Bereaved mothers' and fathers' perceptions of a legacy intervention for parents of infants in the NICU

Digital storytelling online: a case report exploring virtual design, implementation opportunities and challenges

BACKGROUND

Digital storytelling is an arts-informed approach that engages short, first-person videos, typically three to five minutes in length, to communicate a personal narrative. Prior to the pandemic, digital storytelling initiatives in health services research were often conducted during face-to-face workshops scheduled over multiple days. However, throughout the COVID-19 lockdowns where social distancing requirements needed to be maintained, many digital storytelling projects were adapted to online platforms.

METHODS

As part of a research project aiming to explore the day surgery treatment and recovery experiences of women with breast cancer in Peel region, we decided to pivot our digital storytelling process to an online format. During the process, we observed that the online digital storytelling format had multiple opportunities and challenges to implementation.

RESULTS

This paper outlines our promising practices and lessons learned when designing and implementing an online digital storytelling project including pre-production, production and post-production considerations.

CONCLUSIONS

We provide lessons learned for future teams intending to conduct an online digital storytelling project.

Considerations for Practice in Supporting Parental Bereavement in the Neonatal Intensive Care Unit-a Systematic Review

BACKGROUND

Parental bereavement after the death of an infant in a neonatal intensive care unit (NICU) is a complex and nuanced experience. Support from healthcare practitioners can have a significant impact on bereavement experiences in the short- and long-term. Although several studies exist exploring parental perceptions of their experience of loss and bereavement, there has not been a recent review of beneficial practices and common themes in the current literature.

OBJECTIVE

This review synthesizes empirical research to identify considerations that ought to guide the caregiving practices of healthcare professionals to support parental bereavement.

SETTINGS/SUBJECTS

Data was collected from studies identified in MEDLINE, Embase, and CINAHL. The search was limited to English-language studies describing parental bereavement in the NICU population from January 1990 to November 2021.

RESULTS

Of 583 studies initially identified, 47 studies of varying geographic locations were included in this review. Various themes surrounding healthcare support in parental bereavement were identified including ensuring the opportunity for parents to spend time caring for their child, understanding their perception of infant suffering, recognizing the impact of communication experiences with healthcare providers, and offering access to alternative means of support, all of which have been described as suboptimal. Parents generally want the opportunity to say goodbye to their infant in a private and safe space, be supported through their decision-making and be offered bereavement follow-up after loss.

CONCLUSION

This review identifies methods of support in parental bereavement based on first-hand parental experiences and routine implementation of these strategies may be beneficial in supporting parents through their bereavement after the loss of a baby in the NICU.

Bereaved parents' perceptions of memory making: a qualitative meta-synthesis

OBJECTIVE

This study aims to investigate the experiences of parents who have experienced bereavement in their efforts to preserve memories of their deceased child.

METHODS

Employing a qualitative meta-synthesis approach, this study systematically sought relevant qualitative literature by conducting searches across various electronic databases, including PubMed, Embase, CINAHL, PsycINFO, Web of Science, Cochrane Library, and Wiley, up until July 2023.

RESULTS

Nine studies are eligible for inclusion and included in the meta-synthesis. Three overarching categories are identified: (1) Affirming the Significance of Memory Making. (2) Best Practices in Memory Making. (3) Barriers to Effective Memory Making.

CONCLUSION

Bereaved parents highly value the act of creating lasting memories, emphasizing its profound significance. While forming these memories, it is imperative to offer family-centered care and honor diverse preferences and needs. It is essential to offer effective support to parents, offering them a range of choices. Furthermore, a more comprehensive examination of memory-making practices is required to better understand their influence on parents' recollections of their deceased child.

Personal legacy and treatment choices for serious illness: a scoping review

BACKGROUND

Legacy-how one hopes to be remembered after death-is an unexplored and important dimension of decision-making for people facing serious illness.

OBJECTIVES

We conducted a scoping review to answer the following research questions: (1) How do people making treatment choices conceive of legacy? and (2) What treatment choices do people make with legacy in mind?

ELIGIBILITY CRITERIA

Participants included people facing serious illness who discussed how they wanted to be remembered after their own death, or how they hoped to impact others, as they made treatment choices. Studies in English published between 1990 and 2022 were included.

SOURCES OF EVIDENCE

We conducted searches in electronic databases including Medline/PubMed, CINAHL, PsycInfo, SocialWork, AnthropologyPlus, Web of Science, ProQuest and EMBASE databases.

DATA SYNTHESIS

We used an electronic screening tool to screen abstracts and review full-text articles suitable for inclusion. We analysed included articles using Atlas.ti. We constructed tables and narratively synthesised the findings.

