Researching people who are bereaved: Managing risks to participants and researchers

Psychosocial effects of adverse pregnancy outcomes and their influence on reporting pregnancy loss during surveys and surveillance: narratives from Uganda

BACKGROUND

In 2021, Uganda had an estimated 25,855 stillbirths and 32,037 newborn deaths. Many Adverse Pregnancy Outcomes (APOs) go unreported despite causing profound grief and other mental health effects. This study explored psychosocial effects of APOs and their influence on reporting these events during surveys and surveillance settings in Uganda.

METHODS

A qualitative cross-sectional study was conducted in September 2021 in Iganga Mayuge health and demographic surveillance system site, eastern Uganda. Narratives were held with 44 women who had experienced an APO (miscarriage, stillbirth or neonatal death) and 7 men whose spouses had undergone the same. Respondents were purposively selected and the sample size premised on the need for diverse respondents. Reflexive thematic analysis was undertaken, supported by NVivo software.

RESULTS

60.8% of respondents had experienced neonatal deaths, 27.4% stillbirths, 11.8% miscarriages and almost half had multiple APOs. Theme one on psychosocial effects showed that both women and men suffered disbelief, depression, shame and thoughts of self-harm. In theme two on reactions to interviews, most respondents were reminded about their loss. Indeed, some women cried and a few requested termination of the interview. However, many said they eventually felt better, especially where interviewers comforted and advised them. In theme three about why people consent to such interviews, it was due to the respondents' need for sensitization on causes of pregnancy loss and danger signs, plus the expectation that the interview would lead to improved health services. Theme four on suggestions for improving interviews highlighted respondents' requests for a comforting and encouraging approach by interviewers.

CONCLUSION

Psychosocial effects of APOs may influence respondents' interest and ability to effectively engage in an interview. Findings suggest that a multi-pronged approach, including interviewer training in identifying and dealing responsively with grieving respondents, and meeting needs for health information and professional counselling could improve reporting of APOs in surveys and surveillance settings. More so, participants need to understand the purpose of the interview and have realistic expectations.

Voices from the Margins: Aotearoa/New Zealand Young Carers Reflect on Their Experiences

Young carers are a largely invisible and unsupported population of Aotearoa New Zealand (NZ) children and youth aged 25 years and under who physically, emotionally, socially, and/or spiritually support loved ones experiencing ill health, disability, substance misuse, mental illness, or advanced age. The total number of young carers in NZ is unknown because census data only capture those aged 15-25. The nine published NZ studies recommend further research, policies, and services for young carers. However, there is a lack of young carer voices to inform their implementation. This paper provides insight into the experiences and needs of 28 young carers, the largest self-identified cohort in NZ research. Throughout phenomenographic interviews, young caring was described as a natural and valued part of being in a whānau/aiga/family, aimed at supporting their loved one's holistic wellbeing. However, the overwhelming nature of caring without recognition or support resulted in poor educational, social, and mental health outcomes for young carers. This paper concludes with a contextualised NZ young carer definition and an urgent call to address the Carers' Strategy Action Plan and listen to, and deliver on, young carers' expressed needs.

An analysis of the experiences of bereaved relatives and health care providers following palliative sedation: a study protocol for a qualitative international multicenter case study

BACKGROUND

Patients at the end-of-life may experience refractory symptoms of which pain, delirium, vomiting and dyspnea are the most frequent. Palliative sedation can be considered a last resort option to alleviate one or more refractory symptoms. There are only a limited number of (qualitative) studies exploring the experiences of relatives of sedated patients and their health care professionals (HCPs). The aims of this study protocol are: 1) to elicit the experiences of bereaved relatives and health care professionals of patients treated with palliative sedation and 2) to explore the understanding of the decision-making process to start palliative sedation across care settings in 5 European countries.

METHODS

This study protocol is part of the larger HORIZON 2020 Palliative Sedation project. Organisational case study methodology will be used to guide the study design. In total, 50 cases will be conducted in five European countries (10 per country). A case involves a semi-structured interview with a relative and an HCP closely involved in the care of a deceased patient who received some type of palliative sedation at the end-of-life. Relatives and health care professionals of deceased patients participating in a linked observational cohort study of sedated patients cared for in hospital wards, palliative care units and hospices will be recruited. The data will be analyzed using a framework analysis approach. The first full case will be analyzed by all researchers after being translated into English using a pre-prepared code book. Afterwards, bimonthly meetings will be organized to coordinate the data analysis.

