Student midwives may encounter bereaved parents at their most vulnerable time, as they attempt to come to terms with the diagnosis of, and give meaning to, their baby's death (Kelley and Trindad, 2012). Worldwide, there are 2.6 million stillbirths and 2.1 million neonatal deaths annually (Wang et al, 2016). In Ireland, approximately 1 in every 250 births is stillborn, and 1 in every 435 live births dies in the first 7 days of life (Health Services Executive (HSE), 2014). Miscarriage statistics are difficult to deduce, but the Royal College of Obstetricians and Gynaecologists (RCOG) (2011) suggest that an average of 1 in 5 pregnancies miscarry. An estimated 0.8-2% of pregnancies end in second-trimester miscarriage (RCOG, 2011; Cullen et al, 2017).
Most students experience traumatic births and perinatal bereavements early in their training (McKenna and Rolls, 2011). The overall conclusion that bereavement training is inadequate and sparse, and that midwives do not feel prepared for this aspect of their job on qualification, is repeatedly featured in the literature (Chan et al, 2005; Wool, 2013; Ellis et al, 2016; Gardiner et al, 2016; Gandino et al, 2017). The stress of witnessing these events, for which they are not prepared, can affect a student's confidence in performing day-to-day tasks and cause feelings of doubt in their role in emergency situations. Various emotions are described by students, such as helplessness, inadequacy, shock, and a need to cry (Begley, 2003; McKenna and Rolls, 2011). The lack of confidence creates a barrier to developing a trusting and fruitful relationship with the bereaved parents (Alghamdi and Jarrett, 2016). Many students are uncertain as to the appropriateness of displaying raw emotion and often feel the need to ‘hold it in’ until they are on their own (McKenna and Rolls, 2011). This distress makes them vulnerable to unresolved grief, which is associated with burnout (Begley, 2003) and can be a factor in their decision to leave the profession (Green and Baird, 2009; Davies and Coldridge, 2015). Lack of clinical exposure has repeatedly featured in the literature (Begley, 2003; McKenna and Rolls, 2011; Alghamdi and Jarrett, 2016; Coldridge and Davies, 2017). Many students recall being discouraged, either by preceptors or clinical superiors, to gain exposure in bereavement care (Alghamdi and Jarrett, 2016).
Higher quality bereavement care training was recently recommended by the HSE (2016) in Ireland. Support and supervision for staff working with bereaved parents has also been recommended to promote the psychological wellbeing of staff and improve patient care (RCOG, 2011). The Stillbirth And Neonatal Death charity (SANDS) holds interactive, skills-based, 1-day workshops for midwives, student midwives, and multidisciplinary teams. This course is said to give midwives confidence and contains relevant, up-to-date information (SANDS, 2014). Unfortunately, this course is only available in the UK. This led to the development of an educational and training workshop on bereavement care (ETWBC), which focused on the needs of student midwives in an advanced stage of their training to support their confidence in this important area of midwifery practice. Training in bereavement care and personal coping is found to be inconsistent at best (Begley, 2003; Mitchell, 2005; McKenna and Rolls, 2011; Alghamdi and Jarrett, 2016). This has a significant impact on bereavement care provision and in turn, psychological outcomes such as stress, depression and anxiety for parents and healthcare workers (Rogers et al, 2008; Wool, 2013; World Health Organization (WHO), 2014; Ellis et al, 2016). Given the demand on midwives to provide evidence-based care, it is essential to find ways of ensuring that training in this area is efficient and well-integrated into clinical practice (Raisler et al, 2003).
