Reframing How Early Pregnancy Loss Is Viewed in the Emergency Department

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care services: a scoping review

OBJECTIVE

The objective of this scoping review was to investigate and describe what is reported on the role and scope of practice of midwives and registered nurses providing care for women with pregnancy complications under 20 weeks' gestation in acute clinical settings in Australia.

INTRODUCTION

In many high-income countries, women experiencing unexpected complications in early pregnancy attend an acute care service, such as an emergency department, rather than a maternity or obstetric unit. This service structure can impact the care women receive, and determine who provides it. Women and their partners, who are often experiencing emotional distress, have reported difficult experiences when accessing acute services, particularly emergency departments, which are not traditionally staffed by midwives. The role and scope of practice of both midwives and registered nurses providing acute early pregnancy care in most high-income countries, including Australia, is poorly reported. Documenting this area of practice is an important first step in facilitating ongoing research in this important aspect of pregnancy care.

INCLUSION CRITERIA

Published and gray literature that described the role and scope of practice of midwives and/or registered nurses providing care in acute early pregnancy settings in Australia were considered for this review.

METHODS

A scoping review of the literature was conducted following JBI methodological guidance and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) checklist. A 3-step search strategy was conducted to explore evidence from databases and search engines, gray literature sources, and selected reference lists. After screening, data were extracted from records selected for the final review, mapped, and analyzed using content analysis.

RESULTS

The evidence reviewed (n=23) included primary research studies, conference abstracts, and gray literature, such as clinical guidance documents, academic theses, and websites from January 2008 to October 2023. The most common setting for care provision was the emergency department. Midwives' and registered nurses' roles and scope of practice in acute early pregnancy care in Australia can be summarized into 4 areas: physical care, psychosocial support, care co-ordination, and communication. Women's access to midwifery care at this time in pregnancy appears to be limited. Registered nurses, usually employed in emergency departments, have the most prominent role and scope in the provision of care for women with acute early pregnancy complications. Descriptions of midwives' practice focuses more on psychosocial support and follow-up care, particularly in early pregnancy assessment service models.

CONCLUSIONS

This review highlights the inconsistency in midwives' and registered nurses' roles and scope in acute early pregnancy in Australia, a finding which is relevant to other international settings. Both professions could further fulfill role and scope capacity in the provision of supportive, individualized, and timely care for women and families accessing a range of acute early pregnancy services. Emergency departments are the usual practice domain of registered nurses who may be limited in terms of the scope of care they can provide to women with early pregnancy complications. Leaders of the midwifery profession should conduct further research into innovative service models that embed a role for midwives in all settings that provide care for pregnant women, regardless of gestation.

REVIEW REGISTRATION

Open Science Framework osf.io/7zchu.

Do miscarriage care practice recommendations align with individuals' needs?: a scoping review

BACKGROUND

Miscarriage is a common experience; yet individuals often have negative experiences when receiving miscarriage care, signaling a gap in the quality of miscarriage care. We explore the literature on individuals' experiences with miscarriage care across a variety of dimensions and assess how these experiences align with practice recommendations.

METHODS

We conducted a scoping review of peer-reviewed studies in PubMed published in English through April 30, 2022, and focused on individuals' experiences with miscarriage care in healthcare settings and on practice recommendations for providing care in a variety of countries. The search returned 1,812 studies; after screening, 41 studies were included in the analysis.

RESULTS

Included studies reported on individuals' experiences with miscarriage care settings and accessibility, information provision, emotional support, decision-making and follow-up. Overall, individuals are often dissatisfied with their miscarriage care experiences. Practice recommendations are generally responsive to these issues, but more research is needed to address some key gaps and improve the implementation of current practice recommendations.

CONCLUSIONS

Future research should focus on documenting the miscarriage experiences and developing relevant practice recommendations for communities that face the greatest barriers to care, generating evidence on the dimensions that constitute high-quality miscarriage care from patients' perspectives and assessing the barriers and facilitators to effectively implementing existing practice recommendations.

Miscarriage Australia: the use of a human centered design approach to design and develop a website for those affected by miscarriage

Background

Past research has shown that Australians affected by miscarriage want a website specific to both miscarriage and their local region that is accessible, comprehensive, evidence-based and informed by experts. The aim of this study was to design, develop and evaluate the Miscarriage Australia website using human centered design.

Methods

A four stage human centered design approach was used to develop the Miscarriage Australia website which aimed to: (1) Understand the issue and why users need a website; (2) Define users' specific needs; (3) Design solutions to meet those needs; and (4) Evaluate the design by testing with end users. Across the four stages, various types of data and data analysis were developed and utilized including interviews, desktop research, development of personas and tone of voice, followed by usability testing. Process and content were guided by designers, developers and an expert advisory committee of key stakeholders.

Results

Analysis and synthesis of user research across Stages 1 and Stage 2 found 11 key themes pertaining to user's miscarriage experiences and support needs. Using the themes, common experiences, goals, motivations and behaviors of users were identified and similar user types grouped and used to inform the development of two personas. Using the personas and user research findings, design elements (Stage 3) including the "tone of voice guidelines" were developed recommending the Miscarriage Australia website be calm, empathetic, hopeful and authoritative. The tone of voice guidelines guided branding and over 100 pages of content was informed by the research team and reviewed by a 13-member Expert Clinical Advisory Committee over two rounds to ensure it was evidence based and reflected best practice. Using a contextual inquiry approach, usability testing was undertaken with 8 end users to test a low fidelity mockup and high-fidelity prototype of the website. Overall, end users reported the website was highly acceptable in terms of the design, content, layout, language and terminology, describing it in line with the intended tone of voice. Users reported the website was easy to use and navigate and provided useful and appropriate content and resources. Minor areas for improvement included slight changes to specific images, improved links for navigating sections, and a title change to one section heading.

