Recruitment and retention strategies for expert nurses in abortion care provision

Providers' experiences with abortion care: A scoping review

BACKGROUND

Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care.

METHODS AND FINDINGS

This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care.

CONCLUSIONS

The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

Collaboration between maternal-fetal medicine and family planning: a survey of Northeast US academic medical centers

OBJECTIVES

To explore how complex family planning (CFP) and maternal-fetal medicine (MFM) in Northeast academic medical centers work together to provide abortion care.

METHODS

We distributed an exploratory cross-sectional online survey to CFP and MFM faculty and fellows at academic medical centers in the Northeast between July and September of 2020. The survey included demographic information, assessment of practice patterns, hospital/administration support and assessment of collaboration. Likert scale questions examined opinions about collaboration and an open-ended question solicited ideas for improvement. We performed bivariate analysis to examine the association between subspecialty and practice location regarding provision of abortion care and perceived barriers to care.

RESULTS

The response rate was 31 % and was similar by specialty. Of the 69 respondents, 83 % were MFMs, 75 % were faculty, and 54 % practiced in New York. More than 85 % reported personal participation in some portion of abortion care. The two most common perceived barriers to care were "lack or reluctance of physicians/staff" and state laws prohibiting termination. Nearly all (95 %) stated there was a good working relationship between CFP and MFM divisions; however, almost one-third agreed with or were neutral to the statements "MFM and CFP are siloed in terms of work/patient care."

CONCLUSIONS

Academic MFM and CFP providers in the Northeast collaborate well in providing abortion care, though our findings highlight areas that would benefit from improvement. Optimizing collaboration in the Northeast is important given its regional role for ensuring abortion access in the current national landscape. Improved education of all members of the patient care team on the importance of abortion access may also help provide optimal patient care where abortion services still legally exist.

Health providers' reasons for participating in abortion care: A scoping review

BACKGROUND

There is a global shortage of health providers in abortion care. Public discourse presents abortion providers as dangerous and greedy and links 'conscience' with refusal to participate. This may discourage provision. A scoping review of empirical evidence is needed to inform public perceptions of the reasons that health providers participate in abortion.

OBJECTIVE

The study aimed to identify what is known about health providers' reasons for participating in abortion provision.

ELIGIBILITY CRITERIA

Studies were eligible if they included health providers' reasons for participating in legal abortion provision. Only empirical studies were eligible for inclusion.

SOURCES OF EVIDENCE

We searched the following databases from January 2000 until January 2022: Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, ScienceDirect and Centre for Agricultural and Biosciences International Abstracts. Grey literature was also searched.

METHODS

Dual screening was conducted of both title/abstract and full-text articles. Health providers' reasons for provision were extracted and grouped into preliminary categories based on the existing research. These categories were revised by all authors until they sufficiently reflected the extracted data.

RESULTS

From 3251 records retrieved, 68 studies were included. In descending order, reasons for participating in abortion were as follows: supporting women's choices and advocating for women's rights (76%); being professionally committed to participating in abortion (50%); aligning with personal, religious or moral values (39%); finding provision satisfying and important (33%); being influenced by workplace exposure or support (19%); responding to the community needs for abortion services (14%) and participating for practical and lifestyle reasons (8%).

CONCLUSION

Abortion providers participated in abortion for a range of reasons. Reasons were mainly focused on supporting women's choices and rights; providing professional health care; and providing services that aligned with the provider's own personal, religious or moral values. The findings provided no evidence to support negative portrayals of abortion providers present in public discourse. Like conscientious objectors, abortion providers can also be motivated by conscience.

The Use of Nursing Theory to Support Sexual and Reproductive Health Care Education in Nursing Curricula

BACKGROUND

Inclusive sexual and reproductive health care (SRH) content is limited in nursing curricula, resulting in nurses who lack education to provide complex SRH services to marginalized patients, especially sexual and gender minorities (SGM).

METHOD

The 10 Caritas Processes, the framework of Watson's Theory of Caring, were evaluated for being integral components of SRH. This theory is used to advocate for SGM-inclusive SRH content in nursing curricula.

RESULTS

The interpretation of Caritas Processes 2, 4, and 7 provide theoretical support for SGM-inclusive SRH content. Specific strategies to modify and improve nursing curricula are described.

CONCLUSION

There is a need to incorporate inclusive SRH education into nursing curricula to normalize evidence-based SRH for diverse, marginalized patient populations. By emphasizing the caring intentions necessary for nursing professionals, Watson's Theory of Caring is an appropriate framework to guide the development of SGM-relevant SRH content in nursing education. [J Nurs Educ. 2023;62(2):69-74.].

