Bereavement care education and training in clinical practice: Supporting the development of confidence in student midwives
need my dissertation to be written i have attached a file that you need to work on please i have started the work so some is already done. i have also attached two examples for you to look at. 3500 words. we will be writing it in chunks for me to get feedback from tutor then we carry on. In addition there is a literature review proposal which is like a plan. is basically a literature review but i have found the articles to support the title.The word ‘Silence’ is used repeatedly, in literature, to describe ex- periences of perinatal death ( Rowlands and Lee, 2010; Rådestad et al., 2014 ). Not a calm, peaceful silence, but a deafening, empty, heart wrenching silence – silence at the time of diagnosis, when the midwife does not know what to say; silence in the delivery room when the mid- wife passes the baby to the mother; and sometimes just silence…and hand holding…and contemplation ( Gold, 2007; Downe et al., 2013 ). Emotions shift from joyous expectations to an explosion of grief and loss. In that silence, midwives bond with mothers and fathers, and share in their experience. Upon confirmation of a baby’s demise or impending demise, moth- ers experience feelings of profound grief, broken expectations, anxiety, ∗ Corresponding author.
E-mail address: [email protected] (S. Cullen).
and a loss of power and competence ( Koopmans et al., 2013; Malm et al., 2011; Kelley and Trinidad, 2012 ). The care received at the time of the loss has long-term implications on parent’s mental health ( Kelley and Trinidad, 2012; Ellis et al., 2016; Lee, 2012; Lasker and Toedter, 1994 ). According to Engler and Lasker (2000) , the support a mother receives, following the death of her child is the single most crucial fac- tor in predicting the nature of the grief process that she will experi- ence. Midwives, in the forefront of these parents’ care, are in the ideal position to sensitively gauge parent’s needs and support them to say goodbye ( Kelley and Trinidad, 2012 ). Though Basile and Thornsteins- son (2015) reported a marked increase in the satisfaction levels of the care received in hospitals over the past two decades, they also report that almost one in four bereaved parents leave the hospital disappointed with their care. This finding is not dissimilar to other studies, all report- https://doi.org/10.1016/j.midw.2018.06.026
Received 16 April 2018; Received in revised form 11 June 2018; Accepted 12 June 2018
0266-6138/© 2018 Elsevier Ltd. All rights reserved.
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ing substandard and inconsistent care ( Cacciatore and Bushfield, 2007; Downe et al., 2013; Erlandsson et al., 2011; Lee, 2012; Rådestad et al., 2014 ). For a midwife, being involved in bereavement can cause feelings of profound sadness and self-doubt, as well as associated physical symp- toms, such as headaches, stomach pain and palpitations ( Halperin et al., 2011; McNamara et al., 2017; Puia et al., 2013 ). In the short term, feel- ings of inadequacy reduce the efficacy of midwives who are trying to manage these challenging situations ( Gandino et al., 2017 ). The long- term implications can be extensive, with research showing higher levels of post-traumatic stress disorder and depression ( Ben-Ezra et al., 2014 ). The risk of burnout also increases, and some healthcare workers con- sider taking a break from or leaving, the profession ( McCool et al., 2009; Sheen et al., 2015; Shorey et al., 2017 ). Repeatedly featured in the lit- erature is the view that midwives never forget these experiences and they change their lives forever ( Jonas-Simpson et al., 2013; Puia et al., 2013 ). Student midwives’ emotional responses are not unlike that of quali- fied midwives. A student’s lack of control in these situations could lead to a constant re-traumatisation and increase the risk of burnout, deper- sonalisation and compassion fatigue ( Abendroth and Flannery, 2006 ). Noted are feelings of diminished confidence to communicate effectively, and limited competence in providing adequate care, among the student cohort ( Begley, 2003 ; Rondinelli et al., 2015 ). Not knowing what to say is foremost in student’s minds when faced with caring for bereaved par- ents ( Mitchell, 2004 ). Research also strongly suggests that bereavement training is inadequate and sparse, and midwives do not feel prepared for this aspect of their job, upon qualification ( Chan et al., 2005; Ellis et al., 2016; Gandino et al., 2017; Gardiner et al., 2016; Gardner, 1999; HFHP, 2005; Wool, 2013 ). In an Irish survey, by Kalu (2016) , it was reported that only 33.2% of midwives have adequate bereavement sup- port knowledge and just 18.7% reported having bereavement support skills. As well as the improvement of training, the significance of staffsupport and debriefing, after an adverse event or bereavement, have repeatedly been stressed as invaluable to health care workers positive mental health ( Cortezzo et al., 2015; Wallbank and Robertson, 2013 ). Burnout and reduced self-compassion can affect midwives as early on in their career as their training ( Boellinghaus et al., 2014 ). Unfortunately, reduced self-compassion can render a midwife less capable of convey- ing authentic compassion towards the women in their care ( Beaumont et al., 2016 ). The publication, in the Republic of Ireland, of the HSE Standards for Bereavement Care Following Pregnancy Loss and Perinatal Death ( Health Service Executive, 2016 ) and the National Maternity Strategy (2016-2026:95) ( DoH, 2016 ) highlighted the need ‘to improve and stan- dardise bereavement care’ in Irish maternity services. Some of the be- reavement care standards, focus on the training and education of staff; providing culturally sensitive care; involving the parents in the decision- making process; making parents aware of available services; as well as staffsupport and self-care. In response to these Reports an interac- tive workshop for Midwifery Students, called the ‘Educational Training Workshop in Bereavement Care’ (ETWBC) was developed, implemented and evaluated. Aims •To determine the Knowledge and the Skills that is required by Stu- dent Midwives to deliver bereavement care to parents following a pregnancy loss or perinatal death. •To improve Student Midwives’ level of confidence (knowledge and skills) in relation to bereavement care before and after participation in an educational training workshop in bereavement. •To improve Student Midwives’ level self-awareness and self- compassion in relation to delivering bereavement care before and after participation in an educational training workshop in bereave- ment.
•To ascertain if there is a link between Organisational support and Student’ Midwives confidence to provide bereavement care to par- ents following a pregnancy loss or perinatal death.
Methods
Design
A longitudinal sequential mixed methods design was used to evaluate the Educational Training Workshop on Bereavement Care (ETWBC) for Student Midwives. The use of a mixed-methods approach in this study enabled the capture of both outcome and process data to strengthen the evaluation. This paper discusses the development of the ETWBC and the results from the outcome evaluation. The results of the process evaluation will be published separately.
Development of the Educational Training Workshop on Bereavement Care (ETWBC)
Step 1: A literature review focusing on issues related to bereavement care associated with pregnancy loss and perinatal death and the education and training needs of midwives was first compiled. Key points from this review influenced the development of ini- tial workshop content and included the following; students easily forget didactic learning approaches around grief and bereave- ment and approaches around theoretical lectures fail to promote reflection on personal reactions ( Breen et al., 2013 ); empathy is a key feature in bereavement care, and as such should be enhanced wherever possible ( Patterson et al., 2016 ); role-play and simu- lations are regarded as a high standard second option to experi- ence, for exploring different communication skills and methods ( Colwell, 2017; Meyer et al., 2009; Tobler et al., 2014 ); there is a general lack of confidence in communication skills when look- ing after bereaved parents ( Steen, 2015; Fenwick et al., 2007 ); Reflective practice for students can contribute to the develop- ment of skilled, self-aware and engaged practitioners ( Gallagher et al., 2017 ); the importance of intrinsic, as well as emotional and informational care, needs to be highlighted ( Gijzen et al., 2016 ); for any intervention to include memory making, shared decision making and physical care; given that working closely with distressed women could contribute to midwives sense of emotional distress, the well-being of the students should be pri- oritised throughout the training process ( Ben-Ezra et al., 2014 ). Step 2: A focus group was held with a panel of experts ( N = 8) which included; representatives from Senior Management, Midwifery and Nursing stafffrom the Neonatal unit, Antenatal wards, and stafffrom Chaplaincy department in the Maternity Hospital. The purpose of the focus group was to discuss the proposed content and method of delivery of the ETWBC and to gain the experts feedback on the appropriateness of the content and the teaching strategies proposed within. The focus group discussion was audio recorded and transcribed to ensure all the points raised were captured. The feedback from the panel of experts was positive and their suggestions were incorporated into the final workshop course outline. Step 3: The content of the ETWBC contained the following; a short inter- active quiz –To assess students’ knowledge to date, using Socra- tive app. The socrative app allows students to answer questions anonymously on their smart phone, the students’ answers ap- pear on the projector screen so the facilitator could discuss the questions with the group. Supporting bereaved parents : what to say/do, understanding good and bad communication (including the video ‘A Letter To My Doctor’ by Wood (2015) ). This video describes a woman’s experiences of a stillbirth and her advice to 2
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healthcare professionals in relation to communicating with be- reaved parents; Making Memories – including the Feileacain (Still Birth and Neonatal Death Association of Ireland) memory box; importance of holding and bathing the baby, photographs, hand and footprints; family member inclusion, highlighting different services available. Interactive role-play using real life scenarios – one antenatal scenario of a mother booked in for induction for a mid-trimester miscarriage; one postnatal scenario of a mother who has delivered a stillborn baby; one cuddle cot demonstra- tion. Using poetry – Elegy for a Stillborn Child’ poem discussion on the different perspectives of loss ( Seamus Heaney, 1966 ); Self- care – Introduction to a reflection journal; mindfulness hour.
