Compassionate Care: Listening Visits Provided by Neonatal Intensive Care Unit Nurses

PURPOSE

Although mothers of infants hospitalized in a neonatal intensive care unit (NICU) often experience clinically significant levels of depression symptoms, accessing mental-health treatment may be difficult. NICU mothers need emotional support that is conveniently delivered at the infant's point-of-care by a trusted professional who is knowledgeable about the medical and nursing care in the NICU. Listening Visits are an effective and accessible, nurse-delivered depression intervention, yet little is known about what mothers discuss during these sessions. This analysis of sessions recorded during the randomized controlled trial evaluation of Listening Visits in the NICU provides a glimpse into NICU mothers' concerns and experiences.

STUDY DESIGN AND METHODS

This is a secondary, qualitative case analysis of the recorded Listening Visits sessions of four depressed NICU mothers as indicated by a score of 12 or above on the Edinburgh Postnatal Depression Scale. The mothers, who were all White, varied in their economic resources, educational level, availability of support, and infant illness severity.

RESULTS

Mothers discussed similar concerns and experiences, often at analogous temporal points in the six Listening Visit sessions, as well as one common concern they voiced throughout: family and friends do not understand what it is like to have an infant in the NICU.

CLINICAL IMPLICATIONS

For mildly to moderately depressed mothers of infants hospitalized in the NICU, Listening Visits provide a way for bedside nurses to deliver compassionate care by listening to mothers' concerns and experiences.

Postpartum Depression Screening Scale: Its Availability for Use

OBJECTIVE

A silent health crisis in the United States is the underdiagnosed and undertreated mental health of women related to childbirth. This discussion paper describes the Postpartum Depression Screening Scale (PDSS) with its scoring and interpretation along with its psychometric testing and translations.

METHOD

In addition to the studies conducted by the instrument developers, databases were searched for studies where other researchers used the PDSS to assess postpartum depressive symptoms. Studies were included that measured the psychometrics of the scale and studies that reported the translation of the PDSS into other languages.

RESULTS

Evidence is presented that the PDSS is a reliable and valid screening scale for use by psychiatric mental health nurses and other health care providers. The scale also has been translated into 14 languages, so it is available to screen non-English speaking mothers.

CONCLUSION

Childbirth is one of the most powerful triggers of psychiatric illness in a woman's life. Postpartum depression is a treatable mental health condition, but first, women need to be screened so they can be identified and referrals made. Screening for this devastating mood disorder in new mothers is an essential role of psychiatric mental health nurses and other clinicians so that treatment can be started as early as possible to avoid harmful consequences.

Survivors' Experiences of Hyperemesis Gravidarum

Hyperemesis gravidarum can result in life-threatening physical and psychological maternal morbidity, including severe dehydration, weight loss, electrolyte imbalance, depression, and suicidal ideation. The reported prevalence of hyperemesis gravidarum ranges from 0.3% to 3.6%. The purpose of this qualitative study was to investigate what blogs can tell us about women's experiences of hyperemesis gravidarum. Thirty-three blogs written by hyperemesis gravidarum survivors posted on Hyperemesis Australia's website were analyzed using Krippendorff's qualitative content analysis method. Clustering was used and yielded 6 themes: (1) debilitating physical and mental health problems: digging deep to persevere, (2) heartbreaking choices, (3) lack of understanding and dismissed, (4) so much guilt surrounding their unborn infant, (5) it takes a village to support women with hyperemesis gravidarum, and (6) warriors and survivors: giving back. Infusion nurses are in a perfect position to provide support and compassionate care for women who are repeatedly coming to the hospital for rehydration treatment. Infusion nurses can validate women's physical and emotional struggles with hyperemesis gravidarum and help to no longer make women feel stigmatized.

The Value of Secondary Analysis for Qualitative Inquiry

XXXX.

Posttraumatic Growth after Postpartum Psychosis

PURPOSE

To explore positive changes in women's beliefs, emotions, and behaviors following their struggles with postpartum psychosis.

STUDY DESIGN AND METHODS

This is a descriptive qualitative study of women who experienced posttraumatic growth after postpartum psychosis. We recruited participants from postings on three Facebook groups. Participants sent their stories of posttraumatic growth after postpartum psychosis via email attachment. We used the following five domains from Tedeschi and Calhoun's (2004) posttraumatic growth model to guide our deductive content analysis: Relating to Others, Personal Strength, Appreciation of Life, New Possibilities, and Spiritual and Existential Change .

RESULTS

Thirteen women participated. Relating to Others was the posttraumatic growth domain most often described by the participants followed in order of frequency by Personal Strength, Appreciation of Life, New Possibilities , and Spiritual and Existential Change . Partners and family members' support was instrumental in recovery from postpartum psychosis.

CLINICAL IMPLICATIONS

When considering the total sample, participants experienced all five domains of posttraumatic growth after postpartum psychosis though not every individual experienced growth in all five domains. Interventions can be tailored to meet the needs of women depending on which phase of recovery from postpartum psychosis women are in, acute, early recovery, or advanced recovery. Advanced recovery is the most appropriate phase to discuss the possibility of posttraumatic growth with women. Such discussion should be done with caution and sensitivity as not all women experience positive growth, and it can be harmful to frame this in a way that indicates or encourages expectation.

