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Running head: LIVED EXPERIENCE OF CNMS IN PERINATAL DEATH CARE 1

An Exploratory Study

of the Lived Experience of Certified Nurse Midwives

in Providing Perinatal Death Care

Rachel H. Rose

Bethel College

LIVED EXPERIENCE OF CNMS IN PERINATAL DEATH CARE 2

Abstract

It is inevitable that a certified nurse midwife will care for women experiencing perinatal loss.

This type of care is interpersonally and professionally complex for the provider. There is limited

research specific to the certified nurse midwife available that addresses the experience and

effects of perinatal death care. This phenomenological qualitative study seeks to explore the

CNMs’ lived experiences with perinatal death and the effects they experience personally or in

their clinical practice related to these encounters. In-person interviews will be conducted,

recorded, transcribed, and analyzed. The interviews will be semi-structured with open-ended

questions designed to illicit descriptions of experiences in providing care in the setting of

perinatal death. Transcripts will be analyzed for themes. It is hoped the identified themes from

interviews will suggest new or refined forms of support or targeted education in their practice

areas.

Keywords: certified nurse midwife, perinatal death, lived experience


An Exploratory Study of the Lived Experience of Certified Nurse Midwives

in Providing Perinatal Death Care

It is a remarkable human phenomenon that some individuals choose to enter a life of

service that necessarily means being in close proximity to great suffering. As advanced practice

nurses, certified nurse midwives have chosen to provide care and health promotion to women,

which includes pregnancy care and delivery management. This inevitably positions them to

manage care in the setting of perinatal death. There is growing recognition of the toll that this

care takes on the perinatal nurse. However, there is limited research that addresses the unique

experiences of the certified nurse midwife (CNM) who carries the weight of responsibility as

provider, must provide ongoing care after discharge, operates from within the nursing discipline,

and may not have access to the training or bereavement team support designed for the hospital

staff nurse.

This phenomenological qualitative study seeks to explore the CNMs’ lived experiences

with perinatal death and the effects they experience personally or in their clinical practice related

to these encounters. In-person, semi-structured interviews of open-ended questions with each

midwife will invite descriptions of their experiences with perinatal death care and their

perceptions of how these experiences have affected them and their approach to professional

practice. Interviews will be recorded and transcribed verbatim. Analyzed results will identify

and describe themes within their experiences. It is hoped that these results will suggest forms of

improved support or targeted education for CNMs.

Background

Over the past 40 years, perinatal death and bereavement care has been a developing

subset of perinatal nursing. The psychological effects on parents and the care they need are now


well understood. “Exposure to adverse perinatal events can impact the way healthcare

professionals provide patient care” (McNamara et al., 2017, p. 845). CNMs provide care and

management to patients experiencing miscarriage, stillbirth, and newborn death, often after

working with that patient for weeks, months, or years.

Perinatal death is an inevitable and difficult aspect of perinatal nursing. The Centers for

Disease Control (CDC) reported a neonatal mortality rate of 587 per 100,000 live births (2016).

Approximately one million fetal deaths of all gestational ages occur in the U.S. each year,

including approximately 23,000 of 20 weeks gestation or greater (Hoyert & Gregory, 2016).

CNMs witness first-hand the significant loss and grief bereaved parents experience. Midwifery

is an advanced practice nursing specialty known for a focus on patient-centered care and

relationship over the course of pregnancy, childbirth, recovery and post-partum periods. The

midwife-patient relationship makes the midwife’s role key in supporting families experiencing

loss. It also may make the midwife’s experience of providing perinatal death care even more

taxing than the experience of other healthcare team members.

Significance of the Problem

According to the American Midwifery Certification Board, as of August 2017, there were

11,826 CNMs in the United States (2018). Data for 2014 from the National Vital Statistics

Reports noted that CNMs attended 12% of all U.S. vaginal deliveries (Hamilton, Martin,

Osterman, Curtin, & Mathews, 2015). Stillbirth occurs in about 1% of all pregnancies, and each

year approximately 24,000 babies are stillborn in the United States (MacDorman & Gregory,

2015). Anecdotally, CNMs report a lack of clarity regarding their role when caring for the

hospitalized patient experiencing perinatal loss. Medical management is often turned over to a

physician at this point and there is no clear protocol about the midwife’s continued involvement


at the hospital. There is variation among providers regarding whether the patient’s initial follow-

up care occurs with the physician or midwife.

Statement of the Problem

There is a dearth of information for midwives on the care of patients experiencing

perinatal loss that is specific to the role of the CNM. The American College of Nurse-Midwives

(ACNM) affirms principles of care and the ethics endorsed by the American College of

Obstetrics and Gynecology and the Association of Women’s Health, Obstetric, and Neonatal

Nurses (ACNM, 2017). Publications and standards from these bodies guide patient care.