RESULTS

We identified three major intersecting legacy goals that influence choices people facing serious illness make about their treatment and health behaviours, and the types of choices people make with legacy in mind. The three legacy goals are: remembrance of the individual self, remembrance of the social self and impact on others' well-being.

CONCLUSIONS

We identify the importance of legacy to patient treatment choices. Understanding for whom this construct is important, what types of legacy goals people hold and how those goals impact treatment choices is necessary to provide patient-centred whole-person care to people facing serious illness.

Memory making in critical care: A qualitative thematic synthesis

BACKGROUND

Caring for bereaved families is an important aspect of the nursing role in critical care. Memory making practices are one way in which dying, death and bereavement can be acknowledged and supported within critical care. Memory making was introduced into the care of stillborn babies and neonatal deaths to improve parents' experiences of bereavement, and has since become common practice in adult critical care.

AIMS

The aim of this qualitative thematic synthesis was to explore families' experiences of memory making in critical care, with a view of gaining greater understanding of the ways in which memory making impacts bereaved families.

METHODS

A systematic search strategy was developed, and five databases were searched (Medline, CINAHL, PsychINFO, Embase and ASSIA). Seven qualitative studies were included: four were conducted in adult and three in paediatric critical care settings in which memory making was initiated between 2014 and 2020. Memory making practices included, patient diaries, general keepsakes, word clouds and photography.

RESULTS

The thematic synthesis generated four main themes to describe families' experience of memory making in critical care: 'connection', 'compassion', 'engagement and creation' and 'continuation'.

CONCLUSIONS

Memory making is a meaningful activity for families whose loved one dies in critical care; it brings focus and meaning during a devastating process in a highly technical environment. Families rely heavily on nursing staff for support and guidance. The creation of memories and/or keepsakes can have a positive impact on the bereavement experience for families and can facilitate a continuing bond with their loved one.

RELEVANCE TO CLINICAL PRACTICE

Memory making is a worthwhile practice to support and guide family bereavement within critical care. It can provide structure and purpose during an emotionally challenging transition, by supporting families to focus on a meaningful activity during a devasting time.

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings

Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.

Factors that Contribute to Bereaved Parents' Perceptions of Neonatal Palliative Care: A Systematic Literature Review

OBJECTIVES

Neonatal palliative care (NPC) is an emerging subset of care in United States (US) neonatal intensive care units (NICUs) that provides relief for both infants and families at the end of life for infants with terminal diagnoses. Families play a integral role in the decision-making process for their infant, but their experiences with and perceptions of the support and care provided to them via NPC is unclear to health professionals. This literature review summarizes the state of knowledge on parents' perspectives of NPC while focusing on the specific factors that influence their experiences and satisfaction with NPC.

METHODS

A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles published in peer-reviewed journals between January 2010 and January 2021 that investigated parents' perceptions of neonatal palliative care either as their central topic or as a sub-topic as part of a larger focus.

RESULTS

A total of 16 articles (N = 16) were included in this review. Three overarching themes encompass the findings of the literature review: parent-clinician interactions, parent-infant interactions, and parent-self interactions. Within these themes, topics such as consistent and clear communication, involvement in care decisions, and social and psychological support were explored.

CONCLUSION

Clinicians must focus on these important quality indicators to ensure they provide the best care possible to the patients and families that they serve. Further research must be done to investigate parent satisfaction and needs in relation to NPC more deeply and to develop more supportive interventions and protocols.

Bereaved Parent Perspectives and Recommendations on Best Practices for Legacy Interventions

CONTEXT

Many pediatric hospitals offer legacy interventions for families to promote coping and support grief prior to and following the death of a child. Despite this practice, parent perceptions of the value of legacy activities are not well described, and best practices for offering and creating legacy interventions remain poorly understood.

OBJECTIVES

To characterize bereaved parents' perspectives on the value of legacy activities; to describe parent recommendations for optimizing provision of legacy activities by child life specialists and music therapists.

METHODS

In this qualitative study, a purposive sample of 19 bereaved parents of children who died from cancer participated in semi-structured interviews. Interviews were audio-recorded, transcribed, and analyzed inductively using content analysis to identify key concepts and emerging themes.

RESULTS

Analysis of transcripts revealed bereaved parent insights and recommendations across three core themes: 1) the value of legacy items and interventions; 2) the practical roles, uses, and functions of legacy items, and 3) best practices for offering legacy interventions. Bereaved parents sought meaning and purpose in abstract and concrete manifestations of legacy. Parents often used legacy items in specific ways to promote emotional expression and process their grief. Communication, timing, and creativity significantly influenced parent perceptions of legacy-building. Parents recommended individualized assessments to optimize provision of legacy interventions.