Postpartum Mood and Anxiety Disorders: A Lexicon of Metaphors

Undiagnosed and untreated postpartum mental health disorders represent a silent health crisis. The aim of this paper was to develop a lexicon of metaphors women use to describe their postpartum mood and anxiety disorders to assist holistic nurses in recognizing as early as possible these struggling mothers. Mothers may not know the medical terminology to articulate their mental health problems and may turn to using metaphors. The metaphors included in this lexicon were obtained from the author's earlier qualitative studies of metaphors women used to describe their experiences of postpartum depression, postpartum panic disorder, and posttraumatic stress disorder due to traumatic childbirth. In this lexicon these metaphors are organized by these three mental health disorders and includes a table of definitions of each metaphor along with examples of the context of the metaphors represented by quotes from the mothers. Metaphors can be keys that open and unlock doors that stand between holistic nurses and their patients. Being attentive to metaphorical language women use to describe how they are feeling after giving birth can be an innovative approach holistic nurses can use to identify these vulnerable women and provide an opportunity to nurture and empower new mothers.

Lexicon of Metaphors: An Innovative Approach to Detect the Aftermath of Traumatic Childbirth

An innovative approach to help mental health providers identify individuals who may be struggling with the aftermath of birth trauma is to become vigilant in listening for metaphors women may use to describe how they have been feeling. Metaphors can provide a safe bridge for individuals to share and work through painful and challenging feelings. This lexicon of metaphors has four sections: impact birth trauma had on breastfeeding, impaired mother-infant interaction, anniversary of birth trauma, and subsequent childbirth. Examples of these metaphors include empty affair, head in a vise, short fuze, severed ties, great pretender, and mental baggage.

Postpartum Preeclampsia: What Can Stories Posted on the Internet Tell Us?

Postpartum preeclampsia has not received the needed attention that preeclampsia has. It is the lesser-known hypertensive disorder but can be just as life-threatening as eclampsia. Because of the scarcity of qualitative research on postpartum preeclampsia, the purpose of this study was to help fill this gap by exploring personal experiences of this dangerous complication as described in online blogs. Using Google search engine, 25 stories of postpartum preeclampsia were located. Krippendorff's content analysis for qualitative data was the research design used. Five themes were identified: (1) Not even on my radar as a new mom, (2) Bombarded with physical and emotional symptoms, (3) Life-threatening situation: Dismissed or misdiagnosed, (4) Heartbroken: Separation from my newborn, and (5) Trust your instincts and advocate for yourself. Advanced practice nurses and other health care providers need to be on alert for postpartum preeclampsia when a woman, who recently gave birth, presents at the emergency department.

Avoiding Potential Pitfalls in Qualitative Research Methods

The Associate Editor provides strategies for authors to use when they prepare reports of qualitative studies.

Postpartum Depression: A Metaphorical Analysis

BACKGROUND

The reported incidence of postpartum depression in healthy women without a history of depression was 12%, and the prevalence was 17%. A silent health crisis in America is the undiagnosed and untreated mental health of women related to childbirth. Unfamiliar with medical terminology, persons may communicate more effectively by means of metaphors to describe what they are experiencing.

AIMS

To examine the language women used to describe their experiences of postpartum depression with metaphors that can provide a valuable source of insight for psychiatric nurses and other clinicians.

METHODS

Secondary qualitative data analysis of three primary datasets of postpartum depression was conducted. Metaphor identification procedure was the approach used to analyze the texts for metaphorical expressions.

RESULTS

Eleven metaphors were identified that women used to help explain their postpartum depression: being hit by a ton of bricks, being a tightrope walker, living in a nightmare, feeling trapped, being in the middle of the sea, feeling like an alien, being a loner, being a basket case, having cobwebs in the brain, feeling like garbage, and hitting rock bottom.

CONCLUSIONS

These 11 metaphors provide a new voice for women's experiences of postpartum depression. As a result, they provide rich insights for psychiatric nurses and other clinicians to help identify women struggling with postpartum depression.

Secondary Traumatic Stress and Moral Injury in Maternity Care Providers: A Narrative and Exploratory Review

Introduction

A significant percentage of maternity providers have experienced secondary traumatic stress following a traumatic birth. Previous studies identified it as an issue, but this literature review is 5–9 years old. In addition, the construct of moral injury has significantly increased our understanding of secondary trauma for military veterans. In the wake of COVID-19, this construct also applies to healthcare providers.

Objectives

The present article updates these reviews and compares findings for three groups: labor and delivery nurses, midwives, and obstetricians. The second portion of this review re-examines previously published qualitative research to determine whether moral injury might more accurately describe the experiences of maternity personnel.

Methods

A comprehensive review of PubMed, Scopus, Web of Science, PsychINFO, and CINAHL was conducted in June 2021 using search terms such as compassion fatigue, secondary trauma, moral injury, labor and delivery, nurses, midwives, and obstetricians. Forty articles were identified, but only 16 focused on secondary trauma or moral injury.

Results

Secondary trauma is a significant concern affecting at least 25% of maternity staff. However, some countries have very low rates, which correspond to low rates in childbirth-related trauma in mothers. Secondary trauma can lead to several symptoms, including re-experiencing, avoidance, negative changes in mood and cognitions, and hyperarousal, which can cause significant impairment. As a result, many providers decide to leave the field in the wake of a traumatic birth. The incidence of moral injury is unknown, but a re-examination of previously published qualitative data suggests that this construct, generally used to describe combat veterans, does describe some of what providers have reported. Acts of omission, i.e., failure to stop the harmful acts of others had long-term negative effects on labor and delivery nurses, consistent with data from military samples. Two possible mediators were proposed: hierarchical and gendered relationships in hospitals and agency of care.

Conclusion

The effects of traumatic birth on providers can be severe, including possible psychological sequelae, impaired job performance, and leaving the field. Moral injury expands upon the construct of secondary traumatic stress. This construct better describes the experiences of maternity staff in non-primary roles who witness traumatic births and are often haunted by events that they could not prevent, but often question whether they should have.

