This is the second article in a two-part series evaluating, a national termination of pregnancy education programme in the Republic of Ireland using Kirkpatrick's model of evaluation (Kirkpatrick and Kirkpatrick, 2016). The first article provided the findings of levels one and two of the model, participants' reaction to the training experience and their knowledge before and after attending the education programme (Fletcher et al, 2023). This article describes the findings of level three of Kirkpatrick's model of evaluation: to identify if participants applied knowledge gained from attending the programme to clinical practice. Additional education and training required to support midwives and nurses working in termination of pregnancy services was also explored. As a result of a surge in COVID-19 cases and pressures at the front line, the fourth level of Kirkpatrick's model of evaluation was not measured.
Background
The signing into law of the Health (Regulation of Termination of Pregnancy) Act 2018 broadened the circumstances in which termination of pregnancy could be legally performed in the Republic of Ireland (Government of Ireland, 2018). The Irish draft model of care for the termination of pregnancy services highlights the importance of healthcare professionals remaining abreast of the latest international evidence on termination of pregnancy (Health Service Executive, 2018). A thorough understanding of termination of pregnancy legislation and clinical practice guidelines is paramount to reduce maternal mortality and morbidity and ensure high-quality services are provided based on the best available evidence (Dennis et al, 2017). The Irish Institute of Obstetrics and Gynaecologists (2018) recommends that all clinical staff involved in the care of women undergoing a termination of pregnancy should have access to appropriate training and support.
To support the delivery of evidence-based termination of pregnancy care, two national education programmes were delivered over a 5-month period, between November 2020 and March 2021. Both programmes took place virtually, over 6 hours, and included presentations from clinical experts focusing on the following key areas:
- Current legislation in the Republic of Ireland guiding termination of pregnancy service provision
- Support services available to those considering a termination of pregnancy
- Care required for women electing for a termination of pregnancy in early pregnancy
- Care required for women choosing a termination of pregnancy for a fatal fetal abnormality.
The first article on this research study described the findings from online questionnaires which were used to capture participants' reaction to the training experience and their self-assessed knowledge before and after training (Fletcher et al, 2023). The questionnaires highlighted how a short education programme increased participants' knowledge and confidence in caring for women having a termination of pregnancy. Participants agreed that the programme content was relevant, met their expectations and would be applied to their practice. The study identified the positive impact that education had on participants' knowledge of the legislation, their confidence in providing information to women in order for them to make informed decisions regarding their reproductive health, and in caring for women who present with complications following termination of pregnancy.
This second article delves further into participants' experiences of attending a termination of pregnancy education programme, by examining if their newfound knowledge and confidence enhanced their clinical practice. Additional education and training needs were also explored, as it is envisaged that this research will guide future termination of pregnancy curriculum development.
Box 1.Interview guide
- You attended a termination of pregnancy education programme 3 months ago. How has the information you received on the programme impacted your experience of caring for a woman having a termination of pregnancy?
- Do you feel that the content of the programme was relevant?
- Can you give me some examples of how you have applied your learning to practice?
- Has attending the educational programme changed/improved your understanding of the Health (Regulation of Termination of Pregnancy) Act?
- Tell me about your experience in clinical practice of empowering women to make informed decisions regarding their reproductive health choices.
- Have you had the opportunity to apply your knowledge related to women who present with complications following termination of pregnancy?
- Would you feel confident in providing care to a woman with a diagnosis of fatal or complex fetal abnormality?
- Have you had the opportunity to put your learning into practice?
- Have you managed to pass your learning on to colleagues?
- Do you feel that you have any additional education and training needs to enhance the care you provide to women attending for termination of pregnancy?
Methods
Individual, semi-structured interviews took place with participants 3 months following attendance at a termination of pregnancy education programme. A purposeful sample of seven midwives and nurses who volunteered to participate in the study were interviewed, and data saturation was reached at this point. An interview schedule (Table 1) incorporating Kirkpatrick's model of evaluation was developed to ensure consistency. The interview schedule consisted of open questions generated from the programme content. A pilot interview was carried out, following which minor modifications were made to the research questions.