Sampling
A convenience sample ( N = 41) of all 4th year B.Sc. Midwifery De- gree and Higher Diploma Midwifery students were invited to participate through a gatekeeper. The exclusion criteria included participants who had recently suffered bereavement, participants who were unavailable or who did not wish to participate.
Ethical considerations
The study was explained to the relevant students, by a gatekeeper, and only students who were interested in receiving more information about the study completed the ‘consent to be contacted’ form and were then contacted by the research assistant. Confidentiality was maintained throughout the study. All questionnaires were coded. Written, informed consent was received from each participant. Due to the sensitive nature of the study, emotional support was put in place for the duration of the study. Support was provided by the students’ clinical tutor (in the university) or clinical placement co-ordinator (in the hospital).
Procedure
The ETWBC was delivered on two occasions; in March 2017 for a cohort of 4th year B.Sc. Midwifery students and the other in May 2017 for a cohort of Higher Diploma Midwifery students. Due to the nature of the content of the workshop, the facilitators ensured a calming and supportive environment was provided throughout the day for the stu- dents and follow-up care was available to the students if required on the day or in the weeks following the ETWBC. Before attending the ETWBC, the participating students were asked open-ended questions about what promotes or inhibits their confidence to provide perinatal bereavement support, and the education they received during lectures on bereave- ment care. The responses to these questions were mixed. Many com- ments were focused on their lack of confidence and minimal exposure, as well as lack of support at times from senior staff.
Data collection
Primary Outcome: Confidence [measured at all 3 time points; pre ETWBC, post ETWBC and at 3-months follow-up] was measured using the Perinatal Bereavement Care Confidence Scale [PBCCS] ( Kalu, 2016 ; Kalu et al., 2017 ).The PBCCS consists of 4 subscales namely the Be- reavement Support Knowledge Scale; Bereavement Support Skills Scale; Self-Awareness Scale and Organisational Support Scale. These are scored using a 5 point Likert scale ranging from strongly disagree to strongly agree (1–5). Two sub-scales namely the Bereavement Support Knowl- edge Scale and Bereavement Support Skills Scale were used to measure confidence. Good psychometric properties on all 4 PBCCS Scales are re- ported by Kalu et al. with Cronbach’s alpha ranging from 0.797 to 0.855. Secondary outcomes: self-awareness, organisational support, self- compassion [measured at all 3 time points; pre ETWBC, post ETWBC and at 3-months follow-up] with the Perinatal Bereavement Care Confidence Scale [PBCCS] ( Kalu, 2016 , Kalu et al., 2017 ) and the Self-Compassion
Scale-Short Form [SCS–Sf] ( Raes et al., 2011 ). Two sub-scales of the PBCCS namely the Self-Awareness Scale and Organisational Support Scale were used to measure self-awareness and organisational support. Participant’s self-compassion was measured using the SCS–Sf. This scale was developed from the Self Compassion Scale (SCS) 24 item scale ( Neff, 2003 ), which contains six components of self-compassion includ- ing self-kindness; self-judgment; common humanity; isolation; mindful- ness, over-identification. The SCS–Sf scales are scored using a 5 point Likert scale ranging (1–5). Good psychometric properties have been re- ported by Raes et al., (2011) with a Cronbach’s alpha value of 0.86. Socio-demographic information [measured at time 1 only]: Information on age range, gender, level of education and prior work experience was captured.
Measures
Perinatal bereavement care confidence scale [PBCCS] ( Kalu, 2016 ; Kalu et al., 2017 )
The PBCCS was chosen for the study as it had been recently devel- oped with Midwives providing bereavement care in an Irish Maternity Care Service, the PBCCS has good inter-rated reliability and face va- lidity. The PBCCS consists of 4 subscales namely the Bereavement Sup- port Knowledge Scale; Bereavement Support Skills Scale; Self-Awareness Scale and Organisational Support Scale. These are scored using a 5-point Likert scale ranging from strongly disagree to strongly agree (1–5). Two sub-scales namely the Bereavement Support Knowledge Scale and Be- reavement Support Skills Scale were used to measure confidence. Two sub-scales of the PBCCS namely the Self-Awareness Scale and Organi- sational Support Scale were used to measure self-awareness and organ- isational support. Good psychometric properties on all 4 PBCCS Scales are reported by Kalu et al. with Cronbach’s alpha ranging from 0.797 to 0.855.