CONCLUSION

Bereaved parents emphasized the meaningfulness of legacy-building activities and the need for an individualized approach when offering these interventions. Future research should explore the perspectives and recommendations of patients and siblings on legacy activities.

Long-Term Follow-Up of Legacy Services Offered by Children's Hospitals in the United States

Background: Our 2012 survey of providers described legacy services offered at children's hospitals nationwide. Since then, the science related to legacy interventions has advanced, resulting in increased recognition of the importance of legacy services. Yet, legacy interventions offered by children's hospitals have not been recently described.

Objective: To describe current legacy services offered by children's hospitals in the United States and compare with our previous results.

Design: Descriptive cross-sectional design.

Setting/Subjects: Participants included providers (N = 54) from teaching children's hospitals in the United States.

Measurements: Electronic REDCap survey.

Results: Similar to our prior research, 100% of respondents reported that their hospital offers legacy activities with 98% providing such services as a standard of care. Notable increased numbers of children are participating in legacy interventions compared with the previous study, now with 40% (compared with 9.5% previously) of participants reporting >50 children per year. Patients being offered legacy activities include neonatal intensive care unit (NICU) patients, those with life-threatening traumatic injuries, those on life support for extended periods of time, and those referred to hospice. Although not statistically significant, the percentage of hospitals offering legacy-making to children with cancer, neurodegenerative diseases, and life-threatening illnesses is slightly increased from the prior time point.

Conclusions: Children across developmental stages and illness contexts and their families can benefit from both the memories generated through the process of legacy services and the subsequent tangible products. Providers should continue to offer legacy opportunities to seriously ill children and their families across a wide array of settings and illness contexts.

Parent's Lived Experience of Memory Making With Their Child at or Near End of Life

BACKGROUND

Memory making is the process of creating mementos of a child with a life limiting condition, who may be at or near end of life, providing a tangible and visual connection to the child who has died.

AIM

This study explored the lived experience a memory making process had on parents of children who were at or near end-of-life.

DESIGN

A qualitative approach was used. Hermeneutic phenomenology methods provided guidance to the data collection, with a more limited interpretative phenomenological analysis conducted.

SETTING

A purposive selected sample of 6 parents whose child had died and who had engaged in memory making participate. The sample was drawn from parents whose child had received care from a children's hospice.

RESULTS

Individual interviews were conducted with 6 parents, all mothers. Three main themes emerged: Making the memories; the impact of memory making; and the end-of-life care journey. Parents experienced an overwhelmingly positive impact from memory making, as well as tangible and precious mementos that were created. The positive impact the process had on coping with grief and loss was also demonstrated, as well as the effect of helping to keep the deceased child's memory alive and include them in conversation.

CONCLUSIONS

The importance of skilled and sensitive staff with the ability to introduce the concept of memory making, and choice at end of life were highlighted by the parents who took part. Clinicians may benefit from understanding how memory making can positively impact the bereavement experience of parents whose child has died.

Songwriting intervention for cognitively-impaired children with life-limiting conditions: Study protocol

Investigations evaluating the effectiveness of music-based interventions as a complementary approach to symptom management and health promotion for cognitively-impaired children with life-limiting conditions and their families are needed to minimize the physical and psychological burdens on individuals and their caregivers. Songwriting is one music-based strategy for a remote family-centered complementary approach to improve outcomes for cognitively-impaired children with life-limiting conditions, their parents, and families. The overall purpose of this study is to test the feasibility and preliminary efficacy of a songwriting intervention for cognitively-impaired children (ages 5-17 years) who are receiving palliative or complex care and their parents. Specific aims are to: (1) determine the feasibility of songwriting for cognitively-impaired children with life-limiting conditions and their parents, and (2) examine preliminary efficacy of songwriting for child psychological distress and physical symptoms, parent psychological distress, and family environment. The protocol for this 1-group pre-and post-intervention clinical trial (N = 25) is described.

Transforming a Face-to-Face Legacy Intervention to a Web-Based Legacy Intervention for Children With Advanced Cancer

Research is needed to examine new and innovative web-based intervention delivery methods that are feasible, cost-effective, and acceptable to children and their families to increase access to palliative care services in the home and community. Our previous work included the development of a legacy intervention using face-to-face digital storytelling for children with cancer that showed feasibility and strong promise to improve child outcomes. However, face-to-face intervention delivery techniques limited our recruitment, thus decreasing sample size and potential access to broader populations. Here we present the systematic steps of the development of a web-based legacy intervention for children (7-17 years of age) with relapsed or refractory cancer and their parent caregivers. Counts and frequencies for parent (n = 81) reports on satisfaction surveys are presented and parent suggestions for future work. Results suggest the web-based legacy intervention is feasible and acceptable, with parent-perceived beneficial outcomes for the child, parent, and family. Results provide a foundation for web-based intervention development in palliative care and the implementation of a theoretically grounded intervention to reduce suffering of seriously ill children and their family members, thereby advancing the science of symptom management in vulnerable palliative care populations.