Recruitment
All midwives and nurses that booked to attend one of the two advertised termination of pregnancy programmes, from the six hospitals where ethical approval had been granted, were invited to participate in the research study. The education centre's event booking system was used to invite participants to tick a box if they were willing to be contacted by email about the research study. Those who consented to participate were emailed an information leaflet, links to the questionnaires (examined in the first article of this series), and provided with the researchers' contact details, should they wish to partake in an individual interview.
Data collection
Interviews were facilitated by the principal researcher, who was unknown to the participants. Interviews were conducted face to face and lasted between 30 and 45 minutes. To ensure credibility, interviews were digitally recorded and field notes were taken, and the data were transcribed verbatim by the researcher during data collection.
Every effort was made to enhance rigor by being open and transparent in all stages of the research process. To establish dependability and confirmability, the researcher chronicled a record of the research steps to provide an audit trail (Parahoo, 2014). To guarantee personal bias did not influence data collection or interpretation, the researcher practised reflexivity throughout the research process (Sandelowski, 2010). A reflective diary was maintained by the principal researcher during each stage of the research process, capturing their thoughts and emotions at that time, which aided transparency and accountability. This was important to ensure that the researcher's personal beliefs and values did not influence interpretation of the data (Polit and Beck, 2014), but was instead a true reflection of the participant's experiences, which added to the credibility of the research.
Data analysis
Qualitative data from interviews were analysed using thematic analysis by members of the research team. All researchers familiarised themselves with the data by reading and rereading transcripts. Members of the research team independently coded each interview transcript, and meanings were formulated to reflect significant statements, which were then categorised. The research team worked collaboratively to reach consensus, categories evolved into subthemes and eventually two themes emerged.
Ethical approval
Ethical approval was granted by six clinical research ethics committees throughout the Republic of Ireland. Prior to commencing the interview, participants were asked if they had any questions and the interviewer reminded them that participation was voluntary and they were free to withdraw at any time. Written consent was taken prior to commencing the interview. From the outset, participants were given a pseudonym to ensure anonymity.
Results
The results clearly demonstrated behavioural changes in clinical practice following attendance at the termination of pregnancy education programme. Participants reflected on their practice and shared examples of how they applied newly gained knowledge to the care they provided.
‘I reflect on some of the women that I would have worked with over the recent years, and possibly some things that I could have done with them that I didn't do with them, or things that I could have suggested that I didn't know about’.
Sarah
Following data analysis, two main themes were identified: empathetic care and role clarity. In addition, further education and training needs were identified.
Empathetic care
Participants reported having a greater understanding of the perspectives and emotional needs of women having a termination of pregnancy.
‘For somebody who is having a miscarriage or a stillbirth, my heart always went out to them, whereas somebody coming in for a termination of pregnancy I used to always think, “oh they're coming in, they'll be fine”…never really thought about the long-term aspect, even the mental health aspect that they could be experiencing’.
Sarah
There was increased awareness of the associated loss and grief that some women experience when having a termination of pregnancy.
‘They have chosen this path to go down…but it's still a heartbreak, and it's still a loss and it's just to recognise that it is a loss, and a bereavement and a grief’.
Lisa
This increased awareness enabled the provision of empathetic care.
‘Sometimes, if I see a woman very upset, I might give them a little token that we have, a little key ring so that they can put a little part in with the fetus and they can take the key ring away. It's still a loss. They might have wanted this [termination of pregnancy] but it's still a loss that they are experiencing’.
Sinead
However, participants felt that the programme did not adequately prepare them to deal with situations where women choose not to engage in what they perceived as ‘standard bereavement care’.
‘We had to re-educate staff that if the woman or the parents have chosen not to engage with bereavement and they've opted for incineration then the baby doesn't go to the mortuary, the notice of removal isn't filled out. And I think what was hard for staff was there's no record, you know there's no paper trail’.