Barriers and enablers to nurse practitioner implementation of medication abortion in Canada: A qualitative study

In this study we explored nurse practitioner-provided medication abortion in Canada and identified barriers and enablers to uptake and implementation. Between 2020-2021, we conducted 43 semi-structured interviews with 20 healthcare stakeholders and 23 nurse practitioners who both provided and did not provide medication abortion. Data were analyzed using interpretive description. We identified five overarching themes: 1) Access and use of ultrasound for gestational dating; 2) Advertising and anonymity of services; 3) Abortion as specialized or primary care; 4) Location and proximity to services; and 5) Education, mentorship, and peer support. Under certain conditions, ultrasound is not required for medication abortion, supporting nurse practitioner provision in the absence of access to this technology. Nurse practitioners felt a conflict between wanting to advertise their abortion services while also protecting their anonymity and that of their patients. Some nurse practitioners perceived medication abortion to be a low-resource, easy-to-provide service, while some not providing medication abortion continued to refer patients to specialized clinics. Some participants in rural areas felt unable to provide this service because they were too far from emergency services in the event of complications. Most nurse practitioners did not have any training in abortion care during their education and desired the support of a mentor experienced in abortion provision. Addressing factors that influence nurse practitioner provision of medication abortion will help to broaden access. Nurse practitioners are well-suited to provide medication abortion care but face multiple ongoing barriers to provision. We recommend the integration of medication abortion training into nurse practitioner education. Further, widespread communication from nursing organizations could inform nurse practitioners that medication abortion is within their scope of practice and facilitate public outreach campaigns to inform the public that this service exists and can be provided by nurse practitioners.

Abortion policy implementation in Ireland: successes and challenges in the establishment of hospital-based services

Objective

To describe successes and highlight remaining challenges in the establishment of hospital-based abortion services after legal change in the Republic of Ireland.

Methods

We conducted a mixed-methods study on the implementation of abortion policy in Ireland. In this manuscript, we present the results from a qualitative analysis of in-depth interviews conducted with hospital-based providers, service users, and key informants. We used Dedoose software to conduct a thematic analysis of the data.

Results

We report findings from interviews with 28 obstetrician gynecologists, midwives, psychiatrists, anesthesiologists, and nurses; a subset of 7 service users who sought care in hospitals; and 27 key informants. In this analysis, we describe how key themes that pertain to information, capacity and power, facilitated and hindered the implementation of hospital-based abortion services. We found that individual champions are key to establishing the service, but their motivation is not always sufficient to integrate abortion into existing clinical services, and conscientious objection is a persistent barrier to expanding abortion services. The main challenges highlighted here are lack of abortion provision at some hospitals and limited access to surgical abortion at most hospitals due to provider-level, logistical, and infrastructure barriers.

Conclusions

This study presents new information on how abortion policy is implemented on the ground in hospital settings. Its findings can inform public health officials and providers in Ireland and other countries wishing to establish abortion services.

Supporting Staff in Southern Family Planning Clinics: Challenges and Opportunities

Objectives

The aim of this study was to identify key challenges and opportunities to better support non-clinician clinic staff at family planning centers in Southern US states.

Methods

We conducted qualitative interviews with 15 individuals in clinic staff and leadership positions at family planning centers in seven Southern states.

Results

Turnover had negative impacts on both clinic functioning as well as patient care. Participants identified several challenges related to recruitment and retention in family planning health centers in the South, including the conservative contextual landscape, the perceived value of support staff, gaps in communication, and rural locations. In response to these challenges, staff also identified key strategies to better support and retain health center workers. These included prioritizing investment in management, creating career advancement opportunities, prioritizing staff retention, and creating space for self-care. Health center staff and leadership who used these strategies to support and retain staff noted improvements in the effectiveness of staff work as well as increases in patient volume.

Conclusions for Practice

Study findings provide key areas for intervention including providing development opportunities, commitment from leadership to recognize and invest in staff and supporting self-care. Focusing on ensuring internal organizational justice for staff may also facilitate resilience to external challenging environments. Better supporting clinic staff is likely also important for quality services and ensures the full workforce involved in providing family planning care can work at full capacity.

The Space in the Middle: Attitudes of Women's Health and Neonatal Nurses in the United States about Abortion

INTRODUCTION

Despite playing an integral part in sexual and reproductive health care, including abortion care, nurses are rarely the focus of research regarding their attitudes about abortion.

METHODS

A sample of 1,820 nurse members of the Association of Women's Health, Obstetric, and Neonatal Nurses were surveyed about their demographic and professional backgrounds, religious beliefs, and abortion attitudes. Scores on the Abortion Attitudes Scale were analyzed categorically and trichotomized in multinomial regression analyses.

RESULTS

Almost one-third of the sample (32%) had moderately proabortion attitudes, 29% were unsure, 16% had strongly proabortion attitudes, 13% had strongly antiabortion attitudes, and 11% had moderately antiabortion attitudes. Using trichotomized Abortion Attitudes Scale scores (proabortion, unsure, antiabortion), adjusted regression models showed that the following characteristics were associated with proabortion attitudes: being non-Christian, residence in the North or West, having no children, and having had an abortion.