Associations of Age, Gender, and Family Income with Quality of Life in Children With Advanced Cancer

Background: Children with cancer often experience decreased quality of life (QOL) throughout the illness trajectory. The purpose of this study was to explore the associations of demographic characteristics with QOL in children with advanced cancer. Methods: This secondary analysis was part of a larger randomized clinical trial that evaluated the efficacy of a legacy intervention for children (7-17 years) with relapsed/refractory cancer and their primary parent caregivers. Assessments included child self-reports on the Pediatric Quality of Life Inventory (PedsQL) Cancer Module. Researchers used descriptive and linear regression statistical methods. Results: Children (n = 128) averaged 10.9 years (SD = 3.0). The majority were female (n = 68, 53%), white (n = 107, 84%), had a hematologic malignancy (n = 67, 52%), with family incomes of $50,000 or less (n = 81, 63.3%). Statistically significant positive associations of both age and income level with PedsQL scores were observed (p < .05) but not gender (p > .05). The strongest correlations for age were with the procedural anxiety (beta = 0.42), treatment anxiety (beta = 0.26), and total (beta = 0.28) scores (all p < .01). In general, there was a positive correlation between family income levels and PedsQL scores (p < .05). The strongest correlations for income were with nausea (R = 0.49), appearance (R = 0.44), pain, and treatment anxiety (both R = 0.42) (all p < .01). Associations adjusted for age remained essentially the same (all p < .01). Discussion: Children with advanced cancer with lower family income and younger age are at high risk for poorer QOL. Oncology nurses should seek to identify families who may benefit from additional resources to promote QOL.

Nursing interventions for perinatal bereavement care in neonatal intensive care units: A scoping review

BACKGROUND

Despite technological advances and specialist training of neonatal teams, perinatal deaths still occur. Such events are traumatic experiences for the parents and increase the risk of pathological grieving. Nursing is one of the main sources of support. However, the important work of nurses in these situations is made more difficult by the lack of recognized strategies that can be implemented to assist parents and family members in the bereavement process.

AIM

Identify nursing interventions to help parents of neonates admitted to neonatal intensive care units cope with perinatal loss.

METHODS

A scoping review based on the methodological framework established by Arksey and O'Malley was used. A total of 327 relevant studies were identified through a bibliographic search in Pubmed, CINAHL Plus, APA PsycNET and Scopus between 2000 and 2019. The screening process included an initial analysis of the relevance of the abstract and, when required, an extensive review of the full paper.

RESULTS

A total of 9 papers were finally selected which responded to the research question. All nine papers are from the USA and have different methodological characteristics. A number of effective interventions were identified, including legacy creation, support groups, family-centred accompaniment and follow-up, parental involvement in pre-mortem care, intergenerational bereavement programmes, and the use of technological and spiritual resources.

CONCLUSION

In general, the scant evidence that is available about nursing interventions around perinatal bereavement care underlines the requirement to thoroughly assess the effectiveness of those that have already been designed and implemented.

IMPLICATIONS FOR NURSING PRACTICE AND POLICY

This scoping review contributes to the potential implementation of effective interventions to deal with and help parents and family members cope with perinatal bereavement, with nursing staff as the main source of support and leading interventions which have family members in the care team. This review also makes a substantial contribution to the development of a practical and evidence-based clinical guide for nursing, with recommendations that can be adapted to effective quality care criteria. It is additionally intended to encourage visibility in health policies of care and attention to perinatal grief in neonatal intensive care units.

Legacy perceptions and interventions for adults and children receiving palliative care: A systematic review

BACKGROUND

Legacy has been invoked as a means for strengthening human attachments, continuing bonds, and ensuring that individuals will be remembered; however, little is known about the spectrum of approaches to, outcomes associated with, and best practices for legacy interventions.

AIM

To systematically review research on legacy perceptions and interventions in pediatric and adult palliative care recipients.

DESIGN

A systematic mixed studies review synthesizing quantitative, qualitative, and mixed-methods study findings using PRISMA guidelines.