Joanne
This highlighted the personal impact on practitioners, as participants detailed how they would need additional support to handle the complexities that they encountered while working in termination of pregnancy services.
‘Staff would need some additional…support for themselves. Again, if they are hearing dramatic stories as to why women are attending, you know as a result of assault, or just purely for social reasons, all those factors that might need to be discussed’.
Maggie
Role clarity
Some participants reported having greater insight into what their role is in supporting women opting for termination of pregnancy.
‘I suppose I am very clear on my role is not to sway either way, my role is literally to support and not to judge, to support whatever they decide’.
Brid
They considered their role to include facilitating supportive decision making and providing non-judgemental care, irrespective of whether the termination of pregnancy was before 12 weeks or as a result of a fatal fetal abnormality. This role clarity gave them the confidence to engage in an informed conversation and provide women with accurate information at every stage of the termination of pregnancy process.
‘I was able to talk to her more openly about the process. I would just have given them the crisis pregnancy resources and supported them with that, whereas now I can actually have a conversation with them and maybe answer some of the questions they may have about a termination’.
Michelle
They also felt confident in directing women to appropriate additional support that was available.
‘I now know that these are the supports that are in place and I can be very definite. I can give them a very definite pathway to say “look this is where you can get support we can't offer at the moment, but do A B and C” and that's certainly as a result of the study day’.
Brid
However, others highlighted the need for further training in this area.
‘Some patients, they clearly handle it and then they come to the ward and they're not sure, they are at a confused stage and they are emotionally upset and guilty about whether they want to go ahead or not. I think we need an education programme on how to handle that situation…if something comes up’.
Sinead
Despite varying perspectives on role clarity, the majority of participants felt that there was ambiguity among some colleagues when it came to conscientious objection and its application to clinical practice. Participants were of the opinion that this was an area requiring additional education and training.
‘I think people think that they can object to looking after a woman who has a termination for social reasons but then they'll go and look after someone who has had a termination for fatal fetal abnormality. That's not a conscientious objection. That's you deciding who you are going to look after’.
Joanne
‘I don't think we educate staff about what it [conscientious objection] means properly’.
Lisa
Nevertheless, participants underlined the importance of respect for their colleagues who do not wish to take part in the provision of termination of pregnancy services.
‘You have to respect colleagues, that's personal opinion, you cannot say you were wrong for that, no more than they could say you're wrong for supporting that service’.
Maggie
All participants recommended provision of an annual refresher programme to ensure knowledge and practice remains based on the best available evidence and to combat misinformation.
‘For healthcare professionals, these study days are amazing. It gets the correct information out there and any misconceived notions that any of us may have had or any misconceptions or any ideas that we may have had, I think these study days are able to put these at bay’.
Brid
Discussion
Using Kirkpatrick's framework, this study was conducted to ascertain if knowledge gained at a termination of pregnancy education programme was applied to clinical practice. All participants gave examples of how attendance at the programme had prompted reflection, resulting in a behavioural change in clinical practice.
Reflection is a key component of every midwife and nurses' practice and is embedded in their code of professional conduct and ethics (Nursing and Midwifery Board of Ireland, 2021). It encourages healthcare professionals to continuously learn from previous events, which facilitates ongoing personal and professional development, and fosters improvements in clinical practice (Barchard, 2022).
Empathy is an essential component of good midwifery care (Pezaro et al, 2016). In the present study, reflection assisted the participants to be more aware of the importance of providing empathetic care, as the programme brought the emotional and mental health aspects of termination of pregnancy into focus. The midwifery and nursing care and support received during a termination of pregnancy is essential and can have a lasting psychological impact (Lafarge et al, 2014; Maguire et al, 2015; Jones et al, 2017). Women experience a range of emotions, from anxiety and depression to guilt and thankfulness following a termination of pregnancy (Kirkman et al, 2017). Participants reported that the information that they received on the programme regarding the potential emotional and psychological aspects of termination of pregnancy enhanced their ability to provide empathetic care, and this translated to changes in their clinical practice. As a result, participants reported having the knowledge and confidence to direct women to appropriate support services for additional support. They also outlined new practices that they would include in their care following attendance at the programme, for example, the use of items of remembrance, such as memory boxes.