However, they do not address the unique provider role and challenges of CNMs in the setting of

perinatal death care. There is limited research on the effects of perinatal death care on providers

in the role of CNM. There is scarce resource information for the CNM about navigating the

experience of such care or the necessary collaboration required with physicians for providing this

care.

Statement of Purpose

The purpose of this study is to explore the lived experience of CNMs in perinatal death

care. Open-ended interview questions will invite midwives to describe their experiences in

caring for women experiencing a perinatal death and to describe any impact or effect providing

this care had on the midwives personally. Analyzed themes may influence the development or

refining of education regarding perinatal death care for midwives and may indicate strategies to

provide support for midwives providing this complex care. Results may indicate areas for

further study.


Literature Review

Database Searches

Health Source Nursing/Academic edition, Education Resources Information Center,

Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed, PsychINFO,

H.W. Wilson Social Science, and Cumulative Index to Nursing and Allied Health Literature

(CINAHL) were used to search the published research and journal articles using the terms

certified nurse midwife and perinatal death or perinatal loss or perinatal bereavement or

stillbirth. The search was limited to journal articles in English published from 2015 through

January 2019. Of the 75 articles that met this criterion, 44 were unrelated, 18 contained related

topics but were non-contributory, 8 were on related themes and contributed to the subject of

CNMs and perinatal death, and 5 related directly to the experience of CNMs in perinatal death

care. Many articles that were returned contained the term midwife but referred to bachelor level

nurses working on obstetric units and not master’s prepared CNMs responsible for medical

management of obstetric patients. While some contributed to the background of this study, these

were not considered to address the specific subject of this study.

A search was made of the Journal of Midwifery and Woman’s Health, the publication of

the American College of Nurse Midwives from 2000 to 2018 using the search terms stillbirth or

perinatal death or perinatal loss. Only eight articles met the search criteria. Four of these were

unrelated and four addressed the midwife’s experience of perinatal death care.

Empirical Research

Parents’ experience and needs.

Many research studies and articles address the psychological effects of perinatal loss on

families (Flenady et al., 2014). Perinatal loss is complicated. Pregnancy is a period of


expectancy and the life stage of childbearing is focused on new life and anticipation of the new

role of parenting. It is the sharp incongruence with expectations that makes perinatal loss

traumatic. When fetal or infant death occur, common features of grief include shock,

disorientation, preoccupation, yearning, bitterness, self-blame, and disbelief (Cacciatore &

Thieleman, 2019). Perinatal loss is such a disruption in the expected progression of a young

family that it has profound effects, including “shock, anger, emptiness, helplessness, and

loneliness” (Flenady et al., 2014, p. 137). The effects of perinatal death on the mother and

family can be long lasting. A perinatal loss history can lead to “grief symptomatology, high

anxiety and weak prenatal attachment” in subsequent pregnancies (Gaudet, Sejourne,

Camborieux, Rogers, & Chabrol, 2010, p. 247).

The clinical implications for care of parents in this complex circumstance are grounded in

the patients’ and family’s need for sensitive and compassionate support from their providers

(Cacciatore & Thieleman, 2019). Support from clinicians is associated with lower levels of

anxiety and depression in mothers following a stillbirth (Flenady et al., 2014). This needed

support from clinicians should be provided in a variety of forms. Some forms of support

recognized as helpful by patients include: compassionate and accurate information; affirmation

that feelings related to grief are normal; opportunity to create memories, such as holding the

baby; affirmation and support for religious and spiritual practices and beliefs; acknowledgement

of complicating factors such as previous losses; resources related to care for remains;

information about ongoing support; consistency in care and care providers so as not to require

the patient to repeatedly retell her story; and follow-up care, such as sympathy cards or phone

call from trained staff (Fenstermacher & Hupcey, 2019; Richards, Graham, Embleton & Rankin,

2016).


Staff nurses’ experiences and needs.

The psychological effects on health professionals who are present with women

experiencing a perinatal loss are understudied (Ben-Ezra, Palgi, Walker, Many & Hamam-Raz,

2014). Of the published articles which addressed this topic, some provided clear results. A

qualitative analysis of 91 staff nurses’ written accounts of fetal or infant death cases revealed six

themes: “getting through the shift, symptoms of pain and loss, frustrations with inadequate care,

showing genuine care, recovering from traumatic experience, and never forgetting” (Puia, Lewis

& Beck, 2013, p. 321). Phases of perinatal death have been descriptively identified in staff nurse

interviews, including recognizing the loss and its impact, connecting with the mother, dealing

with emotions while acting professionally, preparing to return to work by shifting focus to come

to terms with the situation, and never forgetting (Willis, 2019). The interpersonal and inner

complexity of the work required of nurses in this setting is clear.