Postpartum Depressive Symptoms and Experiences During COVID-19

PURPOSE

To identify postpartum depression risk and describe experiences of women in the first 6 weeks after giving birth during the COVID-19 pandemic.

STUDY DESIGN AND METHODS

Using a convergent mixed-methods approach, we recruited a convenience sample of women living in the United States who gave birth March 1, 2020 or later from social media Web sites. Participants completed the Postpartum Depression Screening Scale-Short Form and provided written answers to open-ended questions regarding their experiences at home with their new infant.

RESULTS

Our 262 participants were on average 32.6 years of age, the majority were White (82%), married or partnered (91.9%), and college educated (87.4%). Mean postpartum depression score was 17.7 (SD = 5.9) with 75% scoring ≥14, indicating significant postpartum depressive symptoms. Qualitative content analysis revealed five themes: Isolation and seclusion continue; Fear, anxiety, and stress filled the days; Grieving the loss of normal: It's just so sad; Complicated by postpartum depression: A dark time; and There is a silver lining. Quantitative and qualitative findings provided a holistic view of women's depressive symptoms and experiences at home with their infants during the COVID-19 pandemic.

CLINICAL IMPLICATIONS

Although policies that reduce risk of COVID-19 exposure and infection for patients and the health care team must continue to be implemented, the adverse effects of depressive symptoms on maternal-infant wellbeing within the context of increased isolation due to the pandemic need to be kept at the forefront. Nurses need to be aware of the consequences of women sheltering in place and social distancing on maternal-infant outcomes, particularly on depression and likelihood of breastfeeding.

The Impact of Traumatic Childbirth on Women’s Breastfeeding Experiences

Background

Researchers are confirming that posttraumatic stress due to traumatic childbirth is significantly associated with lower rates of breastfeeding and low maternal attachment.

Purpose

The purpose of this secondary qualitative data analysis was to identify metaphorical expressions women use to describe the impact their birth trauma had on their breastfeeding experiences.

Methods

The primary dataset used to conduct this analysis was a descriptive phenomenological study that focused on birth trauma and breastfeeding experiences of 52 women from New Zealand, the United States, Australia, the United Kingdom, and Canada. Metaphor Identification Procedure was used to identify metaphorical expressions.

Results

Six metaphors were identified. Breastfeeding after a traumatic birth is your head in a vise, an empty affair, mechanical, true grit, a guilt trip, and a form of forgiveness.

Conclusion

The six metaphors provide a new voice for women who are attempting to breastfeed following a traumatic birth. Perinatal and neonatal nurses need to be attentive to any of the metaphors new mothers are using to help identify women struggling with the aftermath of birth trauma.

The experience of the nurse during the COVID-19 pandemic: A global meta-synthesis in the year of the nurse

Purpose

From its beginnings in China in December of 2019, the novel coronavirus COVID‐19 spread and quickly became the center of nursing care and conversation across the globe (WHO, 2020). This meta‐ethnographic study was conducted in order to provide the profession of nursing interpretative explanations of a common experience during the care of patients with COVID‐19.

Design and method

A literature review focused on the experience of the nurse during the COVID‐19 pandemic revealed a total of 13 qualitative studies conducted in China, Spain, Turkey, Iran, Brazil, and the United States. A meta‐ethnographic review of these qualitative works, using the method of Noblit and Hare, was then conducted which revealed the experience of the nurse across the globe during the COVID‐19 pandemic.

Findings

The review revealed strong similarities between the experiences of the nurse across the 13 studies. Given this reciprocal relationship, translations were constructed and synthesized until four new themes emerged outlining the global experience of the nurse during the COVID‐19 pandemic.

Conclusions

Despite the differences between the structures of healthcare and government of the six countries represented in this meta‐ethnography, the experience of the nurse emerged into a narrative shared by those represented in this study. As the profession of nursing continues to work through ongoing waves of COVID‐19, these results will help guide the resources and training provided to nurses on the frontline of care.

Clinical relevance

Despite great personal risk, nurses across the globe stepped up to the challenge of upholding and improving the health of the world's people during the COVID‐19 pandemic. As health policy, education, and system leaders, we must listen to the common experience revealed in this meta‐synthesis and respond by providing the resources needed to improve nursing practice and care.

Subsequent Childbirth After a Previous Birth Trauma: A Metaphor Analysis

Minimizing the risk of women experiencing a subsequent birth as another traumatic event needs to be a priority for psychiatric-mental health nurses. One approach to identifying women struggling with a subsequent pregnancy is to be attentive to metaphors women use to describe what they are experiencing. The purpose of this secondary qualitative data analysis was to identity the metaphorical expressions women use to describe a subsequent birth after a prior birth trauma. The following five metaphors identified paint a vivid picture of what women experienced: a head buried in the sand, mental baggage, emotional torture, waves of panic, and a back and forth battle. Being knowledgeable about metaphors childbearing women use during a pregnancy following a previous birth trauma can help clinicians to recognize struggling mother-infant dyads and to initiate appropriate interventions. Necessary referrals can be made to psychiatric-mental health nurse practitioners.

Postpartum onset of panic disorder: A metaphor analysis

Prevalence rates of postpartum panic disorder range from 0.5% to 2.9%. New mothers may not know the medical terminology to describe what they are experiencing. Metaphors can provide women with a different voice to help provide a basis for shared understanding with clinicians. The purpose of this secondary qualitative data analysis was to examine the metaphors used by women to describe their panic disorder after birth. Metaphor Identification Procedure was used to analyze the primary dataset. The process revealed the following eight metaphors: caged animal, Coke in my veins, bone-tired, imposter, escape artist, magnifying glass, detective, and hermit.