DISCUSSION

The study aims to have a better understanding of the experiences of relatives and professional caregivers regarding palliative sedation and this within different settings and countries. Some limitations are: 1) the sensitivity of the topic may deter some relatives from participation, 2) since the data collection and analysis will be performed by at least 5 different researchers in 5 countries, some differences may occur which possibly makes it difficult to compare cases, but using a rigorous methodology will minimize this risk.

Developing Suicide Safety Protocols for Qualitative Research as a Universal Equity Practice

Qualitative research offers a range of approaches to elucidate the health and social experiences of populations and communities that are historically oppressed and repressed, yet is not without ethical and practical challenges that may have unintended consequences and added risks for certain individuals and communities. As a result of experiences of trauma and environmental factors, many oppressed and repressed populations have disproportionately high rates of suicide, but there are no widely accepted standards or best practices for addressing suicidality while conducting qualitative research. We describe an example of a qualitative interview during which a participant reported thoughts of suicide, even though the study topic was not directly related to mental health or suicide. We describe how the research team responded and present a framework for developing suicide safety protocols when conducing qualitative research with oppressed and repressed populations.

Evaluation of the Caring Ahead: Preparing for End-of-Life With Dementia Questionnaire

OBJECTIVES

Family caregivers of persons with dementia rarely feel prepared for end of life although preparedness predicts outcomes in bereavement. The Caring Ahead: Preparing for End-of-Life With Dementia questionnaire was developed to measure family caregiver death preparedness. The aim of this study was to evaluate questionnaire psychometrics and refine the Caring Ahead questionnaire.

DESIGN

A quantitative cross-sectional reliability study design was used to evaluate the questionnaire.

SETTING/PARTICIPANTS

Data were collected by mail from 134 English-speaking family caregivers of persons with dementia recruited from more than 50 congregate living facilities in Canada. Thirty-two participants completed a test-retest.

METHODS

Analysis of psychometrics included exploratory factor analysis, calculation of correlation with a single-global preparedness item, Cronbach alpha, intraclass correlation coefficient (ICC) over time.

RESULTS

A 4-factor model with 20 items emerged through exploratory factor analysis with principal factors extraction and promax rotation. The revised questionnaire includes 4 factor subscales: Actions (7 items), Dementia Knowledge (5 items), Communication (4 items), and Emotions and Support Needs (4 items). Evidence was demonstrated for concurrent validity (0.44-0.55, P < .001), internal consistency (alpha > 0.7), and reliability (ICCs > 0.7). Lower levels of preparedness were reported for "knowing what the dying process with dementia may be like" and "discussing end-of-life care and preferences with health care providers."

CONCLUSIONS AND IMPLICATIONS

Preliminary evidence for validity and reliability of the refined 20-item Caring Ahead questionnaire suggests the questionnaire may be useful to clinicians and researchers seeking to assess caregivers' feelings of preparedness, identify specific areas for intervention, and evaluate the effectiveness of caregiver interventions. Additional testing is needed to evaluate predictive validity.

Caring ahead: Mixed methods development of a questionnaire to measure caregiver preparedness for end-of-life with dementia

BACKGROUND

Family caregivers of persons with dementia often feel unprepared for end-of-life and preparedness predicts caregiver outcomes in bereavement. Existing questionnaires assessing preparedness have limitations. A multi-dimensional questionnaire assessing family caregiver preparedness for the end-of-life of persons with dementia is needed to identify caregivers at risk for negative outcomes in bereavement and evaluate the quality of strategies within a palliative approach.

AIM

To develop a multi-dimensional questionnaire titled 'Caring Ahead' to assess feelings of preparedness for end-of-life in family caregivers of persons with dementia.

DESIGN

A mixed methods, sequential design employed semi-structured interviews, a Delphi-survey and pilot-testing of the questionnaire, June 2018 to July 2019.