Some studies have proposed preparation or interventions that may be supportive to staff

nurses providing perinatal death care. Nurses often identify increased education and preparation

as a need for providing quality perinatal death care and maintaining their own well-being

(Alghamdi & Jarrett, 2016; Andre, Dahlo, Eilertson, & Ringdal, 2016; Forster & Donovan, 2016;

Homer, Malata, Hoope-Bender, & Hoope-Bender, 2016; Mousavi, Pottal & Podder, 2014;

Willis, 2019).

Providing perinatal death care requires a multidimensional approach and involves

understanding the meanings intrinsic to the event for the parents (Nurse-Clark, DiCicco-Bloom,

& Limbo, 2019). Encounters with death and bereavement are considered by perinatal nurses as

inevitable aspects of their work. Yet, many voice a sense of feeling awkward in communication

with bereaved parents (Richards et al., 2016). Learning for knowledge acquisition alone,


through lecture or text, may not be adequate preparation for the interpersonal complexity

involved. A study of nurses’ knowledge in perinatal bereavement suggested that learning

through workshops, seminars or from direct interactions with fellow professionals resulted in

higher level knowledge (Mousavi et al., 2014). Use of simulation or role play was noted to

increase self-efficacy in bereavement care in nurses and student nurses (Colwell, 2016). The

affirmation that comes from supportive coworkers and management was identified as helpful to

nurses (Willis, 2019). Debriefing was frequently mentioned as a method to provide both

learning and support for staff, however, it was not always found helpful by staff and providers

(Wahlberg et al., 2016; Willis, 2019).

Certified nurse-midwife experience and needs.

Few studies were found that addressed the specific experiences of CNMs in providing

perinatal death care. Research confirmed that the impact on midwives personally and on their

practice is significant and identified that support is essential (McCool, Guidera, Stenson, &

Dauphinee, 2009). In a study of 1,459 Swedish midwives who had experienced a severe

obstetric event, 15% had some symptoms of post-traumatic stress disorder (PTSD). Reported

responses in those with identified PTSD symptoms associated with a severe obstetric event

included: feelings of fear, helplessness or panic in 43%, sensing a threat to their role or identity

in 17%, feelings of guilt in 28%, re-experiencing the event in 66%, and a reaction of avoidance

or numbing in 35% of midwives. The personal impact on midwives of an encounter with

intrapartum death included a sense of sadness, blame, self-doubt and exposure to conflicting

opinions about appropriate responses and to a culture of silence about responses (McNamara et

al., 2016).


The impact on professional practice may bring midwives to question their career choice

and their own decision-making. They may worry about their ability to cope with the recurrent

sadness that is a part of their job. Some consider leaving the field or changing positions to focus

on outpatient care. Many evaluate learning and educational needs to continue in their role as a

delivering midwife. Midwives reported that there can be positive impact to their practice,

including improved communication skills and improved relationships with subsequent patients

(McNamara et al., 2016).

Midwives cite education and learning as an area of need related to perinatal death care

(Andre et al., 2016). Support was identified as important to midwives, however, some reports

identified barriers in receiving support from colleagues, peers or hospital leadership (Wahlberg

et al. 2016). A “culture of silence” was identified in which providers refrained from expressing

thoughts or feelings in reaction to a perinatal death (Andre et al., 2016).

Theoretical Research

Theoretical research was limited. A concept analysis of “perinatal bereavement”

included a thorough and historical literature review of this term and its development. Results

indicated that the term is not yet well defined or well-differentiated. This is indicative of the

developing nature of this subspecialty over the past 40 years (Fenstermacher & Hupcey, 2013).

One maturing aspect of this area is the emerging models of grief and bereavement applied

to perinatal loss and bereaved parents. Older models focused on the necessity for the bereaved to

detach from the deceased for there to be resolution. Newer models recognize that it is possible to

maintain a healthy connection to the deceased while moving forward with other life tasks. Some

bereavement models acknowledge that the grief experience can be transformative

(Fenstermacher & Hupcey, 2013).


Pregnancy grief intensity is a concept used to evaluate the experience of grief after a

pregnancy or newborn loss. Three influencing factors to grief intensity are reality, congruence

and ability to confront others. The greater the mother’s sense of reality regarding the pregnancy

and/or the baby as an individual person, the greater her risk for intense grief. The greater the

congruence between the actual loss experience and the way the mother perceives the loss should

progress, the lower her risk for intense grieving. The greater the mother’s ability to confront

others regarding care or reactions to the loss, the lower her risk for intense grief. Intense grief

puts the mother at higher risk for depression and for the need for professional support (Hutti &

Limbo, 2019).