The Lived Experience of Pain and Depression Symptoms during Pregnancy

BACKGROUND

Depressive symptoms and pain are prevalent during pregnancy. Untreated pain and depressive symptoms occurring together may have a negative effect on maternal and newborn outcomes, yet little is known about women's experiences with pain and depressive symptoms during pregnancy. The purpose of this study is to describe the lived experience of depressive symptoms and pain occurring in women during the third trimester of pregnancy.

METHODS

A descriptive phenomenological study was conducted. Women during postpartum were recruited from a previous cross-sectional study of women in their third trimester that evaluated the relationship between pain, depression, and quality of life. Twenty-four women entered their responses into an online secure research Web site. These data were analyzed using Colaizzi's method of descriptive phenomenological analysis.

RESULTS

Four themes that described the essence of women's experiences with both pain and depressive symptoms were identified. They were pregnancy: feeling minimized, unheard and overwhelmed; attempting or trying but not treated: living with pain and pain interference; pain, sleep loss, and suffering; and pain and depressive symptoms: helpless, hopeless, and suffering.

CLINICAL IMPLICATIONS

If a woman presents with pain, additional nursing assessments of her sleep and emotional state may be needed. Likewise, a positive depression symptom screening suggests the need for a more in-depth exploration of pain, pain interference, poor sleep, and mental health symptoms. Because the women perceive their pregnancy as minimized, nurses may need to assist in setting realistic expectations and encouraging social support. Nurses listening to women describing these conditions may be essential in promoting the women's wellbeing.

When Fear Surrounding Childbirth Leads Women to Request a Planned Cesarean Birth

Fear surrounding childbirth requires a more in-depth understanding from women’s perspectives, especially those who request a planned cesarean due to that fear. Therefore, we explored primiparous and multiparous women’s lived experiences of fear surrounding childbirth in relation to their decision to request a planned cesarean birth. We used Colaizzi’s (1978) phenomenological method to interview 16 women from 4 provinces and to analyze the data. Women expressed numerous fears and most experienced more than one fear. Most feared their baby/babies being injured or dying during childbirth or developing complications themselves. Others feared experiencing a traumatic birth. Women described numerous emotional and physical manifestations of fear, and all believed that a planned cesarean birth would provide more control over the birth process. For some, the birth of their healthy baby/babies began a healing process, whereas others noted that their fear subsided or resolved upon confirmation that they would have a planned cesarean.

Shortening the Edinburgh postnatal depression scale using optimal test assembly methods: Development of the EPDS-Dep-5

AIMS

This study used a large database to develop a reliable and valid shortened form of the Edinburgh Postnatal Depression Scale (EPDS), a self-report questionnaire used for depression screening in pregnancy and postpartum, based on objective criteria.

METHODS

Item responses from the 10-item EPDS were obtained from 5157 participants (765 major depression cases) from 22 primary screening accuracy studies that compared the EPDS to the Structured Clinical Interview for DSM (SCID). Unidimensionality of the EPDS latent construct was verified using confirmatory factor analysis, and an item response theory model was fit. Optimal test assembly (OTA) methods identified a maximally informative shortened form for each possible scale length between 1 and 9 items. The final shortened form was selected based on pre-specified validity and reliability criteria and non-inferiority of screening accuracy of the EPDS as compared to the SCID.

RESULTS

A 5-item short form of the EPDS (EPDS-Dep-5) was selected. The EPDS-Dep-5 had a Cronbach's alpha of 0.82. Sensitivity and specificity of the EPDS-Dep-5 for a cutoff of 4 or greater were 0.83 (95% CI, 0.73, 0.89) and 0.86 (95% CI, 0.80, 0.90) and were statistically non-inferior to the EPDS. The correlation of total scores with the full EPDS was high (r = 0.91).

CONCLUSION

The EPDS-Dep-5 is a valid short form with minimal loss of information when compared to the full-length EPDS. The EPDS-Dep-5 was developed with OTA methods using objective, pre-specified criteria, but the approach is data-driven and exploratory. Thus, there is a need to replicate results of this study in different populations.

Overestimation of Postpartum Depression Prevalence Based on a 5-item Version of the EPDS: Systematic Review and Individual Participant Data Meta-analysis

OBJECTIVE

The Maternal Mental Health in Canada, 2018/2019, survey reported that 18% of 7,085 mothers who recently gave birth reported "feelings consistent with postpartum depression" based on scores ≥7 on a 5-item version of the Edinburgh Postpartum Depression Scale (EPDS-5). The EPDS-5 was designed as a screening questionnaire, not to classify disorders or estimate prevalence; the extent to which EPDS-5 results reflect depression prevalence is unknown. We investigated EPDS-5 ≥7 performance relative to major depression prevalence based on a validated diagnostic interview, the Structured Clinical Interview for DSM (SCID).

METHODS

We searched Medline, Medline In-Process & Other Non-Indexed Citations, PsycINFO, and the Web of Science Core Collection through June 2016 for studies with data sets with item response data to calculate EPDS-5 scores and that used the SCID to ascertain depression status. We conducted an individual participant data meta-analysis to estimate pooled percentage of EPDS-5 ≥7, pooled SCID major depression prevalence, and the pooled difference in prevalence.

RESULTS

A total of 3,958 participants from 19 primary studies were included. Pooled prevalence of SCID major depression was 9.2% (95% confidence interval [CI] 6.0% to 13.7%), pooled percentage of participants with EPDS-5 ≥7 was 16.2% (95% CI 10.7% to 23.8%), and pooled difference was 8.0% (95% CI 2.9% to 13.2%). In the 19 included studies, mean and median ratios of EPDS-5 to SCID prevalence were 2.1 and 1.4 times.

