Learning about maternal death and grief in the profession: a pilot qualitative study

Which events are experienced as traumatic by obstetricians and gynaecologists, and why? A qualitative analysis from a cross-sectional survey and in-depth interviews

OBJECTIVES

To explore the events perceived as traumatic by obstetricians and gynaecologists (O&G), and to examine factors contributing to the perception of trauma.

DESIGN

Mixed methods: cross-sectional survey and in-depth interviews.

SAMPLE AND SETTING

Fellows, members and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG).

METHODS

An online survey was distributed to 6300 fellows (May-June 2017), members and trainees of RCOG; 1095 (17%) completed surveys were returned. Of these, 728 (66%) reported work-related trauma experience, with 525 providing a brief description of an event. Forty-three participants with trauma experience were purposively sampled and completed an in-depth interview (October 2017-March 2018), which were analysed using Template Analysis. Information regarding the scale and impact of trauma experience is presented elsewhere. The present analysis provides new information describing the events and perceptions of why events were traumatic.

PRIMARY OUTCOME MEASURES

The nature of traumatic events in this clinical setting, taken from survey descriptions of perceived traumatic events and information from the in-depth interviews.

RESULTS

Events perceived as traumatic by O&G were similar between consultants, trainees and other RCOG members no longer working in O&G. Maternal or neonatal death/stillbirth, haemorrhage and events involving a difficult delivery were most frequently reported. Sudden and unpredictable events, perceived preventability, acute sensory experiences and high emotionality contributed to trauma perception. Respondents' trauma was compounded by an absence of support, involvement in investigation procedures and pre-existing relationships with a recipient of care.

CONCLUSIONS

Identification of events most likely to be perceived as traumatic, and wider circumstances contributing to the perception of trauma, provide a basis on which to focus preventative and supportive strategies for O&G. Training on the nature of traumatic events, self-help for early stress responses, processing support and rapid access to trauma-focused psychological input (where required) are needed.

"Once you get one maternal death, it's like the whole world is dropping on you": experiences of managing maternal mortality amongst obstetric care providers in Ghana

BACKGROUND

Maternal mortality has a significant global impact, especially in low-resource settings. Little prior research has been conducted on the potential effects of poor maternal outcomes on the personal and professional well-being of healthcare providers. This study explores the in-depth experiences and perspectives of obstetric providers in Ghana who work in a setting with frequent maternal mortalities.

METHODS

This is a qualitative study of semi-structured interviews conducted at the Komfo Anokye Teaching Hospital in Ghana. Participants were obstetric healthcare providers, defined as midwives, house officers currently rotating on the obstetrics/gynecology service, and obstetrician/gynecologists at any training or practice level (residents, fellows, and specialists). Interviews were audio-recorded, transcribed verbatim, and uploaded into NVivo for qualitative analysis. Using the Attride-Stirling qualitative model, an incremental and iterative process was used to code interviews with keyword phrases and develop a framework of organizing and global themes.

RESULTS

Interviews were conducted with 27 participants-15 midwives and 12 physicians (three obstetrician/gynecologist residents, six obstetrician/gynecologist specialists, and three house officers), with sample size determined by data saturation. Obstetric providers' experiences in a setting with frequent maternal mortalities were dependent on their level of preparedness to manage maternal mortalities and the workplace environment. Providers' level of preparedness was dependent on both the training they had received on the medical management of obstetric emergencies, as well as a lack of training on the mental health aspects of coping with maternal mortality. The impact of the workplace environment was dependent on systems failures and limited resources, blame from colleagues and supervisors, and a lack of support in the workplace. In turn, obstetric providers' experiences managing frequent maternal mortalities impacted their clinical care performance and mental health.

CONCLUSIONS

Maternal deaths have profound personal and professional impacts on the healthcare providers who manage them. A large need exists for additional institutional training and support for obstetric providers who manage maternal mortality, especially in low-resource settings like Ghana.