The concept of relationship building is described as helpful to both staff and parents.

This includes the nurse building relationships with the patient along with the nurse supporting

the mother to build a relationship with the baby (Baxter & Baron, 2011; Limbo & Kobler, 2010).

The research related to this concept is noteworthy given the close nature of midwife-patient

relationships.

Guided participation is a model of interaction that posits that teaching and learning is a

reciprocal process between guides and learners (Hutti & Limbo, 2019). It has been applied to

nursing in the setting of pediatrics, neonatal intensive care units, perinatal hospice programs and

hospital perinatal bereavement programs. Its design includes issues, processes, and

competencies. Through open, invitational communication the nurse and parent co-identify issues

such as the need to nurture, protect or maintain quality of life. The reciprocal processes of this

model include getting and staying connected, sharing understanding, bridging, structuring tasks

and learning, and transferring responsibility. Competencies that are engaged and built in


applying this model include being with, knowing and relating to, problem solving, and regulating

emotions (Hutti & Limbo, 2019).

Caring theory, developed by nurse theorist Swanson, has been applied to perinatal

bereavement nursing. It includes five caring processes: knowing, being with, doing for, enabling

[empowering], and maintaining belief (Koloroutis, 2004). These processes are suited to help the

perinatal nurse focus on approaches to care that can be helpful in the setting of perinatal loss

(Nurse-Clark et al., 2019). It may be that the use of models such as guided participation and

theories such as Swanson’s caring theory will increase nurse self-efficacy, reduce barriers to

connecting and enhance quality of care.

Research Gap

There is a gap in research which addresses the CNM experience in perinatal death care.

The few articles addressing perinatal death care in the Journal of Midwifery & Women’s Health

is telling. While there were many articles found that addressed the experience and effects on

staff nurses, this research did not address the needs or experiences of CNMs in their unique role

of operating from a nursing framework but in the capacity of provider. As the number of

advance practice nurses grows, it is imperative that the nurses in these roles are supported. This

can happen only through nursing research and education that targets the needs specific to their

roles as leaders and providers.

Theoretical Framework

One hallmark of midwifery is continuity in the relationship with the patients they serve.

The slogan for the ACNM is “With Women for Life,” implying that ongoing connection is an

essential part of the care provided by the CNM. Relationship-based care (RBC) will serve as the


guiding framework for this research. Koloroutis, the creator of RBC, introduced the model as

follows:

Relationship-based care (RBC) is comprised of three crucial relationships: care

provider’s relationship with patients and families, care provider’s relationship

with self and care provider’s relationship with colleagues. We experience the

essence of care in the moment when one human being connects to another. When

compassion and care are conveyed through touch, a kind act, through competent

clinical interventions or through listening and seeking to understand the other’s

experience, a healing relationship is created. This is the heart of Relationship-

based care. (pp. 4-5, 2004)

The model of the core relationships of RBC are seen illustrated in Figure 1. The patient

and family are at the center. The nurse labeled as “self” is the middle concentric field. The

nurse is in relationship with the patient and family, with colleagues and with self simultaneously

(Koloroutis, 2004).

Relationship-based Care

Figure 1. (Koloroutis, 2004, p. 4)


The RBC practice model is founded on twelve value assumptions required for high

quality relationship-based provision of care. These assumptions are found in Appendix A. The

first assumption states that “the meaning and essence of care are experienced in the moment

when one human being connects with another (Koloroutis, 2004, p. viii). The key operational

components for health care practice in RBC include leadership, teamwork, professional practice,

care delivery resources and outcomes (see Appendix B). Patient/family relationship with the

provider is always at the heart of these functions and is informed and supported by each of these

components (Koloroutis, 2004). Interview questions for this study will open the door to

expression from midwives regarding these relationships.

Assumptions

This study operates under the assumptions that CNMs practice legally and ethically and

will respond to interview questions veraciously. It assumes that the descriptions of lived

experiences are a valid source of information to gain understanding of complex phenomena.

Aim and Purpose

It is the aim of this study to illuminate the lived experiences of CNMs in perinatal death

care and the impact it has on them and their practice decisions. The purpose of this study is to

use identified themes from the analysis to identify new or refined topics for education or ways to

support CNMs in their practice.

Definitions

Conceptual Definitions

Perinatal death is conceptually defined as death of a fetus at 20 weeks gestation or

greater or the death of a newborn within 28 days of life. The conceptual definition of midwifery


is from the ACNM definition of midwifery and scope of practice of certified nurse-midwives

statement.