CONCLUSIONS

Prevalence estimated based on EPDS-5 ≥7 appears to be substantially higher than the prevalence of major depression. Validated diagnostic interviews should be used to establish prevalence.

Pentadic Cartography: Mapping Postpartum Psychosis Narratives

Writing online narratives of postpartum psychosis allows both self-analysis and catharsis and can also be viewed as a type of sociopolitical expression. Eight narratives posted on the Action on Postpartum Psychosis website were analyzed using Burke's narrative analysis. This method focuses on a pentad of key elements of story: scene, act, purpose, agent, and agency. What drives this narrative analysis is the identification of problematic areas referred to as ratio imbalances between any two of these five terms. The ratio imbalance between Agent and Act appeared most often in these eight narratives. The agent was the mother and the act most often was either her hallucinations or delusions. The second most frequent area of tension was between Scene and Agent. Problematic scenes for the agent (mother) involved admission to the psychiatric ward, entering the electroconvulsive therapy room, or nighttime. These ratio imbalances pinpoint places where clinicians can target specific interventions.

Secondary Traumatic Stress in Maternal-Newborn Nurses: Secondary Qualitative Analysis

BACKGROUND: Secondary traumatic stress can be the cost for clinicians when caring for persons who have been traumatized. Secondary traumatic stress is a syndrome of symptoms similar to posttraumatic stress disorder (PTSD). AIMS: To conduct a secondary qualitative data analysis of three primary data sets of secondary traumatic stress in nurses. METHODS: Cross validation was the type of qualitative secondary analysis used to compare qualitative findings across these multiple data sets. In the three primary studies, the data were analyzed for themes. In this secondary qualitative analysis, a different defining unit was chosen. This time, the four categories of PTSD symptoms (intrusions, avoidance, arousal, and negative alterations in cognitions and mood) were used to analyze the data sets using content analysis. RESULTS: For all three groups of maternal-newborn nurses, the intrusions category was ranked first and the negative cognitions and mood category was ranked second. The remaining two symptom categories were where their rankings differed. The labor and delivery and neonatal intensive care unit nurses ranked arousal symptoms third and avoidance symptoms fourth. For the nurse-midwives, the rankings for these two categories were reversed. The neonatal intensive care unit nurses comprised the one group that did not report any avoidance symptoms. CONCLUSIONS: This secondary qualitative analysis confirmed the presence of PTSD symptoms that maternal-newborn nurses struggled with as a result of caring for either critically ill infants or women during traumatic births. Hospital preventive strategies and interventions for secondary traumatic stress in nurses are discussed.

Comparison of major depression diagnostic classification probability using the SCID, CIDI, and MINI diagnostic interviews among women in pregnancy or postpartum: An individual participant data meta-analysis

OBJECTIVES

A previous individual participant data meta-analysis (IPDMA) identified differences in major depression classification rates between different diagnostic interviews, controlling for depressive symptoms on the basis of the Patient Health Questionnaire-9. We aimed to determine whether similar results would be seen in a different population, using studies that administered the Edinburgh Postnatal Depression Scale (EPDS) in pregnancy or postpartum.

METHODS

Data accrued for an EPDS diagnostic accuracy IPDMA were analysed. Binomial generalised linear mixed models were fit to compare depression classification odds for the Mini International Neuropsychiatric Interview (MINI), Composite International Diagnostic Interview (CIDI), and Structured Clinical Interview for DSM (SCID), controlling for EPDS scores and participant characteristics.

RESULTS

Among fully structured interviews, the MINI (15 studies, 2,532 participants, 342 major depression cases) classified depression more often than the CIDI (3 studies, 2,948 participants, 194 major depression cases; adjusted odds ratio [aOR] = 3.72, 95% confidence interval [CI] [1.21, 11.43]). Compared with the semistructured SCID (28 studies, 7,403 participants, 1,027 major depression cases), odds with the CIDI (interaction aOR = 0.88, 95% CI [0.85, 0.92]) and MINI (interaction aOR = 0.95, 95% CI [0.92, 0.99]) increased less as EPDS scores increased.

CONCLUSION

Different interviews may not classify major depression equivalently.

Synthesis of Mixed Research on Posttraumatic Stress Related to Traumatic Birth

OBJECTIVE

To synthesize mixed-research results (quantitative and qualitative) on posttraumatic stress in women who experienced traumatic births.

DATA SOURCES

PubMed, Scopus, and PsycINFO databases.

STUDY SELECTION

Quantitative and qualitative studies were included if they were published in English from January 1, 2009, through December 31, 2018, and focused on posttraumatic stress in the postpartum period related to traumatic childbirth.

DATA EXTRACTION

The final sample consisted of 59 studies: 4 qualitative and 55 quantitative. Both authors independently appraised each study using the Critical Appraisal Skills Programme. Quantitative studies were synthesized by narrative synthesis and vote counting, and qualitative studies were synthesized by content analysis.

DATA SYNTHESIS

In the included studies, prevalence rates of elevated posttraumatic stress ranged from 0.8% to 26%. Significant predictors of posttraumatic stress that occurred before childbirth and those that were birth related were identified. Reports of six intervention studies to decrease posttraumatic stress symptoms after traumatic births were included. These interventions focused on postnatal debriefing, expressive writing, online cognitive behavioral therapy, a brief cognitive intervention, and the implementation of the nine instinctive stages of the infant during the first hour after birth. We created four themes from the findings of the qualitative studies: Distressing Symptoms, Detrimental Effect of Posttraumatic Stress on Women's Relationships With Their Infants and Partners, Critical Influence ofSupport, and Debriefing.

