicated that they were more satisfied with the program than were the physicians. Each discipline received the same education. This finding simply suggests that although the nurses and physicians both received the same education and were involved in the program, the nurses subsequently were more satisfied with the improvements than were the physicians. Only 3 patients responses were received from 25 patient surveys that were distributed; this response rate does not allow for any advanced statistical analysis. However, the information gleaned from those three subjects certainly suggests that the packet has the strong potential to help patients cope with their loss and the grieving process. Possible reasons for the low return rate were that patients may not have reviewed the packet, they might have believed that the packet was too painful to review and reflect on, or they simply may not have been interested in returning the survey. The ED staff can use a simple fetal bereavement packet as a guide for patient education around the grief and grieving process and to assist them in meeting the bereavement needs of the family. Such tools can be used as an adjunct to physical care to help the patient and family cope with the early pregnancy loss. Conclusion
Dealing with early fetal loss is a common occurrence in emergency nursing practice. Often times it does not require lifesaving interventions, and frequently patients are discharged home. It may be difficult for nurses and physicians alike to find the right words to say to offer condolences and provide patients with the emotional support they need to help them deal with this profound loss. A simple tool such as an early fetal bereavement packet that staff can provide to patients may prove to be a very valuable educational tool and can help satisfy the needs of patients and ED staff.
March 2013
VOLUME 39 • ISSUE 2
REFERENCES 1. Callister LC. Perinatal loss: a family perspective. J Perinat Neonatal Nurs. 2006;20(3):227-34. 2. Ventura SJ, Abma JC, Mosher WD, Henshaw SK. Estimated pregnancy rates by outcome for the United States, 1990-2004. Natl Vital Stat Rep. 2008;56(15):1-26. 3. Simpson J, Jauniaux E, et al. Pregnancy loss. In: Gabbe S, ed. Obstetrics: Normal and Problem Pregnancies. Philadelphia, PA: Churchill Livingstone; 2007:629-49. 4. Coppola PT, Coppola M. Vaginal bleeding the first 20 weeks of pregnancy. Emerg Clin North Am. 2003;21:667-77. 5. Morrison L, Spence J. Obstetrics and gynecology. In: Tintinalli J, ed. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York, NY: McGraw Hill; 2007:665-730. 6. American College of Obstetricians and Gynecologists. Management of stillbirth (ACOG Practice Bulletin No. 102). Obstet Gynecol. 2009; 113:748-61. 7. Limbo R, Kobler K. The tie that binds: relationships in perinatal bereavement. MCN Am J Matern Child Nurs. 2010;35(6):316-21. 8. Limbo R, Kobler K, Levang E. Respectful disposition in early pregnancy loss. MCN Am J Matern Child Nurs. 2010;35(5):271-7. 9. Cacciatore J. Stilbirth: patient centered psychological care. Clin Obstet Gynecol. 2010;53(3):691-9. 10. Whitaker C, Kavanaugh K, Klima C, et al. Perinatal grief in Latino patients. MCN Am J Matern Child Nurs. 2010;35(6):341-5. 11. Moore T, Parrish H, Black BP, et al. Interconception care for couples after perinatal loss: a comprehensive review of the literature. J Perinatal Neonatal Nurs. 2011;25(1):44-51. 12. Gold KJ, Dalton VK, Schwenk TL. Hospital care for parents after perinatal death. Obstet Gynecol. 2007;109(5):1156-66. 13. Krenz M, Karlik B, Kiniry S. A nursing diagnosis based model: guiding nursing practice. J Nurs Admin. 1989;19(5):32-6. 14. Bacidore V, Warren N, Chaput C, Keough VA. A collaborative framework for managing pregnancy loss in the emergency department. J Obstet Gynecol Neonatal Nurs. 2009;38(6):730-8.
Submissions to this column are encouraged and may be sent to Nancy McGowan, RN, PhD [email protected]
WWW.JENONLINE.ORG
161