Midwifery as practiced by certified nurse-midwives…encompasses a full range of

primary health care services for women from adolescence beyond menopause.

These services include primary care, gynecologic and family planning services,

preconception care, care during pregnancy, childbirth and the postpartum period,

care of the normal newborn during the first 28 days of life, and treatment of male

partners for sexually transmitted infections. Midwives provide initial and ongoing

comprehensive assessment, diagnosis and treatment. They conduct physical

examinations; prescribe medications including controlled substances and

contraceptive methods; admit, manage and discharge patients; order and interpret

laboratory and diagnostic tests and order the use of medical devices. Midwifery

care also includes health promotion, disease prevention, and individualized

wellness education and counseling. These services are provided in partnership

with women and families in diverse settings such as ambulatory care clinics,

private offices, community and public health systems, homes, hospitals and birth

centers. CNMs are educated in two disciplines: midwifery and nursing. They earn

graduate degrees, complete a midwifery education program accredited by the

Accreditation Commission for Midwifery Education (ACME), and pass a national

certification examination administered by the American Midwifery Certification

Board (AMCB) to receive the professional designation of CNM.

(ACNM, 2011)


The RBC description of professional nursing further informs the operational definition of CNM/

nursing scope of practice.

Professional nursing exists to provide compassionate care to individuals and their

loved ones. Nursing is a segment of complex interdependent health care delivery

team. Nurses help patients and their families maintain health, affect healing, cope

during times of stress and suffering, and when all medical options are exhausted,

to experience a dignified and peaceful death. The bring to this noble pursuit

clinical knowledge and proficiency and a profound understanding of the human

condition. (Koloroutis, 2004, p. 123)

Operational Definitions

Operationally the definition of perinatal death will encompass the conceptional definition

and any other pregnancy losses which the midwife perceives as deaths or the midwife perceives

her patients view as a death. Operationally, lived experience will be defined as any direct

personal experience the midwife has had with perinatal death care or any experiences associated

with perinatal death which affects that midwife or the midwife’s practice decisions. Certified

nurse midwife will be conceptually and operationally defined as having current certification in

nurse midwifery by the board of the ACNM. CNM practice will operationally be defined as

provision of midwifery care within practice settings such as a clinic, office, hospital, birthing

center and/or home delivery.

Methods and Procedures

Research Design

This will be an exploratory phenomenological study. Participants will be selected by

convenience and snowball sampling. CNMs will be individually interviewed regarding their


lived experience with perinatal death care. Demographic information will be collected, including

length and setting of practice experience. Interviews will be recorded and then transcribed

verbatim into a Word document. Transcriptions will be analyzed for themes.

Weaknesses of Design

Exploratory phenomenological studies may not lead directly to solutions or

improvements. Rather, it is more likely that an exploratory descriptive study will lead to refined

research topics or identification of issues that lead to development of research questions. The

convenience, snowball sampling will not produce a true cross-section of CNMs and so the

participants’ responses may not be representative of CNMs across the United States.

Strengths of Design

Exploratory descriptive studies allow for examination of issues and subjects not

previously well investigated. Using semi-structured interviewing directly with CNMs will allow

for the views and experiences of these subjects to be explored specific to the topic of perinatal

death care. Conducting face-to-face interviews may provide for candid input and expression of

issues or concerns not yet demonstrated in the literature.

Interview Design

The interview will be semi-structured, and all initial interviews will be face-to-face.

Interviews will be recorded on a hand-held digital recorder and transcribed for analysis. After

collecting demographic information, the core of the interview will be an invitation to share an

experience they have had caring for a patient experiencing perinatal loss (see Appendixes C and

D). Follow-up questions may be used to broaden or deepen responses or to clarify responses.

As themes are later identified, arrangements will be made for a follow-up interview. Participants

may be asked to elaborate on an experience, describe the importance of a statement made in the


original interview or to clarify the meaning of statements they have made. Additional questions

may be developed to further clarify responses.

Setting

Interviews will be conducted in locations most convenient to the subjects. Initial

interviews will be face-to-face. Initial interviews are estimated to last 45 minutes. Interviews will

be conducted not during work hours and in private, distraction-free places such as a private

office, home, or private study room at a library. Follow-up interviews may be conducted either

in person or by telephone. Follow-up interviews are estimated to be 20- 30 minutes. All

interviews will be private and confidential. Interviews will take place in northern Indiana or

southwestern Michigan in medium-sized cities and small towns.

Population and Sampling

All subjects in this study will be over 18 years of age and will be CNMs who have been

in practice for at least one year. Initial contacts to prospective participants will be through

convenience sampling based on the researcher’s collegial familiarity with CNMs. Each

participant will be asked to refer the researcher to additional prospective participants.