CONCLUSION

When a woman experiences posttraumatic stress related to a traumatic birth, the entire family unit is vulnerable. Findings from quantitative predictor studies can be used to develop an instrument to screen women for risk factors for posttraumatic stress related to birth trauma. Primary interventions are needed to prevent women from experiencing traumatic births.

Traumatic Childbirth and Its Aftermath: Is There Anything Positive?

Up to 45% of new mothers have reported experiencing birth trauma. For some individuals who have experienced a traumatic event, there can be a positive legacy called posttraumatic growth. Using Tedeschi and Calhoun's Posttraumatic Growth Model as the theoretical framework, the purpose of this pilot study was to determine levels of posttraumatic stress, core beliefs disruption, and posttraumatic growth in women who have experienced traumatic childbirth. Thirty mothers completed the Posttraumatic Stress Disorder Symptom Scale-Self Report, Core Beliefs Inventory, and Posttraumatic Growth Inventory. Type of birth and length of time since the traumatic birth occurred predicted 38% of the variance in posttraumatic growth. In order to help mothers, childbirth educators need to understand the process involved in posttraumatic growth.

“Being With Woman”: Is There a Cost for Midwives and Students Attending Traumatic Births?

Witnessing and/or providing care during a traumatic birth increases vulnerability to secondary traumatic stress, with potential effects on mental health of and attrition among the midwifery workforce. With the global shortage of the midwifery workforce, retention and peak functioning are critical to the well-being of childbearing women and their infants. PubMed, Scopus, CINAHL, and PsycINFO databases were searched to identify studies that examined secondary traumatic stress in both midwives and midwifery students. Fifteen studies were located from eight different countries. Four of these studies examined secondary traumatic stress in midwifery students and 11 in practicing midwives. This article discusses the limited research on secondary traumatic stress among midwives and students who have attended or witnessed traumatic births. The vulnerability and potential workforce attrition of midwives and students experiencing secondary traumatic stress are highlighted. The development of a comprehensive body of literature is needed on prevalence, impact, clinical implications, and healing strategies addressing this workforce issue.

Refugee and Immigrant Women’s Experience of Postpartum Depression: A Meta-Synthesis

The aim of this work is to synthesize qualitative research on refugee and immigrant women’s experiences of postpartum depression (PPD) to gain insight into the unique needs of this group of women. This population is more at risk of developing PPD due to a complexity of issues including pre- and postmigratory stressors; however, there is currently little research on this topic available to health care providers and policy makers. Thirteen articles met inclusion criteria, and five themes emerged from the meta-synthesis: (a) suffering in solitude, (b) the invisible illness, (c) cultural conceptualizations, (d) barriers to help seeking, and (e) facilitators of help seeking. Conclusions suggest immigrant women with PPD may lack understanding of their condition, are often isolated, are alone, fear stigmatization, and risk being considered an unfit mother. Raising awareness with health care providers of the meaning of PPD for immigrant women is key to the provision of effective care.

The Anniversary of Birth Trauma: A Metaphor Analysis

The aim of this qualitative secondary data analysis was to identify the metaphors women used to describe their anniversary of their traumatic births. The existing data set that was reanalyzed was from a phenomenological study of the anniversary of birth trauma. Metaphor identification procedure was the method used to identify 8 different metaphors from the women's descriptions that provided a rich source of insight into their yearly struggles. These metaphors characterized the anniversary of traumatic birth as a great pretender, a lottery, a trigger, a clock watcher, a giant rubber band, a guilt trip, a sea of sadness, and bottled up anger.

Posttraumatic Stress in Mothers Related to Giving Birth Prematurely: A Mixed Research Synthesis

BACKGROUND

Globally the preterm birth rate for 184 countries in 2010 was 11.1%. Preterm births can be a traumatic experience for mothers.

OBJECTIVE

This article provides a mixed research synthesis of the quantitative and qualitative studies on posttraumatic stress in mothers who have given birth prematurely.

DESIGN

Narrative synthesis was the mixed research synthesis approach used.

RESULTS

Included in this narrative synthesis were quantitative prevalence studies ( n = 19), quantitative intervention studies ( n = 6), and qualitative studies ( n = 5). Prevalence rates ranged from 14% to 79%. Four of the intervention studies had significant results and two did not. Qualitative data synthesis revealed five themes: (a) shocked and horrified, (b) consuming guilt, (c) pervasive anxiety and hypervigilance, (d) intrusive thoughts, and (e) numbing and avoiding reminders.

CONCLUSIONS

Women's traumatic experiences of preterm birth are clearly important issues for psychiatric nurses to address.

A Mixed-Methods Study of Vicarious Posttraumatic Growth In Certified Nurse-Midwives

INTRODUCTION

The purpose of this mixed-methods study was to investigate vicarious posttraumatic growth in certified nurse-midwives (CNMs) who have struggled after attending traumatic births. Vicarious posttraumatic growth involves positive changes in a clinician's life due to caring for patients who are traumatized.

METHODS

A convergent parallel mixed-methods design was used. The American College of Nurse-Midwives (ACNM) sent out e-mails to all CNM members with a link to the electronic survey. CNMs completed the Posttraumatic Growth Inventory and the Core Beliefs Inventory in the quantitative portion. For the qualitative portion CNMs responded to a statement asking them to describe their experiences of any positive changes in their beliefs or life after attending traumatic births. IBM SPSS 23.0 and Krippendorff's content analysis were used to analyze the quantitative and qualitative data, respectively.

