Women with fetal death: nurses' care limitationsSchmalfuss, Joice MoreiraI Matsue, Regina YoshieI Ferraz, LucimareI
- IUniversidade Comunitária da Região de Chapecó. Chapecó, Santa Catarina, Brazil.
To present the limitations of the nursing care for women with fetal death, reflecting on this challenge for care practices.
Reflective study with theoretical focus on national and international publications, along with the experience of the authors in the area of women’s health and obstetrics.
There are limitations related to nursing care, which involve feelings of insecurity and powerlessness, inappropriate attitudes of these professionals in front of women, difficulties to manage emotional aspects, and structural problems of health services.
This study points out that there are challenges to qualify nursing care for women with fetal death, which included academic studies and continuing education in health services. Relational aspects should be valued and demand more sensitivity from nurses, with more empathic relationships in the care for women with fetal death.
Fetal Death, Women’s Health, Nursing Care, Nurse-Patient Relations, Health Services Needs and Demand
The death of a baby in the womb reverses the logic that people are born, grow old, and die; therefore, because of the usual representations constructed by people, it requires a peculiar working-through process (1). The rupture of the “natural order” of life usually has profound effects on parents and family (2), and the lack of appreciation of the whole context can cause significant damages (1) for the bereaved people.
It is assumed that if parents and families who experience fetal death receive adequate assistance at that time of reversal of human existence, and if the healthcare team provides qualified care in the physical, emotional and social dimensions, the processes of working-through and coping with grief may be facilitated.
In this perspective, professionals who provide obstetric care for women with fetal death and those who work in maternal and child care, in maternities or in rooming-in units are included. Among these, the performance of the nurse, a professional qualified to provide Nursing care, stands out. However, despite being directly related to the essence of care, this professional is not always prepared and comfortable to provide qualified assistance in the context of fetal death.
Some fragilities in the care provided to women with fetal death have been pointed out and are generally related to the assistance provided by health professionals - considered unsatisfactory and with a tendency to underestimate, distort, minimize and have iatrogenic effects. In addition, problems related to the structure of health services can also result in care deficiencies (1,3-5).
Moreover, despite the information on women’s health and obstetrics that is published in materials from the Ministry of Health and the World Health Organization, attention specifically focused on women with fetal death has not yet been a priority in public health programs and policies. Furthermore, few studies have addressed this problem, demonstrating it is a research gap and indicating the need to advance in investigations that reveal these demands and support the elaboration of protocols and care plans aimed at providing comprehensive and qualified care for these women.
Given the above, the guiding questions for this research are: what are the limitations of nurses when caring for women with fetal death? How does this challenge affect the care practices of these professionals?
This investigation aims at presenting the limitations of the nursing care for women with fetal death, reflecting on this challenge for care practices.
This is a reflective study with theoretical focus on national and international publications, along with the experience of the authors in the area of women’s health and obstetrics.
LIMITATIONS OF NURSES WHO CARE FOR WOMEN WITH FETAL DEATH
Cases of fetal death, most of the time, have great emotional impact on all involved in the process. Thus, each person will adopt a posture that matches their way of life, personal experiences, culture, social context, their position in the health service and, consequently, their professional experience. In addition, the fact that it is a sensitive issue that causes discomfort to many people, may make the assistance provided to women at this time of loss an underestimated procedure in the routine of work, especially in a scenario where the professionals are constantly hearing cries of babies in the transition to extrauterine life after birth.
In this sense, caring for a woman who has lost her unborn baby can be a difficult task for the nurse. A study aimed at examining the experiences of, meanings for and personal consequences for obstetric nurses caring for women after fetal death revealed that these professionals feel insecure about the best care possible (6). The feeling of insecurity, in turn, may generate a sense of powerlessness in these professionals, with a consequent idea of having provided incomplete care (5).
The nurse’s insecurity and sense of powerlessness in relation to the care provided, along with the lack of strategies, skills and resources of this professional may result in difficulties to deal with situations of fetal death. Besides that, an inappropriate professional attitude can have negative effects on the evolution of the parents’ grieving process, failing to meet the demands of these patients (4).
In addition, the emotional aspect, in most cases, is the component that demands more attention from the professionals. In this context, a study that aimed to identify similarities and differences in the needs and concerns of nurses and midwives in the United States and Spain concluded that they present difficulties to provide emotional support to bereaved parents, with problems on communication skills, knowledge and management of personal feelings (7).
Regarding the management of personal feelings, professionals use different strategies to alleviate their anguish and feelings, such as focusing only on the physical care of the women with fetal death and avoiding emotional involvement (4). Thus, in order to control the stress caused by the work routine, professionals may sometimes adopt attitudes that convey detachment and coldness in relation to such experience (4).
These behaviors are common and show not only the suffering of the professional but also their lack of preparation and a tendency to conceal the true meaning of loss (1). In addition, focusing this care only on biological aspects is another factor that indicates the lack of preparation of these professionals, disguised by strategies such as negation and avoidance (5). Thus, as much as nurses value the emotional support that must be offered to mothers who have suffered this type of loss, they delegate these tasks to other professionals because they do not feel they are prepared to deal with this demand (5).