Participants will be limited to those midwives currently practicing in Michigan or Indiana.

Target sample size is 15- 20 participants.

Ethical Considerations

Approval will be sought from Bethel College Institutional Review Board (IRB) to

conduct the proposed research. The researcher has completed the National Institutes of Health

on-line course “Protecting Human Research Participants” (see Appendix E). Each participant

will be informed about the study in writing and given the opportunity to ask questions. Each

participant will sign an informed consent form (see Appendix F) prior to the interviews.


Included in the consent form and during the interview it will be acknowledged that the interview

process may be emotional. Each participant will receive a printed resource list with information

about coping strategies and counselors they may access for support (see Appendix G).

Participants will be encouraged to debrief the interview experience as needed with a trusted

colleague, family member or with the researcher.

The researcher has worked as a bereavement coordinator and in related roles in

maternal/newborn service line for over 18 years. The researcher has provided education to

students, nurses, chaplains and providers in the areas of coping, debriefing, and providing patient

and colleague support at the institutional, university, community and state levels.

All interview recordings and transcripts will be kept confidential. The names of the

participants will not be associated with recordings or transcripts and will not be included in

written report or dissemination presentations. Interview recordings and transcripts will be kept

in locked or password protected locations or devices.

Data Collection

Once approval is obtained from Bethel College IRB, prospective participants will be

contacted in the method that is convenient, including phone, email or in person. The informed

consent form will be provided prior to the interview and will be signed at the time of the initial

interview. Data will be collected through recording in-person interviews on a hand-held digital

recorder and through a printed demographics form (see Appendix C). Follow-up interviews will

be recorded using a hand-held digital recorder whether conducted by phone or in person.

Recordings will be transcribed verbatim into a word document within 3 days of the interview.

Demographic data will be analyzed via descriptive statistics.


Data Analysis

Transcripts of interviews will be analyzed to identify themes within the descriptions of

lived experiences of participants. Primary themes and subthemes will be refined and reviewed

for relevance and application to further research or recommendations.

Dissemination

Participants will be invited to a presentation to disseminate results that will include

opportunity for group discussion. Participants unable to attend will have access to the

presentation through Go-To-Meeting or WebEx or a similar electronic access. Participants will

receive printed results either in person or by mail. Representatives from Bethel College School

of Nursing will attend the presentation and be provided printed results. The possibility of

submitting results for publication will be evaluated with advisors from the Bethel College School

of Nursing.

Discussion

Limitations

As exploratory phenomenological research, this study will not necessarily produce

solutions to problems. It is more likely that it will help describe issues in the experience of

CNMs in perinatal death care. Identification of issues may lead to further study or supportive

strategies at a local level. The sample of CNMs will not be a cross-section and participants will

be from a limited region of the United States and therefore results may not be representative of

CNMs in the nation. The probable homogeneity of the sample is a related weakness. The

inexperience of the researcher in interviewing and analysis also poses a weakness.


Implications

Evidence is mounting that perinatal death care is stressful for obstetric nurses. Evidence

is clear that CNMs get little training and very little experience in the care of those experiencing

perinatal loss during their course work and practicum. Some studies demonstrate that CNMs

wish for more training or avenues of support. There is a gap in the literature related to perinatal

death care and its impact on CNMs. This phenomenological study will provide an exploration of

the lived experience of CNMs’ experience of perinatal death care and its effects on them and

their practice decisions. It is hoped that the results will identify indications for further study and

possibly insight into helpful strategies for CNMs at local or area levels. This study is part of an

unfolding international trend in focus on perinatal death care and its ramifications for parents,

nurses, and providers over the past 40 years.


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Appendix A

Value Assumptions of Relationship-based Care

1. The meaning and essence of care are experienced in the moment when one human being

connects with another

2. Feeling connected to one another creates harmony and healing, feeling isolated destroys spirit.

3. Each and every member of and organization, in all disciplines and departments, has a valuable

contribution to make.

4. The relationship between patients and their families and the clinical team belongs at the heart

of care delivery.

5. Care providers’ knowledge of self and self/care are fundamental requirements for quality care

and healthy interpersonal relationships.

6. Healthy relationships among members of the health care team lead to the delivery of quality

care and result in high patient, physician and staff satisfaction.

7. People are most satisfied when their roles and daily work practices are in alignment with their

personal and professional values when they know they are making a positive difference for

patients, families and their colleagues.

8. The value of relationship in patient care must be understood, valued and agreed to by all

members of the health care organization.

9. A therapeutic relationship between patient/family and a professional nurse is essential to

quality patient care.