Conclusion

The Miscarriage Australia website was successfully implemented and commended by users as meeting their needs. As a result of using human centered design, the Miscarriage Australia website provides an ideal template or blueprint on how to develop a successful and useful digital resource for users, particularly around sensitive women's health issues.

Midwives' and registered nurses' role and scope of practice in acute early pregnancy care services in Australia: a scoping review protocol

OBJECTIVE

The objective of this review is to review and synthesize what is documented on the role and scope of practice of midwives and registered nurses working in acute early pregnancy care settings in Australia.

INTRODUCTION

Women experiencing complications before 20 weeks of pregnancy may need to attend an acute care service, often a hospital emergency department. Midwives and registered nurses provide care for women with early pregnancy complications, and it is important that their role and scope of practice is documented. This review will explore the literature relating to acute early pregnancy care in Australia to better understand how midwives' and registered nurses' roles and scope are currently described in this setting.

INCLUSION CRITERIA

Any literature that explores the role and scope of practice of midwives and registered nurses who care for women who present to acute care services in Australia with early pregnancy complications will be considered for inclusion in the review.

METHODS

A 3-step review process will involve a preliminary search of MEDLINE and ProQuest, followed by a more detailed search of a larger selection of databases, using identified keywords and phrases from the initial search. Reference lists of retrieved literature will then be examined for relevant citations. Literature in English will be considered, including relevant gray literature. Search results will be imported into reference and review support software. Data that align with the inclusion criteria will be organized into tabulated and narrative formats for presentation.

DETAILS OF THIS REVIEW PROJECT ARE AVAILABLE AT

Open Science Framework https://osf.io/5bnqz.

Compassionate Care for Parents Experiencing Miscarriage in the Emergency Department: A Situation-Specific Theory

In many countries, parents experiencing miscarriage seek treatment in the emergency department (ED). Parents frequently report dissatisfaction with ED care, while nurses report not knowing how to provide optimal care. This article describes the development of a situation-specific theory, Compassionate care for parents experiencing miscarriage in the ED, based on 4 concepts (change trigger, transition properties, conditions of change, and interventions). This theory evolved from a comprehensive review of the literature, 2 empirical studies, Transitions Theory, and collaborative efforts of an experienced team. The detailed theory development process facilitates its integration in practice and supports new theory development.

Toward Optimal Emotional Care During the Experience of Miscarriage: An Integrative Review of the Perspectives of Women, Partners, and Health Care Providers

INTRODUCTION

Miscarriage is frequently associated with significant emotional impact, causing psychological distress, trauma, and grief. Unfortunately, women and partners frequently report dissatisfaction with care around miscarriage, and health care providers report feeling ill-prepared and underequipped to provide emotional support. This integrative review synthesizes the individual perspectives of the woman experiencing the miscarriage, the partner, and the different health care provider roles involved in the care to better understand what future research is necessary to improve the experiences of bereaved parents and their health care providers.

METHODS

Electronic databases were searched for studies that covered emotional care around miscarriage from the perspective of women, partners, or health care providers. The review included studies published in English between 2015 and 2022, using either quantitative or qualitative methods. Thematic analysis was carried out, and conclusions from these articles were integrated into themes and subthemes.

RESULTS

A total of 60 studies met the inclusion criteria. Two main themes were identified for women: (1) a need for more information and (2) a need for acknowledgment of their loss. Two main themes were likewise identified for partners: (1) a need for more information and (2) a need for recognition. Three main themes were identified for health care providers: (1) a need for additional training, (2) components of quality care, and (3) perceived barriers to providing care.

DISCUSSION

There is broad overlap in the needs identified by bereaved parents and their health care providers, as well as general agreement regarding the barriers to providing effective care. Five areas of future research priority were identified to understand how best to meet these needs: empirical evaluation of strategies to meet identified needs, investigation of setting-specific needs, integrated consideration of all relevant roles, investigation of the care needs of diverse groups, and an investigation of the predictors of emotional impact.

Co-designing a web-based education platform for patients with early pregnancy loss

Canadian emergency departments (EDs) frequently provide care to patients undergoing early pregnancy loss. Unfortunately, in this setting, patients commonly have negative experiences, in part due to lack of appropriate follow-up and education on symptoms that may arise after discharge. In response to this gap, our team created a free, web-based, patient-informed educational platform for women to access accurate information on early pregnancy loss. This free and publicly accessible resource was launched in May 2022 at Mount Sinai Hospital in Toronto and was shared with EDs across Canada.

Emergency Medicine Clinician Experiences Addressing Uncertainty in First-Trimester Bleeding

The purpose of this work is to understand Emergency Department (ED) clinicians’ experiences in communicating uncertainty about first-trimester bleeding (FTB) and their need for training on this topic. This cross-sectional study surveyed a national sample of attending physicians and advanced practice providers (APPs). The survey included quantitative and qualitative questions about communicating with patients presenting with FTB. These questions assessed clinicians’ frequency encountering challenges, comfort, training, prior experience, and interest in training on the topic. Of 402 respondents, 54% reported that they encountered challenges at least sometimes when discussing FTB with patients where the pregnancy outcome is uncertain. While the majority (84%) were at least somewhat prepared for these conversations from their training, which commonly addressed the diagnostic approach to this scenario, 39% strongly or moderately agreed that they could benefit from training on the topic. Because the majority of ED clinicians identified at least sometimes encountering challenges communicating with pregnant patients about FTB, our study indicates a need exists for more training in this skill.