Self-compassion scale [SCS–Sf] ( Raes et al., 2011 )
Participant’s self-compassion was measured using 12-item Self- Compassion Scale–Short Form (SCS–SF). This scale was developed from the Self-Compassion Scale (SCS) 24 item scale ( Neff, 2003 ), which contains six components of self-compassion including self- kindness; self-judgment; common humanity; isolation; mindfulness, over-identification. This scale was chosen over the original one as it was short and “offered an economical alternative …was reliable and has the same factorial structure as the original scale ”(Raes et al. Pg250). The SCS–Sf scales are scored using a 5-point Likert scale ranging (1–5). Good psychometric properties have been reported by Raes et al. with a Cron- bach’s alpha value of 0.86 for the total scale score which was the score used in this study.
Data analysis
Quantitative data obtained from the questionnaires was analysed by computer using IBM Statistical Package for the Social Sciences (SPSS version 24.0) and p < .05 was set as significant. Both descriptive and in- ferential statistics were used in the analysis and description of the data set using univariate and bivariate statistics where appropriate. Descrip- tive statistics (frequencies, measures of central tendency, and measures of variability) was used to summarise results from the instruments used in the study. The types of nonparametric inferential tests used to analyse data was determined by the level of measurement and assumptions of normality. A series of repeated measures ANOVA’s were used to address the main study questions. 3
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Table 1
Demographics.
Age
78.9% ( n = 30) of the participants were 20–29 years of age.
15.8% ( n = 6) of the participants were 30–39 years of age.
5.3% ( n = 2) of the participants were 40–49 years of age.
Higher diploma student midwives previous experience in the nursing
18.4% ( n = 7) had 1–2 years’ experience
15.8% ( n = 6) had 3–4 years’ experience
13.2% ( n = 5) had 5–6 years’ experience
No participants had 7–8 years’ experience
2.6% ( n = 1) had 9–10 years’ experience
5.3% ( n = 2) had over 10 years’ experience
Results
Demographics
Of the total 41 eligible Higher Diploma and 4th year B.Sc. midwifery, 39 students participated in the workshop and 38 (97.44%) of the partic- ipants completed all 3 questionnaires. All participants were female, 21 (55.3%) were Higher Diploma Midwifery students with the 18 (44.7%) of the participants registered on the 4 year B.Sc. Midwifery Programme. The majority of participants 78.9% ( n = 30) were aged between 20 and 29 years of age. No students on the B.Sc. Midwifery programme had experience working in nursing related services prior to commencement studies, whereas all Higher Diploma students had previous experience (see Table 1 ).
Primary outcome – confidence
The confidence of the student midwives to provide bereavement care to parents who have experienced a perinatal loss was measured using 2 subscales from the PBCCS namely, Bereavement Support Knowledge and Bereavement Support Skills. Bereavement support knowledge: a one-way repeated measures ANOVA was conducted to compare Student Midwives level of the bereavement support knowledge at Time 1 (prior to the ETWBC), Time 2 (1 week following the ETWBC) and Time 3 (3-month follow-up) (see Table 2 ). Mauchly’s Test of Sphericity was non-significant and Sphericity was assumed. There was a statistically significant difference [ F (2,72) = 21.150, p < .000, partial eta squared = 0.370] in Student Midwives level of bereavement support knowledge between the 3 time points in this study. Post hoc Bonferroni tests indicated that Student Midwives’ level of bereavement support knowledge prior to participating in the ETWBC (Time 1; M = 55.08, SD 3.83) was significantly lower than their level of bereavement support knowledge following their participation in the ETWBC (Time 2; M = 57.03, SD 2.95; Mean difference − 1.946 p < .005) and was also was significantly lower than their level of bereavement support knowledge at 3 months follow-up (Time 3; M = 58.65, SD3.54; Mean difference − 3.568 p < .000). Furthermore, Student Midwives’ level of bereavement support knowledge improved between Time 2 post ETWBC and at the 3-month follow-up (mean difference − 1.622, p < .005). In summary, Student Midwives bereavement support knowl- edge improved following their participation in the educational training workshop in bereavement care, and this improvement was sustained at the 3- month follow-up. Bereavement support skill: a one-way repeated measures ANOVA was conducted to compare Student Midwives level of the bereavement sup- port skill at Time 1 (prior to the ETWBC), Time 2 (1 week following the ETWBC) and Time 3 (3-month follow-up) (see Table 2 ). Mauchly’s Test of Sphericity was significant ( p < .008) therefore Greenhouse- Geisser results were used. There was a statistically significant difference [ F (1.6,60) = 48.460, p < .000, partial eta squared = 0.567] in Student