10. Patient experiences improve measurably when staff “own” their practice and know that they

are valued for their contributions.

11. People willingly change when they are inspired and share a common vision when an

infrastructure is implemented to support new ways of working; when relevant education is

provided for personal and professional development and when they see evidence of the success

of the new plan.

12. Transformational change happens one relationship at a time.

(Koloroutis, M., 2004, pp. viii-ix)


Appendix B

Relationship-Based Care Model

(Koloroutis, M., 2004)


Appendix C

Demographics Questionnaire

Participant # ____

Age:

Gender:

Race/Ethnicity:

How long have you worked in maternal/child nursing?

How long have you been a certified nurse-midwife?

Did you have classroom education in perinatal death care in midwifery school?

Was perinatal death care education a part of your practicum for midwifery?

Since becoming a CNM, have you had any professional training in perinatal death care?

In what settings do you deliver? Circle all that apply.

hospital birthing center home

Describe your practice. Circle all that apply.

Private practice, no partners CNM partners Physician partners


Appendix D

Interview Outline

1. As a CNM, how many times have you assisted in providing care during perinatal loss?

2. Please describe an occasion that you cared for a patient with perinatal loss.

Possible follow up questions:

Would you share some thoughts or feelings you had during care?

Would you share some thoughts or feelings you had after this occasion?

How would you describe the patient interactions within that occasion?

How would you describe the colleague interactions within that occasion?

Would you like to say more?

Is there another incident you would like to describe?

3. What education or training do you believe would be helpful to CNMs related to perinatal

death care?

4. What forms of support do you believe would be helpful to CNMs related to perinatal death

care?

5. Possible closing question: What do you consider your strengths in caring for patients and

families who have had a perinatal loss?

6. With whom could you debrief this interview experience?

7. What else would you like to share with me about your experiences?


Appendix E

Protecting Human Research Participants” Training Certificate


Appendix F

Informed Consent Form

Research Information and Consent

Study title: A Phenomenological Exploration of the Lived Experience of Certified Nurse Midwives in Providing Perinatal Death Care

Investigator: Rachel Rose BSN, RN, CPLCMSN Nursing Student, Bethel College of Nursing, Mishawaka, Indiana.

Rachel Rose is an MSN student at Bethel College and has been a labor and delivery nurse and perinatal bereavement coordinator for 18 years. She currently coordinates a perinatal hospice program.

The Institutional Review Board at Bethel College, Mishawaka, Indiana approved the study and procedures. Your participation may contribute to a better understanding of the CNM experience in perinatal death care and may contribute to the development of support or training efforts for CNMs in your region. You are asked to participate in an in-person interview which will last approximately 45 minutes with a brief (20-30 minutes) follow-up interview by phone or in person, at a later date. Interviews will be held in a private distraction-free setting such as private office, home or library study room. Interviews will be recorded, then transcribed. The subject matter of the study may be emotionally impactful. Some participants may find the interview evocative or even upsetting. The interviewer commits to being sensitive and supportive to each participants’ responses. You, the interviewee, may suspend or end participation at any time. Information about sources of support will be provided. You will be provided with your favorite non-alcoholic beverage during the interview. The names of each participant will be entered into a drawing for a $25 gift certificate to your favorite local shop or restaurant.

You are being invited to participate in this study because you are at least 18 years of age, are a certified nurse-midwife, and have been in practice for at least 1 year. Names will not be associated with recordings or transcriptions. Recordings will be destroyed after use. Participants will receive a print copy of the research findings and be invited to a dissemination of findings. You may be asked to recommend other CNMs who may be interested in participating in the study.

By signing this consent, I agree that I have been informed about the study by reading this information and have had questions concerning this research answered. I voluntarily agree to participate in this study. I acknowledge that I have been given a copy of this form and may contact the researcher at any time through the contact information listed below.

_____________________________ ___/___/2019 _____________________________Signature of Participant Printed Name

I have explained this study to the above participant, have sought his/her understanding for informed consent and have provided a copy of this form.

_____________________________ ____/___/2019Investigator

Rachel H. Rose, BSN, RN, CPLCInvestigatorBethel College School of Nursing1001 Bethel CircleMishawaka, IN 46545office: 574.335.2339cell: [email protected]

Deborah Gillum, PhD, MSN, RN, CNEDean of NursingBethel College School of Nursing1001 Bethel CircleMishawaka, IN 46545office: 574.807.7015 fax: [email protected]


Appendix G

Resources for Interviewees

Resources for You

Discussing perinatal death experiences can be emotional and can stir up memories and

emotions. You are encouraged to engage in healthy self-care by employing one or more of the

suggested resources listed below. The first two, Debriefing and PRAM are things that can be

used in the moment for difficult situations. Using them regularly may help you keep perspective

for a variety of situations.