Study design
In developing the initial content for the ETWBC, a literature review was conducted. Communication skills, the importance of memory-making, culturally sensitive care, shared decision-making, and self-care were all recommended to be included in any bereavement care training programme (El Sayed et al, 2013; Williams et al, 2008). The content of the workshop was then discussed with an expert panel from the participating hospital and the final content was agreed (Table 1).
| Time | Topic |
|---|---|
| 08.00–08.20 | Welcome and introduction |
| 08.20–08.50 | Bereavement in midwifery |
| Quiz using Socrative app | |
| 08.50–09.30 | Supporting bereaved parents; what do I say and do? |
| Video: One Pink Balloon (12 mins) | |
| 09.30–10.00 | Coffee |
| 10.00–10.20 | Making memories |
| 10.20–10.50 | Elegy for a stillborn child |
| 10.50–1100 | Explain role plays and divide into groups |
| 11.00–12.45 | Role play: |
| 11.00–11.20 | Role play 1 (stillbirth) Repeated 3 times |
| 11.20–11.40 | Role play 2 (second trimester miscarriage) Repeated 3 times |
| 11.40–12.00 | Cuddle cot demonstration (repeated 3 times) |
| 12.00–12.45 | Feedback from role plays |
| 12.45–13.30 | Lunch |
| 13.30–1400 | Reflective diary |
| 14.00–15.00 | Self-care: mindfulness exercise |
| 15.00–15.30 | Discussion and debriefing |
| 15.30– | Tea and coffee |
Research questions
Ethical approval
Ethical approval was granted by the Research Ethics Committee in the National Maternity Hospital, Dublin and an ethical exemption was granted by the University College Dublin Research Ethics Committee.
Methodology
A longitudinal sequential mixed-methods design was chosen as the best design to evaluate the ETWBC for student midwives in the overall study. The advantage of using of the mixed-methods approach led to the capture of both outcome and process data. The quantitative data (outcome evaluation) enabled the capture of numerical data on the students' knowledge, skills, and perceptions, and the qualitative data (process evaluation) allowed for the capture of the students' experiences of participating in the ETWBC. Both the quantitative and qualitative data were integrated to add depth and clarification to the results, thereby strengthening the evaluation of the ETWBC overall. However, it was not possible to present all the findings in one article and so this will focus on the evaluation of the process (experience) of those participating in the ETWBC. This was completed using focus groups as the qualitative part of a sequential mixed-method.
Although not reported here, the quantitative data was collected at three time points for the outcome evaluation: pre- and post-completion of the ETWBC (within 1 week) and at 3-month follow-up. Confidence was defined as ‘bereavement care knowledge’ and ‘bereavement care skills’, and two of the scales from the Perinatal Bereavement Care Confidence Scale (PBCCS) (Kalu et al, 2017) were used to measure the students' confidence. Secondary outcomes relating to students' self-awareness and organisational support were also measured using the PBCCS Self-Awareness Scale and Organisational Support Scale, respectively. The student midwives' level of self-compassion was measured using the Self-Compassion Scale–Short Form (SCS–Sf) (Raes et al, 2011). All the scales used in the outcome evaluation were chosen to assess if the content of the workshop supported change in the student midwives' overall confidence in providing bereavement care to parents who were grieving.
Sampling
Convenience sampling was used. All fourth-year BSc and Higher Diploma Midwifery students who participated in the ETWBC were invited to communicate their interest in participating in the focus groups. Only students who expressed an interest were contacted.
Data collection
The ETWBC was facilitated by two bereavement specialist midwives and one academic from the affiliated university. Two focus groups (n=12) were held with six consenting members from each group of students (fourth-year BSc Midwifery and first-year Higher Diploma Midwifery students) within 10 days of completing the ETWBC. The focus groups were facilitated by the research assistant and an experienced researcher from the University. The aim of the focus groups was to gain an understanding of the students' experiences of participating in the ETWBC. Barriers and facilitators to gaining confidence to provide bereavement care were also examined, as well as students' further educational needs. The themes identified from the data captured essential elements relating to the research questions.
Ethical considerations
Participants gave consent to being audio recorded before commencement. Transcripts were anonymised, and only the leader and co-leader of the focus groups knew the participants' identities. Neither the leader nor the co-leader had involvement in the implementation or the running of the workshop. Due to the sensitive nature of the study, emotional support was put in place for the duration of the study.