Midwives level of bereavement support skill between the 3 Time Points in this study. Post hoc Bonferroni tests indicated that Student Midwives’ level of bereavement support skills prior to participating in the ETWBC (Time 1; M = 27.74, SD = 4.64) were significantly lower than their level of be- reavement support skills following their participation in the ETWBC (Time 2; M = 32.58, SD 3.10; Mean difference − 4.842 p < .000) and were also was significantly lower than their level of bereavement support skills at 3 months follow-up (Time 3; M = 33.84, SD = 3.26; Mean dif- ference − 6.105 p < .000). Furthermore, Student Midwives’ level of be- reavement support skills improved between Time 2 post ETWBC and at the 3-month Follow-up (Mean difference − 1.263 p < .000). In summary, Student Midwives bereavement support skills improved following their participation in the educational training workshop in bereavement care, and this improvement was sustained at the 3-month follow-up.
Secondary outcomes – self-awareness
The self-awareness of the student midwives to provide bereavement care to parents who have experienced a perinatal loss was measured using 2 subscales (‘awareness of the needs of bereaved parents’ and ‘awareness of my personal needs in relation to providing bereavement support’) from the PBCCS. Awareness of the needs of bereaved parents ; a one-way repeated measures ANOVA was conducted to compare Student Midwives’ self- awareness of the needs of bereaved parents at Time 1 (prior to the ETWBC), Time 2 (1 week following the ETWBC) and Time 3 (3-month follow-up) (see Table 2 ). Mauchly’s Test of Sphericity was non- significant and Sphericity was assumed. There was a statistically signifi- cant difference [ F (2,72 ) = 20.311, p < .000, partial eta squared = 0.361] in Student Midwives level of self-awareness of the needs of bereaved families between the 3 Time Points in this study. Post hoc Bonferroni tests indicated that Student Midwives self- awareness prior to participating in the ETWBC ( M = 18.86, SD 2.8) were significantly lower than their level of self-awareness of the needs of bereaved parents following their participation in the ETWBC (Time 2; M = 20.92, SD 2.31; Mean difference − 2.054 p < .001) and were also was significantly lower than their level of self-awareness of the needs of bereaved families at 3 months follow-up (Time 3; M = 21.59, SD1.8; Mean difference − 2.730 p < .000). Student Midwives’ self-awareness of the needs of bereaved parents did not change significantly between Time 2 post ETWBC and at the 3-month follow-up (mean difference − 0.676 p > .05). In summary, Student Midwives self-awareness of the needs of bereaved parents improved following their participation in the educa- tional training workshop in bereavement care, and this improvement was maintained at the 3 month follow-up though it did not change sig- nificantly between Time 2 and Time 3. A one-way repeated measures ANOVA was conducted to compare Student Midwives level of the self-awareness of personal needs in rela- tion to providing bereavement support at Time 1 (prior to the ETWBC), Time 2 (1 week following the ETWBC) and Time 3 (3-month follow-up) (see Table 2 ). Mauchly’s Test of Sphericity was significant ( p < .028) therefore Greenhouse-Geisser results were used. There was a statisti- cally significant difference [ F (1.7, 61) = 30.387, p < .000, partial eta squared = 0.458] in Student Midwives level of self-awareness of their personal needs in relation to providing bereavement support between the 3 Time Points in this study. Post hoc Bonferroni tests indicated that Student Midwives self- awareness of their personal needs in relation to providing bereavement support prior to participating in the ETWBC ( M = 9.89, SD 1.74) was significantly lower than their self-awareness of their personal needs following their participation in the ETWBC (Time 2; M = 12.00, SD 1.53; Mean difference − 2.108 p < .000) and were also was signifi- cantly lower than their level of self-awareness of their personal needs at the 3 month follow-up (Time 3; M = 12.16, SD 1.90; Mean differ- ence − 2.270 p < .000). Student Midwives’ self-awareness of their needs 4