Debriefing is a proven coping strategy when you have faced a difficult patient situation,

including perinatal death. Debriefing can be informal or structured, personal or developed by an

organization. A key to successful debriefing is an open, trusting, non-punitive environment.

Who may you debrief this interview with?

PRAM –PRAM is a strategy for keeping personal and professional perspective in the moment

when facing a difficult patient encounter. I recommend using this simple in-the-moment

technique before each time you enter your patient room/ company and also at the end of the

encounter/ day/ case.

PRAM- Pause, Reflect, Acknowledge, be Mindful

Designed for caring for your inner self while continuing to connect to patients.

Pause: Stop be still. Center yourself. Focus on being in the reality of your

immediate environment. Feel your feet on the floor.

Reflect: Pay attention to your breathing. Think about the situation you are about

to encounter (entering a patient room). Reflect on the relationship between you

and the person(s) you are about to encounter.

Acknowledge: Name what you feel, acknowledge that it is OK to feel the way

you do. Acknowledge your ability to move into and through the encounter.

be Mindful: Bring your attention to the meaning of the relationship that has

brought you to this encounter. Silently bless the space.

Information about Moral Distress and Moral Resilience- This article gives a good overview

of how our moral distress can be transformed into moral resilience. (Will have print copies

available)


Moral Distress: A Catalyst in Building Moral Resilience

Rushton, Cynda; Caldwell, Meredith; Kurtz, Melissa

AJN, American Journal of Nursing

Issue: Volume 116(7), July 2016, p 40–49

doi: 10.1097/01.NAJ.0000484933.40476.5b

Information about grief and loss- Seeing our patients experience loss can trigger feelings

related to personal losses we have experiences. It is good to reflect on our views related to death

and on grief we may carry with us from our own losses. This book is supportive and healing and

applies to many types of losses. I recommend it highly. (Will have example copy present.)

A Grace Disguised: How the Soul Grows through Loss

Gerald Lawson Sittser, 2004

Grand Rapids, MI: Zondervan

Spirituality and Faith- Spiritual and religious frameworks often help us reduce internal conflict

and help us view experiences with balanced perspective. If you are a person of faith, consider

seeking moral support and guidance from a trusted person of your faith, specific to your

challenges encountered in your practice, including perinatal loss and your personal and

professional responses.

Individual counseling- Using an individual counselor can help identify and address your

personal areas of struggle related to perinatal death care experiences or address and support

career choices or career/work-life balance. If you are considering this option, you are

encouraged to take the action steps to begin. If you know of a counselor you trust, that may be

the best place to start. Consider asking for a recommendation from your primary care provider.

Some counselors are listed to help you identify one to start with.


Area Counselor Practice Contact Comments

Plymouth Candace Papke MA, LMHC

Renewed Hope Counseling

574.406.0580

Rochester IN

Treatment approaches include Cognitive Behavior Therapy (CBT), Dialectical Behavioral Therapy (DBT), Christian Counseling, Person Centered, and an eclectic, individualized approach

Plymouth

And

Elkhart

Lisa Cooper, MSW, LCSW

Private practice in Plymouth.

Lincoln Therapeutic Partnership, Elkhart

317.561.5001

Plymouth

574.326.3590

Elkhart

Wide range of treatment approaches including: Biofeedback, DBT, CBT, Mindfulness (MBCT), Motivational interviewing, Narrative, Trauma focused, psychoanalysis, and Interpersonal

South Bend/ Mishawaka

Dr. Auna Preston PhD, and six additional counselors

Season’s Counseling of Michiana

574.277.0274

17195 Cleveland Rd. South Bend

Approach to practice here is multidisciplinary, incorporating body mind and spirit. They serve people of all backgrounds and belief systems. CBT, DBT, Eye Movement Desensitization and Reprocessing (EMDR) and Christian counseling approaches are offered.


Suzanne Courtney PsyD

SJHS Physician Network

574.335.6580

611 Douglas Rd. Ste 406 Mishawaka

Issues addressed include work/life balance, Medical professionals’ practice related stress, moral distress in medical practice. A variety of supportive therapies and coping strategies employed.


Dr. Jeff Feathergill.

Dr Jennifer Cummings, Michele Schricker LCSW, and Kate Bowers LCSW

Feathergill and Associates

574.282.1090

Ext #1

Stress management, work/life balance, trauma and PTSD, and depression are issues that this practice addresses with individualized plans that may include DBT, CBT, Jungian, person-centered and Narrative Therapy.

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