Data analysis
Attride-Stirling (2001) developed a series of steps to follow for thematic network analysis (Table 2), and this was chosen to be the most appropriate method of data analysis of the focus group data. Validation of the emergent themes was achieved through discussion with two other members of the research team, in order to confirm findings.
| Stage A: Reduction or breakdown of text | |
| Step 1 | Code material |
| Step 2 | Identify themes |
| Step 3 | Construct thematic networks |
| Stage B: Exploration of text | |
| Step 4 | Describe and explore thematic network |
| Step 5 | Summarise thematic network |
| Stage C: Integration of exploration | |
| Step 6 | Interpret patterns |
Findings
Twelve basic themes were identified. From there, three organising themes were determined, united by one global theme: ‘promoting confidence in bereavement care’.
Theme 1: Exposure to bereavement care
The first organising theme covers the students' exposure to bereavement. The students all made similar comments concerning the importance of having exposure as early as possible, and although the workshop was deemed beneficial, it was recognised that early exposure was imperative to improve their confidence. This was demonstrated by one student's account of receiving advice from a newly qualified midwife,
‘So she was kind of saying she's only just qualified and she finds it daunting that this is the first experience she was being thrown in for, and if she could've gone back she said, “No, get in … for all of them, if you can.”’
Previous exposure
The exposure to bereaved mothers that the BSc students had experienced was varied but limited. They explained that this usually happened ‘by accident’, and often involved bringing water or doing observations, rather than being involved in attending to all the care needs of the bereaved mother.
‘Kinda like, “Oh, can you take her obs”, and that's it. You're coming in detached from the whole story.’
The students also commented on occasions where they were brought in to view the body of a baby, but did not have the chance to look after the mother.
‘And then in third year, again, like accidentally. I seen a baby … and I was like, “Ooh.”’
Barriers
The most significant barrier to providing bereavement care is the perceived lack of support from preceptors and senior staff, to encourage, or allow, exposure. The BSc students discussed, throughout the focus group, that they were ‘over-protected’. This over-protection was perceived as a substantial barrier to exposure.
‘[Senior staff said] “There's no point getting bogged down. Get all your basic or normal stuff down”, and they just felt there was no need.’
The Higher Diploma students also brought up the experience of discouragement from staff as a barrier to exposure, but these students agreed with each other that it was the mothers who are being protected, not the students. This was perceived to be a kind and empathic act, to improve the experience for the mother and her family at this vulnerable time.
‘I think they're protecting the mum … Are you going to send that person in to say something random or may do something inappropriate? Then you have a worse scenario on your hands.’
Facilitators
The most common suggestion by the student midwives to increase their confidence was to spend time with the bereavement midwives in the hospital. A positive relationship between the student and the preceptor was also put forward as a factor that could provide more opportunities to assist in the care of a bereaved mother.
‘I think it was good as well that I had my week with the bereavement … midwife specialists … I picked up some bits from them, which was helpful.’
Cultural awareness
The majority of students felt that there was a lack of cultural awareness related to bereavement care in the hospital. All students agreed that more education around death rituals for different cultures was missing in this workshop and that they would value this education.
‘I think definitely going through different religions and cultures … And I just think if we had some idea and be like, “Oh right”. Just have it in your head, “Right, I don't wash the baby”, so make sure I go in and, you know, whatever it is … I think, like a little booklet, or something.’
Theme 2: The workshop
General impression
The general feedback from the workshop was extremely positive, with all the students agreeing that their confidence to provide bereavement care improved. Although the students found participating in the workshop beneficial, they also said how they were realistic about their expectations of it. It was mentioned that they might never be completely prepared to care for someone suffering from bereavement.
‘I think we're never gonna be fully prepared. It's gonna be traumatic, it's gonna be awful.’
The layout and atmosphere of the room were commented on as having a positive and calming effect on the students.
‘I think it was just such a soft, calm day that I feel if I am confronted with it here, that hopefully … that kind of calmness will stay with me.’
Student emotions/promotion of self-care
The mindfulness activities reiterated the promotion of self-care, which justified the decision to incorporate it. Feedback showed ample appreciation for the effort made by the facilitators to make the students feel looked after and genuinely cared for.