The grief and loss women may encounter following a miscarriage or a termination of pregnancy for medical reasons is well documented (Heaney et al, 2023). Research studies outline the traumatic, lonely and emotionally challenging consequences of losing a baby as a result of a termination of pregnancy for a fatal fetal abnormality (Heaney et al, 2023). McCoyd (2007) found that the assumption that termination of pregnancy is a ‘chosen loss’, which allows women to move on quickly, is gradually changing. The importance of providing compassionate care for termination of pregnancy for a fatal fetal abnormality is described throughout the literature (Lotto et al, 2016; Irani et al, 2019; Armour et al, 2021). However, there is a dearth of research in relation to healthcare professionals' feelings towards caring for termination of pregnancy at earlier gestations. The present study highlights that attendance at the education programme gave midwives and nurses a greater appreciation of the grief and loss that some women may experience following a termination of pregnancy, irrespective of gestation. Participants gave examples of how they supported these women through their loss and grief. Furthermore, the education provided highlighted the importance of forming a connection with women, whether they are grieving a loss as a result of termination of pregnancy or a miscarriage.
Research demonstrates that healthcare professionals are ill equipped to process grief and sadness, which they encounter on a regular basis (Armour et al, 2021). It was evident from the present study that midwives and nurses struggled to deal with situations where women who opted for a termination of pregnancy chose not to engage in any form of bereavement care. The dignified and respectful treatment of the body is an important part of the healthcare worker's role and experience (Armour et al, 2021). Participants reported feeling challenged when incineration was chosen by the woman following termination of pregnancy, and felt further education was required in future programmes to ensure healthcare professionals were adequately prepared to support women's choice. This is important given the impact that inadequate training can have on staff at both a personal and professional level when caring for bereaved parents (Nash et al, 2018). Caring for women having a termination of pregnancy can lead to strong emotions and emotional fatigue, which can deplete resilience and lead to significant psychological consequences, including burnout and post-traumatic stress disorder (Ben-Ezra et al, 2014; Fernández-Basanta et al, 2020; Armour et al, 2021).
The programme provided clarity for midwives and nurses on their role in providing termination of pregnancy care to women. Traditionally, the role of midwives was to be ‘with women’ throughout pregnancy, from conception until the end of the postnatal period (Ramsayer and Fleming, 2020). However, according to Ramsayer and Fleming (2020), midwives working ‘with women’ having a termination of pregnancy require a different set of skills because the term ‘being with women’ is seen as a dynamic and challenging, when the outcome is a deliberate termination of pregnancy. Those who choose to embrace the expanded role of working in termination of pregnancy services must be able to respect and support the woman (Bradfield et al, 2018). Participants in the present study reported that they are now clear that their role in practice is to provide non-judgemental support to women. They described how they are more confident communicating with women and answering questions, a change in practice that they attributed to the knowledge gained on the education programme. This is an important finding considering the key role midwives and nurses play in termination of pregnancy services, both in care provision, but also as educators and reliable sources of information for women (O'Shaughnessy et al, 2021).
In the present study, participants highlighted a need for further support to enable them to cope with the many complexities that they may encounter while working in termination of pregnancy services. This is an important finding, as international research has illustrated that healthcare professionals can perceive their work in termination of pregnancy services as being socially unacceptable, occasionally preventing them from seeking support (Armour et al, 2021), which can cause social isolation (Dempsey et al, 2021).
Participants also highlighted a deficit in their ability to support women emotionally and felt further education was required. This concurs with the literature, which found healthcare professionals require specific training in counselling to provide emotional support to women considering termination of pregnancy (Mauri and Squillace, 2017). Healthcare professionals need further training on emotional aspects to enable them to better support and provide information to women during the entire process (Fisher and Lafarge, 2015; Lotto et al, 2016; Kirkman et al, 2017; Sriarporn et al, 2017; Irani et al, 2019).