SETTING/POPULATION

Participants included five current and 16 bereaved family caregivers of persons with symptoms advanced dementia from long-term care homes in Ontario, Canada; and 12 professional experts from clinical and academic settings in Canada, Europe, United States.

RESULTS

Interviews generated three core concepts and 114 indicators of preparedness sampling cognitive, affective and behavioural traits in four domains (i.e., medical, psychosocial, spiritual, practical). Indicators were translated and reduced to a pool of 73 potential questionnaire items. 30-items were selected to create the 'Caring Ahead' preparedness questionnaire through a Delphi-survey. Items were revised through a pilot-test with cognitive interviewing.

CONCLUSIONS

Family caregivers' feelings of preparedness for end-of-life need to be assessed and the quality of strategies within a palliative approach evaluated. Future psychometric testing of the Caring Ahead questionnaire will evaluate evidence for validity and reliability.

Experiences of becoming widowed in old age - a cross-countries study with qualitative interviews from Denmark and quantitative measures of association in a Swedish sample

Purpose: Becoming widowed is a stressful health-threatening event causing major life changes. We explored how widowed people experience becoming widowed and examined if these experiences are quantitatively associated with widowhood.

Methods: A multi-methods study using an exploratory sequential mixed-methods approach including a qualitative descriptive study with widowed people from Denmark and a Swedish cohort study. Qualitative interviews (n = 9) were analysed using qualitative content analysis, describing experiences as explained by the widowed people. The quantitative association of the experiences was examined by identifying proxies for the qualitative experiences of widowhood in the cohort study and examining the occurrence in widowed people compared to married people (n = 1,095).

Results: Six categories of experiences emerged: the circumstances around spousal death, mental health and well-being, physical health, social relations, activities and practicalities. The quantitative examination showed a significant association with widowhood regarding mental and physical health problems.

Conclusion: The circumstances around spousal death and the time before spousal death, in general, were important to how participants felt being widowed. Being ill negatively affected mental health and well-being, partly because of the inability to participate in activities and social relations. This is important, as health problems are more common among widowed people than married people.

Self-care while undertaking qualitative nursing research

BACKGROUND

Nursing research is usually carried out by registered nurses with some experience of practice. However, nurses may find that the role of the nurse researcher is very different from that of the practising clinical nurse and has its own challenges.

AIM

To explore the differences between the two roles and offer some guidance to nurses carrying out qualitative research, particularly research into sensitive topics.

DISCUSSION

Nurses need to be aware of various issues that could affect their ability to carry out nursing research and be emotionally traumatic.

CONCLUSION

There is a general need for greater awareness about the potential risks of carrying out qualitative research into sensitive topics.

IMPLICATIONS FOR PRACTICE

Nurse researchers must consider self-care when planning a research project, assessing their role, personality, background, personal experiences and stress triggers, and ensuring peer and supervisory support, reflection and a healthy lifestyle.

Exploring the experiences and perspectives of substitute decision-makers involved in decisions about deceased organ donation: a qualitative study protocol

INTRODUCTION

In Canada, deceased organ donation provides over 80% of transplanted organs. At the time of death, families, friends or others assume responsibility as substitute decision-makers (SDMs) to consent to organ donation. Despite their central role in this process, little is known about what barriers, enablers and beliefs influence decision-making among SDMs. This study aims to explore the experiences and perspectives of SDMs involved in making decisions around the withdrawal of life-sustaining therapies, end-of-life care and deceased organ donation.

METHODS AND ANALYSIS

SDMs of 60 patients admitted to intensive care units will be enrolled for this study. Ten hospitals across five provinces in Canada in a prospective multicentre qualitative cohort study. We will conduct semistructured telephone interviews in English or French with SDMs between 6 and 8 weeks after the patient's death. Our sampling frame will stratify SDMs into three groups: SDMs who were not approached for organ donation; SDMs who were approached and consented to donate and SDMs who were approached but did not consent to donate. We will use two complementary theoretical frameworks-the Common-Sense Self-Regulation Model and the Theoretical Domains Framework- to inform our interview guide. Interview data will be analysed using deductive directed content analysis and inductive thematic analysis.