More than burnout: qualitative study on understanding attrition among senior Obstetrics and Gynaecology UK-based trainees

OBJECTIVES

Workforce retention among UK-based Obstetrics and Gynaecology (O&G) trainees has been a particular concern for a number of years, with 30% trainees reportedly leaving specialty training. With specialty focused research being limited and tending to analyse the training programme as a whole. The aim of this study was to explain why senior O&G trainees within reach of completing training were leaving the specialty.

DESIGN

Qualitative study based on Constructivist Grounded Theory methodology using semi-structured interviews. Data collection and analysis continued until theoretical saturation was achieved. The key themes were used to build an explanatory model, in the form of a concept map for attrition.

SETTING

London.

PARTICIPANTS

Nine senior O&G trainees (ST5-7) of which six were committed to the specialty, two were not going to pursue a consultancy post once training was complete and one ex-trainee.

RESULTS

Five major themes emerged from the study, of which four; 'Just get on with it', 'Just a number', 'Tick-box exercise' and 'It has not happened to me but…' were described by all participants. However, the final theme, relating to the lack of professional identity, 'I did not see myself as an Obstetrician and Gynaecologist' was only demonstrated among those who had left or were not going to pursue a consultancy post once training was complete. Potential strategies for facilitating professional identity development were focused into three areas; establishing meaningful connections, adequate support mechanisms and regional initiatives.

CONCLUSION

Previous research on attrition in the medical profession have suggested burnout and the lack of resilience as being the key factors for leaving training. However, based on this study's findings, an alternative pathway related to the lack of professional identity has been proposed for senior O&G trainees.

ETHICS

This study was registered at King's College London, Kings Reference: LRU-18/19-10632 and was awarded ethical approval through the Research Ethics Committee (REMAs).

Healing Our Own: A Randomized Trial to Assess Benefits of Peer Support

OBJECTIVES

This study aimed to develop and evaluate a structured peer support program to address the needs of providers involved in obstetric adverse outcomes.

METHODS

In this pilot randomized controlled trial, participants were providers who experienced an obstetric-related adverse outcome. Providers were randomly assigned to routine support (no further follow-up) or enhanced support (follow-up with a trained peer supporter). Participants completed surveys at baseline, 3 months, and 6 months. The primary outcome was the use of resources and the perception of their helpfulness. Secondary outcomes were the effect on the recovery stages and the duration of use of peer support.

RESULTS

Fifty participants were enrolled and randomly assigned 1:1 to each group; 42 completed the program (enhanced, 23; routine, 19). The 2 groups were not significantly different with respect to event type, demographics, or baseline stage; in both groups, most participants started at the stage 6 thriving path. Most participants required less than 3 months of support: 65.2% did not need follow-up after the first contact, and 91.3% did not need follow-up after the second contact. Participants who transitioned from an early stage of recovery (stages 1-3) to the stage 6 thriving path reported that they most often sought support from peers (P = 0.02) and departmental leadership (P = 0.07). Those in the enhanced support group were significantly more likely to consider departmental leadership as one of the most helpful resources (P = 0.02).

CONCLUSIONS

For supporting health care providers involved in adverse outcomes, structured peer support is a practicable intervention that can be initiated with limited resources.

Preparedness to deal with maternal mortality among obstetric providers at an urban tertiary hospital in Ghana

OBJECTIVE

This study explores the impacts of managing frequent maternal mortalities on obstetric healthcare providers in Ghana.

METHODS

Two hundred and seventy obstetric providers at the Komfo Anokye Teaching Hospital in Ghana completed an electronic survey. Questions included coping strategies, sources and adequacy of support, training, and emotional impact. Logistic regression assessed predictors of perceived preparedness to manage maternal mortalities.

RESULTS

Over half of participants (55.1%) did not report adequate support to deal with maternal death and only 35.9% received training. The vast majority (96.4%) agreed that managing maternal deaths takes a large emotional toll-27.6% considered giving up their obstetric practice, half experienced guilt or shame, and half worried about legal or disciplinary action. After adjusting for age, gender, years in practice, and annual maternal mortalities managed, perceived adequacy of support (odds ratio [OR] 6.6, 95% confidence interval [CI] 3.0-14.7, P < 0.001) and receiving training (OR 9.5, 95% CI 3.5-25.8, P < 0.001) were significantly associated with preparedness to deal with maternal mortality.