‘I think that it made me think more about the fact that it is so important to look after ourselves, you know.’
Timing of workshop
Both groups discussed the timing of the workshop, and made a wide variety of suggestions. The BSc students had their workshop in the third month of their internship year. Most of the participants agreed that it was important to commence preparation for bereavement care earlier in their training.
‘I think awareness needs to be made (earlier in the programme) ‘cause I was exposed in first year. I was only small.’
‘You remember things a bit better if they're later, in a way.’
The Higher Diploma students' workshop was during their second semester. They had undertaken an exam the previous day and were due to do another the following day. As a result, although they remained engaged during the workshop, they were quite tired, and this was mentioned during the focus group.
‘I think somewhere away from block, somewhere … [when] no-one is worried about assignments or study or deadlines like that … Or even at the start of block, where the workload hasn't been thrown too deep.’
Suggestions for improvement
The majority of the suggestions for improvement were requests for additional content to be included in future workshops, rather than changes or omissions to the one in which they participated. Some suggestions were made for an expansion of the role plays, and some recommendations were made for different scenarios to be played out. Incorporating role-playing that included partners, and discussing how to break bad news to siblings, were mentioned on several occasions.
‘Just another topic to touch on would be telling siblings, talking to the siblings about it.’
Some participants also requested for more photographs of babies who had died, to further prepare them.
‘So that was my first. I just had to walk in and go, “Oh, he's beautiful”, and I was shocked. And I'm trying to pretend I'm not shocked.’
Theme 3: Teaching strategies
Role play
The role plays were deemed the best part of the day by all students, and when asked about the general impression of the day, some students immediately started discussing the role plays as the central aspect of the workshop.
‘You could see how it would happen in real life. There was nothing uncomfortable about it … Everything they said, you were just going, “Oh yeah, like, that's what you'd see.”’
Promoting empathy with the use of literature
The discussion of the poem ‘Elegy for a Stillborn Child,’ which was incorporated to increase students' empathy, also received mainly positive reviews, with most of the students enjoying the discussion it brought. It did take some moments for some students to get into the mindset of the poem interpretation.
‘I liked it. And this was his friend, kind of, reflecting [on] what his friend is going through, and you know, there's a whole circle of people affected really. It was just nice, kind of, just to think outside the box a little bit.’
Theoretical learning
When asked about the value of the lectures they had received in college about grief, loss and bereavement care, some found the lectures beneficial, while a number of the students commented that the workshop had been more useful than the lectures they had received.
‘In college, there's a lot of talk about like, emotional, you know, not what to say/what not to say, but nobody says all practical stuff like what you need.’
What to say/not say
The video called A Letter to my Doctor (Wood, 2015), which was played as part of the ‘What to say/not say’ lesson, received mixed reactions, with most students finding it beneficial and informative, giving relevant and helpful advice, and some finding it upsetting.
‘Upsetting, but helpful at the same time. It was good exposure.’
Discussion
The primary aim of the overall study was to increase student midwives' confidence in providing bereavement support to parents following a pregnancy loss or perinatal death after participation in the ETWBC. The study was completed using a longitudinal sequential mixed-methods design and this article reports on the key results from the process evaluation.
The students' educational needs when providing care to bereaved parents after pregnancy loss and perinatal death were explored with a group of student midwives, following their experiences with a 1-day ETWBC. Changes to the workshop, as well as students' perceptions of the facilitators and barriers to increasing their confidence in providing bereavement care in their clinical practice, were discussed.
One important finding from the study was the number of responses from the students about lack of confidence and exposure, and a perceived lack of support from senior staff. These reactions extend previous literature reporting similar lack of confidence in other health professionals dealing with perinatal bereavement support (Puia et al, 2013; Nurse and Price, 2017).
The organisers put considerable effort into creating a caring, calming environment for the duration of the workshop. The room was laid out with candles and tablecloths and appropriate lighting. Students were each given chocolates when they left to go home and were requested to look after themselves that evening. The students commented on how lovely it was that they were so well looked after. This appreciation was brought up on several occasions during the focus groups, implying the importance of organisational support to the students. Bereavement debriefing sessions could be introduced into clinical practice, as standard, allowing staff to reflect on the experience and express their grief (Keene et al, 2010).