ETHICS AND DISSEMINATION

This study has been approved by the Centre Hospitalier de l'Université de Montréal Research Ethics Board. The findings from this study will help identify key factors affecting substitute decision-making in deceased organ donation, reasons for non-consent and barriers to achieve congruency between SDM and patient wishes. Ultimately, these data will contribute to the development and evaluation of tools and training for healthcare providers to support SDMs in making decisions about organ donation.

TRIAL REGISTRATION NUMBER

NCT03850847.

From hospitalization to grief: meanings parents assign to their relationships with pediatric oncology professional

OBJECTIVE

To understand the meanings assigned by bereaved parents to their relationships with healthcare professionals during the end-of-life hospitalization of their child.

METHOD

Qualitative-interpretative study based on hermeneutics. Data were collected from interviews with parents who were grieving the death of a child with cancer in the hospital and participant observation in an oncology ward. Deductive thematic analysis for data interpretation ensued.

RESULTS

The experience of parents is the sum of all relationships during treatment. Therefore, meanings form a tangle of interrelated senses built not only in the interaction with these professionals, but also with the child and with grief itself. In relationships with professionals, meanings related to the memories of the child, negative emotions and regret were identified.

CONCLUSION

The experiences and meanings of grief are shaped by the social processes and interactions experienced by the family in the hospital. The relationship with the professionals represents part of the support in coping with the grief after the child's death in the hospital, due to the perpetuity of the love shown for the child as a possible legacy in the legitimacy of the experienced interactions.

A Systematic Review of the Association Between Bereavement and Biomarkers of Immune Function

OBJECTIVE

Bereavement is associated with increased risk for morbidity and all-cause mortality across epidemiological, meta-analytic, and case-control studies. The body of research examining the association between bereavement and immune function, beginning in 1977, has yet to be reviewed. The current systematic review clarifies these findings, identifies limitations of the diverse literature, and suggests a model and directions for future research.

METHODS

The PRISMA guidelines for systematic reviews were used to synthesize 41 years of research. Compared with a meta-analysis, a systematic review is appropriate given the heterogeneous nature of the studies. We used the National Heart, Lung, and Blood Institute Study Quality Assessment Tool to assess the quality of select studies.

RESULTS

Thirty-three publications met inclusion criteria. Most studies support the association between bereavement and maladaptive changes in immune parameters in adults, with mixed findings on bereavement-related changes in cellular immunity. A handful of recent, good-quality studies show bereaved people demonstrate higher levels of systemic inflammation, maladaptive immune cell gene expression, and lower antibody response to vaccination compared with nonbereaved controls. Individual differences in psychological response to bereavement (e.g., depression, grief) seem to influence the association between bereavement and immune function.

CONCLUSIONS

Research examining the association between bereavement and biomarkers of immune function is heterogeneous in methods and quality. Despite these limitations, there is evidence supporting maladaptive changes in immune function after bereavement. The research area would benefit from longitudinal research with larger sample sizes, advanced immunological methods, and incorporating measures of psychological responses to bereavement. The field is poised to refine and scale up its investigation of this common and important phenomenon.

Recruitment and retention in clinical and experimental bereavement research: Lessons learned from creating a research registry

A small body of research investigates recruitment and retention of bereaved people in experimental and intervention research. The present study compares the effectiveness of different recruitment strategies implemented by a grief laboratory at a large state university in order to optimize recruitment efforts. The most effective method is letters sent to bereaved community members identified through online newspaper obituaries. Despite a small overall response rate, the large population from which to sample provides continuous accrual every month. Other methods include electronic/print media, community institution referrals, word of mouth and community outreach. Best practices for recruitment and retention are recommended.

Invitation to grief in the family context

Grief is a family affair, yet it is commonly viewed as an individual phenomenon. As an international, interdisciplinary team, we explore grief within a family context across theoretical, research, practice, and educational domains. Families are complex and working with this complexity is challenging but necessary for a holistic view of grief. We therefore encourage an increased focus on theorizing, researching, practicing, and educating using innovative approaches to address the complexities of grief within the context of families. Learnings from within each domain will affirm and enhance the development of family-level thinking and approaches.