RESULTS

The sample consisted of 425 CNMs who completed the quantitative portion and 315 (74%) who completed the qualitative portion. CNMs reported a small degree of both disruption of their core beliefs and vicarious posttraumatic growth. Personal Strength was the dimension of the Posttraumatic Growth Inventory that reflected the highest growth, followed by Appreciation of Life, Relating to Others, Spiritual Change, and New Possibilities. In the qualitative findings, Personal Strength was also the category of vicarious posttraumatic growth most frequently described.

DISCUSSION

This study confirmed a positive relationship between the degree that a CNM's core beliefs are challenged and the amount of vicarious posttraumatic growth that is experienced. The qualitative comments of the CNMs matched the quantitative scores of the Posttraumatic Growth Inventory.

Vicarious Posttraumatic Growth in Labor and Delivery Nurses

OBJECTIVE

To investigate vicarious posttraumatic growth in labor and delivery nurses who cared for women during traumatic births.

DESIGN

A convergent parallel mixed-methods design was used.

PARTICIPANTS

The sample consisted of 467 labor and delivery nurses who completed the quantitative portion and 295 (63%) who completed the qualitative portion of this mixed-methods study via the Internet.

METHODS

The Association of Women's Health, Obstetric and Neonatal Nurses sent out e-mails to members who were labor and delivery nurses with a link to the electronic survey. Labor and delivery nurses completed the Posttraumatic Growth Inventory and the Core Beliefs Inventory in the quantitative portion. For the qualitative portion, the nurses were asked to describe their experiences of any positive changes in their beliefs or life as a result of their care for women during traumatic births.

RESULTS

Labor and delivery nurses who cared for women during traumatic births reported a moderate amount of vicarious posttraumatic growth as indicated by their Posttraumatic Growth Inventory scores. Appreciation of Life was the dimension of the Posttraumatic Growth Inventory that reflected the highest growth, followed by Relating to Others, Personal Strength, Spiritual Change, and New Possibilities. In the qualitative findings, Relating to Others was also the dimension of posttraumatic growth most frequently described.

CONCLUSION

We compared our results with those of previous studies in which researchers assessed vicarious posttraumatic growth in clinicians, and we found that labor and delivery nurses who cared for women during traumatic births experienced growth levels that were scored between the lowest and highest reported levels of therapists and social workers. Nurses need to be aware of the potential to experience this growth despite the significant stress and unpredictability of the labor and delivery environment, which could decrease burnout and improve retention rates.

Middle Range Theory of Traumatic Childbirth: The Ever-Widening Ripple Effect

A middle range theory of traumatic childbirth was developed using Morse’s method of theoretical coalescence. The scope of this qualitative theory was increased by formalizing the connections between 14 individual studies all conducted by the same researcher on the same topic, with different groups, using different research designs and different types of analyses. Axioms were derived from this research program along with attributes of traumatic childbirth, posttraumatic stress, and secondary traumatic stress. This middle range theory addresses the long-term chronic consequences of a traumatic birth for mothers including its impact on breastfeeding, subsequent childbirth, and the anniversary of birth trauma. The impact on fathers and clinicians present at the traumatic birth is highlighted as secondary traumatic stress comes into play. Troubling glimpses of difficulties in mother–infant bonding are revealed.

A mixed-methods study of secondary traumatic stress in certified nurse-midwives: shaken belief in the birth process

INTRODUCTION

Secondary traumatic stress (STS) is an occupational hazard for clinicians who can experience symptoms of posttraumatic stress disorder (PTSD) from exposure to their traumatized patients. The purpose of this mixed-methods study was to determine the prevalence and severity of STS in certified nurse-midwives (CNMs) and to explore their experiences attending traumatic births.

METHODS

A convergent, parallel mixed-methods design was used. The American Midwifery Certification Board sent out e-mails to all their CNM members with a link to the SurveyMonkey study. The STS Scale was used to collect data for the quantitative strand. For the qualitative strand, participants were asked to describe their experiences of attending one or more traumatic births. IBM SPSS 21.0 (Version 21.0, Armonk, NY) was used to analyze the quantitative data, and Krippendorff content analysis was the method used to analyze the qualitative data.

RESULTS

The sample consisted of 473 CNMs who completed the quantitative portion and 246 (52%) who completed the qualitative portion. In this sample, 29% of the CNMs reported high to severe STS, and 36% screened positive for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnostic criteria for PTSD due to attending traumatic births. The top 3 types of traumatic births described by the CNMs were fetal demise/neonatal death, shoulder dystocia, and infant resuscitation. Content analysis revealed 6 themes: 1) protecting my patients: agonizing sense of powerlessness and helplessness; 2) wreaking havoc: trio of posttraumatic stress symptoms; 3) circling the wagons: it takes a team to provide support … or not; 4) litigation: nowhere to go to unburden our souls; (5) shaken belief in the birth process: impacting midwifery practice; and 6 moving on: where do I go from here?

DISCUSSION

The midwifery profession should acknowledge STS as a professional risk.

Childbirth in exile: asylum seeking women's experience of childbirth in Ireland

OBJECTIVES

the purpose of this study was to gain insight into women's experiences of childbirth in Ireland while in the process of seeking asylum. This paper will focus on one of the primary findings of the study, how lack of connection, communication and cultural understanding impacted the health and well-being of the women who participated.

DESIGN

researchers adopted a structural approach to narrative analysis using Burke's (1969) dramatistic pentad to analyse 22 women's narrative accounts of their childbirth experiences. Ethical approval was granted, and the study was funded by the Irish Health Research Board.

FINDINGS

Burke's (1969) dramatistic pentad revealed numerous accounts of Scene/Agent and Act/Agency imbalance in the women's experiences, highlighting lack of communication, connection and culturally competent care evident in their experiences and how this impacted the care they received.