The limitations of nursing care and the fact that these professionals do act in situations of fetal death, even if their practices are not ideal, allude to the need for care directed to these professionals. A study that aimed to know the experience of health professionals in situations of perinatal death and the consequent grief found that “the interviewed professionals manifest feelings of sorrow, anxiety, insecurity, resentment, guilt, rage, feeling of failure and impotence, which are mainly related with not knowing how to face and manage these situations” (4).
In this context, studies indicate that caregivers need attention, help and support, formal and informal opportunities to discuss situations with their colleagues, and frequent self-care measures (1,6-7). The importance of extending this care to the entire nursing team is also highlighted, since the nurse is part of this reality and, generally, is responsible for managing and leading the care.
Care is closely related to the professional-patient dyad, while caring for oneself is the basic premise for understanding the other person’s singularity. This precaution will allow a relationship with consideration and respect, based on acts that involve competence, safety and that promote health and well-being of patients, highlighting their potentialities (8).
Based on the above, considering the limitations and the individual and collective needs exemplified and faced daily in the assistance to women with fetal death, we outline some alternatives with the purpose of facilitating the nurses’ work.
SEARCHING FOR THE IDEAL CARE
adaptation of nursing curricula,
inclusion of classes on perinatal grief in schools and universities,
articulation between academic and practical training,
creation of nursing protocols,
constant and specific training on grief,
improvement of relational and communication techniques,
care that articulates technical and emotional aspects,
individualized assistance to each woman/family,
humanization of care during labor and delivery,
adequate working conditions,
adequate structure of health services,
favoring support networks and
change of care paradigms.
Regarding the structural problems of the health services, it is important to point out that many institutions present difficulties related to the hospitalization of women with fetal death, from the moment of access to the service until discharge. Examples of these problems can be seen when a woman in the process of delivery of a dead fetus is admitted to a bed next to another woman who will give birth to a live baby who will be born vigorous and crying; or when a woman who has experienced fetal death is placed in the same room/ward as a woman hospitalized in rooming-in with her newborn. This can occur due to small physical space, overcrowding, administrative aspects related to the management of beds and patients, lack of communication among professionals, among other variables (1,3-5).
As previously discussed, since nurses represent a profession that considers care in its essence, to achieve success in the task of caring, the nurse must not only master the technical aspects, but also explore their capacity and ability to communicate (7).
Relational aspects, not restricted to face-to-face interactions, are also important and require more sensitivity from nurses, regardless of their lack of experience, lack of knowledge about what to tell these women, and the context of this care (7,9). In addition to sensitivity, empathy is an essential skill to be developed in order to establish an effective communication (10) between the professional and the woman who has experienced fetal death.
have deep respect for the individuality and diversity of parents;
provide objective information (sometimes in written), in a calm and supportive way aiming to maintain the tranquility of those who have experienced the loss;
enable the creation of memories by helping parents to see and/or hold and/or talk to their baby, bathe and dress the baby, conduct religious or naming ceremonies, introduce the baby to the rest of the family, post photos and videos, and take utensils used by the baby to their homes;
provide help and support through appropriate care;
consider grief as part of the human experience and not as a situation that means failure of their work.
However, besides following these essential recommendations for qualified care, it is important to emphasize that they must be considered and applied according to the different contexts and diversity of cultural groups (2). Interactions between health professionals and people involve multiple logics of care, which are determined by the way people relate to each other, to their environment and to society (9).
The possible recommendations to qualify the assistance to women with fetal death are related to aspects that include the training of future professionals and the care practices of nurses who care for women in the pregnancy-puerperal cycle, both in primary and in secondary health care.
Caring for women with fetal death represents a significant challenge for nurses working in care. Limitations related to feelings of insecurity and powerlessness, lack of skills and resources, inappropriate attitudes, difficulties in providing emotional support, detachment, coldness and feelings of pity, anxiety, resentment, guilt, anger and failure can lead to incomplete care that can cause damages for this professional, for the woman and for the bereaved family.
Fetal death is a sensitive issue, often veiled in society, academic community and care scenarios. One of the reflections was related to universities and how they have addressed fetal death during academic studies and training. Even with universities including this content in the curricula, it needs to be more and better debated throughout the student’s training. Students graduate without practical experience in providing care for women with fetal death and professionals who already work in this context feel unprepared to deal with this situation. In this context, it is important to think of innovative strategies, such as clinical simulation in the teaching/learning process, as well as in activities of continuing education in health, which would allow students and professionals to build knowledge and improve their skills in good care practices directed at women with fetal death.
Health professionals, especially nurses, need to recognize their limitations and needs, which in general are not exclusively restricted to technical actions, also including relational and personal issues. Therefore, this article aimed at discussing elements that allowed a reflection on the importance of qualified listening, dialogue, empathic relationship and sensitive posture, in order to improve nurses’ practices when caring for women with fetal death.