The introduction of termination of pregnancy in the Republic of Ireland represents a significant change and expansion of clinical practice for healthcare professionals who choose to be part of the service (Mullally et al, 2020). The European Convention on Human Rights ensures the protection of freedom of conscience as a core human right in Europe (European Court of Human Rights and Council of Europe, 2013). The Nursing and Midwifery Board of Ireland (2021; 2022) state that if you have a conscientious objection to providing termination of pregnancy care, you must transfer care to another healthcare provider; however in an emergency situation, you must provide care irrespective of having a conscientious objection. Participants portrayed respect for their colleagues who chose not to engage in termination of pregnancy services. Nevertheless, they highlighted that professional ambiguity exists around conscientious objection. A systematic review by Fleming et al (2018) failed to identify studies from a midwifery and nursing perspective on termination of pregnancy and conscientious objection. This reflects the invisibility of midwives and nurses in the debate on conscientious objection, which is concerning considering that they are core to the provision of the service (Fleming et al, 2018). The present study adds to the literature, as midwives and nurses identified a requirement for more open conversations, to explore what exactly conscientious objection means, at future education programmes. This is to ensure that accurate information is conveyed to all healthcare professionals.
Limitations
The strengths of this study lie in the use of a mixed-methods approach. Capturing different but complementary data adds a rich understanding to the findings and provides a solid foundation for drawing conclusions (Simonovich, 2017). To ensure transferability of the data, midwives and nurses were invited and participated from a wide geographical spread, representing urban and regional maternity services. The authors believe that the selected population was representative of the target population, because of the geographical spread of participants. While this is a small-scale study, it is the first to have been undertaken on this topic in the Republic of Ireland, and thus has the potential to contribute to the published literature.
Findings from levels one, two and three of Kirkpatrick's model of evaluation are reported in this two-part series. However, it was not possible to measure the fourth level of the Kirkpatrick model of evaluation, as a result of pressures on frontline staff, including COVID-19 and redeployment. There may have been potential recruitment bias associated, as those more interested in and supportive of termination of pregnancy services may have been more likely to participate.
Conclusions
The results of this study highlighted that attendance at a termination of pregnancy education programme prompted reflection on clinical practice for midwives and nurses, resulting in behavioural changes to practice. Participants provided examples of how they had enhanced their provision of the care since attending the programme, indicating that education is key for healthcare professionals to provide safe, effective, high-quality and evidence-based termination of pregnancy care to women in the Republic of Ireland. Additional training needs were also identified to guide future programme development.
To the best of the authors' knowledge, this is the first study to evaluate midwives' and nurses' experiences of attending a termination of pregnancy education programme in the Republic of Ireland. Despite studies highlighting requirements for continuous professional development education in termination of pregnancy care, there is a dearth of research outlining the exact training needs of midwives and nurses. Given that termination of pregnancy services have been expanded in the Republic of Ireland, it is timely that midwives' and nurses' educational needs are explored. It is anticipated that the findings from this study will be used to inform the content of future education programmes in termination of pregnancy, so that midwives and nurses can maintain the required knowledge and skill base for safe and effective practice.
Key points
- The legislation on termination of pregnancy has changed in the Republic of Ireland.
- Midwives and nurses are pivotal to the provision of termination of pregnancy services.
- Education assisted midwives and nurses to reflect on and enhance their practice.
- The complexities of providing a termination of pregnancy service were highlighted.
- Support required, as well as additional areas for education and training on termination of pregnancy, were identified.
CPD reflective questions
- Have you ever provided care to a woman having a termination of pregnancy? Reflect on the care you provided and examine what you may do differently if in that situation again.
- How can midwives and nurses enhance the emotional care that they provide to women choosing to terminate a pregnancy?
- How might this article have clarified your role in termination of pregnancy care?
- What additional education and training do you need to enhance the care that you provide to women having a termination of pregnancy?
- How might this article influence your future discussions with colleagues regarding termination of pregnancy care?