CONCLUSIONS

Understanding nurses' attitudes toward abortion, and what characteristics may influence their attitudes, is critical to sustaining nursing care for patients considering and seeking abortion. Additionally, because personal characteristics were associated with antiabortion attitudes, it is likely that personal experiences may influence attitudes toward abortion. A large percentage of nurses held attitudes that placed them in the "unsure" category. Given the current ubiquitous polarization of abortion discourse, this finding indicates that the binary narrative of this topic is less pervasive than expected, which lends itself to an emphasis on empathetic and compassionate nursing care.

Anesthesia providers' perspectives on abortion provision: deductive findings from a qualitative study

INTRODUCTION

A clinician's willingness to provide abortion care is complex. Anesthesia providers' experiences in providing anesthesia for abortion are not well studied. We aimed to explore anesthesia providers' perspectives on abortion provision.

METHODS

We conducted semi-structured, qualitative interviews with currently practising anesthesia providers in the southeastern United States. Participants were recruited from scientific meetings of two regional anesthesiology organizations and via snowball sampling. A semi-structured interview guide included domains of standardized second trimester abortion cases and personal abortion attitudes. Data were coded and analyzed iteratively using both inductive and deductive approaches with MAXQDA software. Deductive results are presented.

RESULTS

Fifteen participants completed interviews from February 2018 to February 2019, at which point thematic saturation occurred. Participants represented a range of provider type, years of experience, workplace setting, and prior abortion experience. Participants demonstrated varied personal abortion attitudes, with greater acceptability of maternal or fetal health indications than social or financial indications for abortion. Most participants were willing to provide anesthesia for abortion in specific clinical scenarios.

CONCLUSIONS

Southeastern United States anesthesia providers hold a spectrum of personal views on abortion and are willing to provide anesthesia for second trimester abortion in specific clinical scenarios. Findings may inform future research or professional development activities, which are important efforts toward improving multidisciplinary abortion care.

Factors influencing retention among hospital nurses: systematic review

BACKGROUND

Recruitment and retention of nursing staff is the biggest workforce challenge faced by healthcare institutions. Across the UK, there are currently around 50 000 nursing vacancies, and the number of people leaving the Nursing and Midwifery Council register is increasing.

OBJECTIVE

This review comprehensively compiled an update on factors affecting retention among hospital nursing staff.

METHODS

Five online databases; EMBASE, MEDLINE, SCOPUS, CINAHL and NICE Evidence were searched for relevant primary studies published until 31 December 2018 on retention among nurses in hospitals.

RESULTS

Forty-seven studies met the inclusion criteria. Nine domains influencing staff turnover were found: nursing leadership and management, education and career advancement, organisational (work) environment, staffing levels, professional issues, support at work, personal influences, demographic influences, and financial remuneration.

CONCLUSION

Identified turnover factors are long-standing. To mitigate the impact of these factors, evaluation of current workforce strategies should be high priority.

"It's a horrible assignment": A qualitative study of labor and delivery nurses' experience caring for patients undergoing labor induction for fetal anomalies or fetal demise

OBJECTIVES

This study sought to explore labor and delivery (L&D) nurses' experiences caring for women undergoing induction for intrauterine fetal demise (IUFD) or termination for fetal anomalies, and to characterize reluctance towards participation in abortion care or - conversely - the commitment to provide services.

STUDY DESIGN

Researchers conducted a qualitative study that consisted of open-ended, semistructured interviews with 15 registered nurses who care for women on L&D at a large metropolitan hospital. We analyzed these data for content and themes.

RESULTS

Labor and delivery nurses struggle emotionally, logistically, and morally with bereavement care, whether their patients are experiencing an IUFD or termination for fetal anomalies. The analysis generated the following themes: the emotionally intense work of perinatal loss, feelings of incompetence in bereavement care, ethical conflicts, and judgment of both termination and IUFD patients. In addition, nurses who chose to provide care for patients undergoing induction termination for fetal anomalies described a duty to care for all patients despite the increased logistic and emotional burden.

CONCLUSIONS

Much of the discomfort L&D nurses reported caring for patients undergoing induction termination stems from the emotional toll, lack of skills, and bureaucratic burden of bereavement care rather than a moral objection to abortion. Instituting interventions to improve staffing, simplify paperwork, augment bereavement training, and improve support for the emotional burden of caring for these patients may therefore increase access to competent and compassionate abortion care.

IMPLICATIONS

Labor and delivery nurses struggle with bereavement care whether their patients are experiencing an IUFD or termination for fetal anomalies. Instituting interventions - like interdisciplinary simulation - to support nurses in bereavement care may increase the number willing to participate in abortion care, thereby improving patient access.

Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care

OBJECTIVE

To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation.

DESIGN

Retrospective chart review.

METHODS

Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge.

SETTING

A single clinical site that employs seven expert nurses.

PARTICIPANTS

A total of 194 medical records were available for this analysis.

RESULTS

All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038).

CONCLUSION

Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.