CONCLUSION

inadequate, poorly organised maternity services complicated by lack of training in cultural understanding and sporadic access to interpreter services had a detrimental impact on care provision. Providers appeared to have little insight into the specific needs of this vulnerable group already traumatised by pre and post migratory stressors. The resulting lack of effective connection and communication exacerbated women's experiences of alienation, loneliness, and isolation and were universal in the women's accounts. Implications for practice need to focus in Burkean terms on 'How' (Agency) providers can meet the maternity care needs of asylum seeking women. Dedicated community based services, mandatory training in cultural competence, 24 hour access to interpreters, information leaflets in several languages are essential measures. Further research looking specifically at the antenatal care and childbirth education needs of ethnic minority women is needed. Also, there is an urgent need for further exploration of the barriers to communication and the utilisation of trained interpreters in the provision of effective care to non-English speaking ethnic minority women.

Is there still gender bias in nursing research? An update

Data from 300 studies published in four research journals in 2010-2011 were analyzed to assess whether nurse researchers continue to oversample females. One-third of the studies had samples that were 100% female and, on average, 74% of all study participants were female. As was found for studies published 5 years earlier, the bias against male participants was consistent across studies differing in methods, specialty areas, funding, and sample characteristics. Studies with male first authors, however, were significantly less likely to have biased samples. Authors of only 23.6% of studies with mixed-sex samples provided information about sex differences in outcomes. Because of gender bias, the evidence base for nursing practice may suffer from problems with generalizability.

Posttraumatic stress disorder in new mothers: results from a two-stage U.S. national survey

BACKGROUND

Prevalence rates of women in community samples who screened positive for meeting the DSM-IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two-stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP).

METHODS

In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale-Self Report (PSS-SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire-2 (PHQ-2).

RESULTS

Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS-SR. A total of 18 percent of women scored above the cutoff score on the PSS-SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health-promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well-being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ-2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey.

CONCLUSION

In this two-stage national survey the high percentage of mothers who screened positive for meeting all the DSM-IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic.

A metaethnography of traumatic childbirth and its aftermath: amplifying causal looping

Integrating results from multiple analytic approaches used in a research program by the same researcher is a type of metasynthesis that has not often been reported in the literature. In this article the findings of one type of qualitative synthesis approach, a metaethnography, of six qualitative studies on birth trauma and its resulting posttraumatic stress disorder from my program of research are presented. This metaethnography provides a wide-angle lens to view and interpret the far-reaching, stinging tentacles of this often invisible phenomenon that new mothers experience. I used Noblit and Hare's seven-step approach for synthesizing the findings of qualitative studies. The original trigger of traumatic childbirth resulted in six amplifying feedback loops, four of which were reinforcing (positive direction), and two which were balancing (negative direction). Leverage points that identify where pressure in the amplifying causal loop can break the feedback loop where necessary are discussed.

Secondary traumatic stress in nurses: a systematic review

BACKGROUND

Is there a "cost of caring" for health care providers of traumatized patients?

OBJECTIVES

The aim of this study is to review the literature on secondary traumatic stress in nurses in order to answer the following questions: What studies have been conducted on secondary traumatic stress in nurses in all clinical specialties? What instruments were used to measure secondary traumatic stress in nurses and what psychometric properties were reported?

DESIGN

A systematic review.

DATA SOURCES

CINAHL, PubMed, and PsycINFO databases were searched for the years 1981 to the present. Keywords used in the database searches included secondary traumatic stress, compassion fatigue, vicarious traumatization, secondary trauma, PTSD, and nurses.

REVIEW METHODS

Research studies were reviewed for the following inclusion criteria: the sample included nurses, the secondary traumatic stress symptoms were measured, and the language was English.

RESULTS

Seven studies were found in which researchers examined secondary traumatic stress in nurses. The samples in five of these studies consisted of all nurses, whereas in the remaining two studies, nurses were included in the samples but the results were not specifically reported for the subgroup of nurses. Presence of secondary traumatic stress was reported in forensic nurses, emergency department nurses, oncology nurses, pediatric nurses, and hospice nurses. Three instruments were identified that measured secondary traumatic stress in practitioners who care for traumatized populations: Secondary Traumatic Stress Scale, Compassion Fatigue Self Test for Helpers, and the Compassion Fatigue Scale-Revised.

CONCLUSIONS

Presence of secondary traumatic stress in nurses was reported in all of the studies included in this literature review. The use of small samples and a number of different instruments to measure secondary traumatic stress symptoms, however, hindered the ability to make comparisons across studies and to draw conclusions. None of the studies conducted to date have focused on secondary traumatic stress in psychiatric nurses. Suggestions for future research and clinical implications for what can be done to protect nurses from secondary traumatic stress are addressed.

Generalization in quantitative and qualitative research: myths and strategies

Generalization, which is an act of reasoning that involves drawing broad inferences from particular observations, is widely-acknowledged as a quality standard in quantitative research, but is more controversial in qualitative research. The goal of most qualitative studies is not to generalize but rather to provide a rich, contextualized understanding of some aspect of human experience through the intensive study of particular cases. Yet, in an environment where evidence for improving practice is held in high esteem, generalization in relation to knowledge claims merits careful attention by both qualitative and quantitative researchers. Issues relating to generalization are, however, often ignored or misrepresented by both groups of researchers. Three models of generalization, as proposed in a seminal article by Firestone, are discussed in this paper: classic sample-to-population (statistical) generalization, analytic generalization, and case-to-case transfer (transferability). Suggestions for enhancing the capacity for generalization in terms of all three models are offered. The suggestions cover such issues as planned replication, sampling strategies, systematic reviews, reflexivity and higher-order conceptualization, thick description, mixed methods research, and the RE-AIM framework within pragmatic trials.