According to the findings from the focus groups, the role-play activities had the most significant impact of the day, and there were many positive opinions about the effectiveness of this aspect of the workshop. Many of the amendments to the workshop that the students recommended involved increasing time spent on role-play: giving the option for more students to participate; expanding the scenarios to include partners, siblings and delivering bad news; and watching the experts perform a scenario. These findings were similar to the existing evidence supporting the effectiveness of role-playing in bereavement simulations. In their systematic review, Cooper et al (2012) highlighted the advantages of simulated learning programmes to increase all midwifery skills. They also concluded that for skills where clinical practice is infrequent, such as perinatal bereavement, using simulations can reduce the time taken to achieve competence, and can improve confidence in ‘non-technical’ skills (Cooper et al, 2012). Although education is essential, experience can more often predict comfort in delivery of perinatal bereavement care (Rondinelli et al, 2015; Bäck et al, 2017). Role-play was chosen as a teaching method for this workshop so that no parent would be upset or inconvenienced, and no student would not feel humiliated or uncomfortable (Meyer et al, 2009).
Some concerns were raised by the student midwives about insufficient cultural competence and knowledge. The importance of being culturally competent and sensitive is repeatedly suggested in the literature (Walter, 2010; Peng et al, 2012; Banovcinova and Maskova, 2014). Previous research strengthens the findings of this study, and suggest more education on this subject (Attard et al, 2014; Repo et al, 2017). As such, the authors recommend that any future workshop introduce an element of training to assist in the increase of cultural competence for student midwives.
Suggestions were also put forward by the students regarding the provision of extra information to be included into the ETWBC, such as blood tests and post-mortems. This information would prove to be a valuable addition to the information already included and, as such, would be recommended in any future workshop.
Strengths and limitations of the study
The evidence to-date suggests that student midwives in general do not feel confident when providing bereavement care to parents after a pregnancy loss or neonatal death, and this study supports this view for students before they attended the workshop. However, given that the ETWBC was evaluated in one clinical site with 38 student midwives and no comparison group, the overall findings of the study need to be viewed with caution, as their generalisability is limited. Furthermore, while every endeavour was made to ensure that confidentiality was maintained during the process evaluation, some students may have felt inhibited during the discussion in the focus groups. Accountability and credibility are the critical components to ensuring reliability of a study (Braun and Clarke, 2006). The authorship of this study was made up of experts in the fields of education, bereavement, psychology, and midwifery, thereby strengthening the development of the workshop, the reliability of the execution and the findings of this research study. Reflectivity is a valuable tool to promote understanding of the researcher's role and was used by the researcher to promote rigour. After each focus group, the researcher reflected on the session, maintaining a reflective diary throughout the research process. Additionally, rigour was maintained by the involvement of three of the researchers engaging in the data analysis and reaching a consensus on content and themes for the thematic network analysis (Attride-Stirling, 2001; Braun and Clarke, 2006).
Conclusion and recommendations
The results from this study showed that student midwives lacked confidence and exposure to provide bereavement care, and that participation in a workshop improved their confidence in the absence of exposure. Although the students found the workshop beneficial, especially the role-playing element of the day, they maintained that lack of exposure was a severe barrier to gaining more confidence. Extra support from preceptors to gain exposure, and more emphasis on management to relay the importance of self-care, such as offering clinical supervision as standard, is recommended. This study provided valuable information in relation to students' experiences of participating in a workshop on delivering bereavement support.
The ETWBC is recommended for all student midwives and can be tailored for any healthcare setting. More emphasis needs to be placed on supporting student midwives to gain exposure to perinatal bereavement, to increase their confidence in this area of clinical practice, and increase the levels of satisfaction from bereaved parents. A follow-up study to assess how to best support the delivery of bereavement care education and training to newly-qualified midwives is needed.