CONCLUSION

Managing maternal mortalities has significant emotional impact on obstetric healthcare providers. Preparedness to deal with maternal death is significantly improved when providers receive adequate support and training.

De-stressing From Distress: Preliminary Evaluation of a Nurse-Led Brief Debriefing Program

In critical care units, distressing events related to patient and family-centered care can influence job dissatisfaction and emotional distress.1-8 Strategies for processing difficult incidents are limited, creating a need for standardized real-time debriefing tools. This study evaluated an innovative nurse-led program that was developed and piloted in one acute care unit of a large academic medical center. An evidence-based practice nurse-led debriefing process provided a sequential process for facilitation of an interdisciplinary group after the occurrence of a distressing event. Throughout a 2-year period, 104 real-time debriefings (>380 staff participation) took place. Emergent situations precipitated the most debriefings followed by disruptive patient/family behavior. Over 80% of the participants affirmed the debriefing process was beneficial, assisted them in coping with the traumatic event, and recommended this type of debriefing to others. These results show that members of an interdisciplinary team will engage in a brief (∼10 minute) nurse-led debriefing program when offered the opportunity to do so, and that this intervention was successful beyond the acute care unit where it originated.

The impact of critical incidents on nurses and midwives: A systematic review

AIMS

To synthesise the existing literature, which focuses on the impact of critical incidents on nurses and midwives, and to explore their experiences related to the support they received in the current healthcare environment to move on from the event.

DESIGN

Systematic review and qualitative synthesis.

DATA SOURCES

The electronic databases CINAHL, MEDLINE, PsycINFO, PubMed, Embase and Nursing and Allied Health (ProQuest) were systematically searched from 2013-2018, and core authors and journals identified in the literature were manually investigated.

REVIEW METHODS

Qualitative studies of all research design types written in English were included according to the PRISMA reporting guidelines. The methodological quality of included studies was evaluated using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research.

RESULTS

A total of 7,520 potential publications were identified. After removal of duplicate citations, study selection and appraisal process, 11 qualitative primary research papers progressed to the meta-synthesis by meta-aggregation. The 179 findings and sub-findings from the included studies were extracted, combined and synthesised into three statements addressing three different aspects within the context of critical incidents: the experiences of the impact, the perceptions of support and the ability to move on.

CONCLUSION

This review illuminated that moving-on after critical incidents is a complex and wearisome journey for nurses and midwives. More attention should to be drawn to second victims within general nursing and midwifery practice to strengthen their ability to navigate the aftermath of critical incidents and reclaim the professional confidence indispensable to remain in the workforce.

Adverse events as transitional markers - Using liminality to understand experiences of second victims

Healthcare professionals are socialized into a tacit, professional identity of competences and skills - to save lives, repair trauma and facilitate good and trustful relational care. When severe adverse events happen, healthcare professionals may struggle to accept their own fallibility, and the event may pose a threat to the selfdeclared 'superior' or 'infallible' professional identity. The consequences of a sudden identity shift between the 'potentially infallible HCP' and 'potentially fallible HC P' caused by an adverse event is the analytical object of this study. The aim of the paper is to derive new understandings of how HCPs in maternity services experience adverse events by using Arnold van Gennep's and Victor Turner's 'rites of passage' theorizations and the concept of liminality to explain the process of transition between the two professional identities. Through five focus groups conducted in June 2018 with midwives and obstetricians-gynecologists, we have examined i) how second victim experiences can be understood using theories of transition and liminality, and ii) how the organizational procedures in a Danish university hospital may serve as a ritual for the involved HCPs in the aftermath of adverse events. The findings suggest that the inconsistency in the level of support contributes to the chaos that may be experienced by the healthcare professional. The organizational structure does not provide rites of transition or any other ritual processes, except for debriefings that, in many cases, are experienced as deficient. Since liminal states suggest danger and threat, because the previous professional identity is replaced by ambiguity and separation, the lack of clear rituals and support may put further strain on the HCP adding to the associated psychological and social distress. Considering the liminality and the need for structured transition rites within the work environment may prove useful when constructing adequate second victim support programs.

The second victim phenomenon in health care: A literature review

Aim: This study aimed to explore the knowledge on the second victim phenomenon (SVP) in health care, more specifically within the speciality of obstetrics. Methods: An extensive electronic search of multiple databases, with additional hand searching of the reference lists of pertinent articles regarding the SVP, was performed from May 2017 to December 2018. Results: A review of the literature suggests consistent evidence of the substantial impact of adverse medical events on health-care professionals across a range of specialities. The effects of an adverse medical event for the health-care professional are ominous, with many experiencing feelings of sadness, guilt and anxiety, as well as some displaying symptoms consistent with post-traumatic stress disorder. Negative effects may be exacerbated for health-care professionals in the case of an adverse maternal event due to its highly sensitive and dramatic nature, involving both maternal and neonatal lives. The provision of timely and effective support at the individual and more specifically the organisational level has been positively correlated with a second victim’s recovery. Yet, limited organisations have formal support interventions designed specifically for the needs of the second victim. Conclusions: It is evident that the consequences of adverse medical events on health-care professionals can be intense and numerous. The unique nature and high sensitivities surrounding obstetric care have the potential to exacerbate the negative consequences for the health-care professional following an adverse event. Still, there remains a dearth of information of the extent of adverse medical events and the SVP in the speciality of obstetrics.

The perceived effect of serious adverse perinatal events on clinical practice. Can it be objectively measured?

OBJECTIVE

Obstetrics involves a high degree of clinical risk. While serious adverse events resulting in substantial maternal or neonatal morbidity or mortality are relatively rare it has been shown that exposure to a such an event can have a predominantly negative personal and professional impact on the healthcare professionals who are involved. There is little in the published literature to show an objective change in clinical practice as a result of an adverse event. The aim of this study was to identify if it was feasible to design a study that could objectively demonstrate if a change in labour ward clinical activity occurred in the 28 days following a serious adverse perinatal event. If this proved possible, the second aim was to identify if these changes could be attributed to the preceding adverse event.

STUDY DESIGN

This study was conducted in a large tertiary teaching hospital in Ireland. This was a retrospective observational study conducted using data from a 25-month period from August 2013 to September 2015. Six of the most serious adverse perinatal events that occurred over that time period were identified from the hospital's clinical risk register. Various outcome variables in the form of aggregate data on all deliveries that occurred in CUMH for the 28 days preceding and succeeding the events were collected by the lead author. The medical records for each severe adverse perinatal event were reviewed and the clinical case details recorded. Based on these clinical details individual hypotheses were created for each event. Data was analysed using IBM-SPSS.

RESULTS

Aggregate data relating to 6180 deliveries was collected and analysed. Data analysis revealed some statistically significant changes in clinical activity in the 28 days following five of the six adverse events. These changes in clinical activity did not, however, always match what we had expected from our original hypotheses.

CONCLUSION

This novel study aimed to identify if it was possible to objectively demonstrate this practice change. We identified some statistically significant changes in clinical activity in the 28 days following five of the six adverse events but were unable to definitively conclude if the change in activity was a direct result of each event.

Profissionais de saúde e o processo de morte e morrer dos pacientes: uma revisão integrativa

Objetivo: conocer la producción científica sobre la relación entre los profesionales de salud y la muerte del paciente. Metodología: revisión integradora de la literatura mediante análisis de proximidad temática. Resultados: se elaboraron cuatro categorías: profesionales de salud no preparados para enfrentar la muerte; desafíos para lidiar con el proceso de muerte y morir en diferentes escenarios; tipos de muerte y sus interpretaciones, y profesionales de salud; y aspectos personales sobre cómo enfrentar la muerte. Concluciones: los profesionales de salud no están preparados para enfrentar el proceso del final de la vida; más allá de eso, sienten una falta de atención al tema, especialmente en relación con las estrategias de afrontamiento.

Work-related adverse events leaving their mark: a cross-sectional study among Dutch gynecologists

BACKGROUND

Health care professionals who are frequently coping with traumatic events have an increased risk of developing a posttraumatic stress disorder. Research among physicians is scarce, and obstetrician-gynecologists may have a higher risk. Work-related traumatic events and posttraumatic stress disorder among obstetricians-gynecologists and the (desired) type of support were studied.

METHODS

A questionnaire was emailed to all members of the Dutch Society of Obstetrics and Gynaecology, which included residents, attending, retired and non-practicing obstetricians-gynecologists. The questionnaire included questions about personal experiences and opinions concerning support after work-related events, and a validated questionnaire for posttraumatic stress disorder.

RESULTS

The response rate was 42.8% with 683 questionnaires eligible for analysis. 12.6% of the respondents have experienced a work-related traumatic event, of which 11.8% met the criteria for current posttraumatic stress disorder. This revealed an estimated prevalence of 1.5% obstetricians-gynecologists with current posttraumatic stress disorder. 12% reported to have a support protocol or strategy in their hospital after adverse events. The most common strategies to cope with emotional events were: to seek support from colleagues, to seek support from family or friends, to discuss the case in a complication meeting or audit and to find distraction. 82% would prefer peer-support with direct colleagues after an adverse event.

CONCLUSIONS

This survey implies that work-related events can be traumatic and subsequently can lead to posttraumatic stress disorder. There is a high prevalence rate of current posttraumatic stress disorder among obstetricians-gynecologists. Often there is no standardized support after adverse events. Most obstetrician-gynecologists prefer peer-support with direct colleagues after an adverse event. More awareness must be created during medical training and organized support must be implemented.

Healthcare professionals' response to intrapartum death: a cross-sectional study

BACKGROUND

Exposure to adverse perinatal events can impact on the way healthcare professionals (HCPs) provide patient care. The aim of this study was to document the experiences of HCPs following exposure to intrapartum death (IPD), to identify opinions surrounding education and suitable support strategies, and to ascertain if involvement with an IPD had any impact on clinical practice.

METHODS

A questionnaire study, with open and closed questions, was developed and set in a tertiary maternity hospital. Consultant obstetricians, trainee obstetricians and midwives were invited to participate. Respondents were questioned about the impact that an intrapartum death had on them, the support they received in the immediate aftermath and their opinions regarding ongoing education and training in the areas of intrapartum death and self-care.

RESULTS

Eighty percent of HCPs in our study had a direct involvement with an IPD. Most (82%) HCPs received no training in dealing with IPD while 94% had no education on self-care strategies. Despite it being desired by most (80%), debriefing was offered to just 11% of HCPs who were involved in an IPD. Three main qualitative themes emerged from the data; the personal impact of IPDs on HCPs, implications for professional practice and future patient care, and the importance on non-judgemental support.

CONCLUSION

Maternity hospitals need to improve their support structures for HCPs following an IPD. It is hoped that this study will inform future educational practice and identify potential support strategies.

Blame and guilt - a mixed methods study of obstetricians' and midwives' experiences and existential considerations after involvement in traumatic childbirth

INTRODUCTION

When complications arise in the delivery room, midwives and obstetricians operate at the interface of life and death, and in rare cases the infant or the mother suffers severe and possibly fatal injuries related to the birth. This descriptive study investigated the numbers and proportions of obstetricians and midwives involved in such traumatic childbirth and explored their experiences with guilt, blame, shame and existential concerns.

MATERIAL AND METHODS

A mixed methods study comprising a national survey of Danish obstetricians and midwives and a qualitative interview study with selected survey participants.

RESULTS

The response rate was 59% (1237/2098), of which 85% stated that they had been involved in a traumatic childbirth. We formed five categories during the comparative mixed methods analysis: the patient, clinical peers, official complaints, guilt, and existential considerations. Although blame from patients, peers or official authorities was feared (and sometimes experienced), the inner struggles with guilt and existential considerations were dominant. Feelings of guilt were reported by 36-49%, and 50% agreed that the traumatic childbirth had made them think more about the meaning of life. Sixty-five percent felt that they had become a better midwife or doctor due to the traumatic incident.

CONCLUSIONS

The results of this large, exploratory study suggest that obstetricians and midwives struggle with issues of blame, guilt and existential concerns in the aftermath of a traumatic childbirth.