DATA SOURCES

PubMed, PsycINFO, and CINAHL databases were searched on October 1, 2020. GRADE criteria were used to assess quality of quantitative reports, and the Johns Hopkins Evidence Level and Quality Guide was used to rate qualitative, mixed methods, and review articles. Data were synthesized using integrative thematic analysis.

RESULTS

The 67 studies reviewed describe a variety of legacy perceptions and interventions with adult and pediatric patients receiving palliative care. Statistically significant improvements in various dimensions of wellbeing are documented, with significant reduction in incidence and symptoms of depression in adults. Studies highlight the utility, feasibility, and perceived benefits of legacy interventions according to adult patients and their caregivers, and parents/caregivers of pediatric patients.

CONCLUSIONS

Though future research with high-quality, experimental designs is needed, the positive outcomes associated with legacy interventions are documented in adult patient populations; additionally, the application of legacy interventions for children with serious illnesses receiving palliative care is reasonable based on the existing body of evidence. A consistent and operational concept of legacy is still needed for future research and practice.

Improved Parent-Child Communication following a RCT Evaluating a Legacy Intervention for Children with Advanced Cancer

Although legacy-building is a priority for quality palliative care, research has rarely examined effects of legacy interventions in children, particularly their impact on parent-child communication.We examined the impact of a web-based legacy intervention on parent-child communication. We hypothesized that compared to usual care, legacy-making would improve quality of parent-child communication.Between 2015 and 2018, Facebook advertisements were used to recruit families of children (ages 7-17) with relapsed/refractory cancer. Parent-child dyads were randomly assigned to the intervention or usual care group. The intervention website guided children to create digital storyboards over 2 weeks by directing them to answer legacy questions about themselves and upload photographs, videos, and music. Families received a copy of the child's final digital story. Children and parents completed the Parent-Adolescent Communication Scale pre- (T1) and post-intervention (T2). Linear regressions tested for differences in change from T1 to T2 between the groups controlling for T1 values using an alpha of p < .05. Intervention effects were measured using Cohen's d. Ninety-seven parent-child dyads were included for analysis. Changes in parent-child communication were not statistically significantly different between the groups, yet meaningful intervention effects were observed. The strongest effects were observed for improving father-child communication (Cohen's d = -0.22-0.33). Legacy-making shows promise to facilitate improved parent-child communication, particularly for fathers. Future studies should include fathers and measure expression of feelings and parent-child interaction. Providers should continue to facilitate family communication for children with advanced disease and realize that legacy interventions may impact mother-child versus father-child communication differently.

My child's legacy: a mixed methods study of bereaved parents and providers' opinions about collaboration with NICU teams in quality improvement initiatives

OBJECTIVE

Although stakeholders' participation in healthcare is increasingly recommended, bereaved parents are often excluded for perceived potential risks to them. The objective of this study is to describe the ongoing involvement and the perspectives of bereaved parents engaged in different types of activities in Neonatal Intensive Care Units and providers who work with them.

DESIGN/METHODS

Mixed methods convergent analysis.

SETTING

Canadian paediatric tertiary care university hospital.

PARTICIPANTS

All bereaved members of the resource parents group (n=8) and most providers who work with them (n=16) answered a satisfaction/needs questionnaires.

RESULTS

Since 2011, eight bereaved parents were involved in a large number of activities mostly related to palliative care (research, education or clinical care initiatives). Three engaged in peer-to-peer support activities while the others preferred activities outside of clinical units and/or without direct interactions with other families. All of them reported that their participation had positive impacts, but two parents also reported a reactivation of traumatic experiences during a medical simulation activity. All participants expressed a desire for further collaboration. Motivation to contribute gravitated around two central themes: helping others and helping themselves. Many wanted to give back, help other families, improve the system and meet with providers who had cared for their child. All stated that this kind of involvement empowered them and gave meaning to their experiences. Providers and researchers all reported positive experiences, mainly due to the unique perspectives of bereaved parents who took part in their projects.

CONCLUSIONS

With careful recruitment and supervision, some bereaved parents can become resource parents involved in different types of activities. It is important to understand the positive impacts this type of engagement can have on their healing process and to control the risks related to their participation. Research is needed to develop pertinent tools and measures to evaluate the outcomes and impacts of their participation.

Women and Infants in the Deep South Receiving Perinatal and Neonatal Palliative and Supportive Care Services

BACKGROUND

While women in the Deep South area of the United States have higher rates of maternal and infant mortality, palliative and supportive care programs are lacking. Additionally, few studies have detailed referral triggers that are specific to the mother, infant, or pregnancy for inclusion in perinatal and neonatal palliative and supportive care programs.

PURPOSE

The purpose of this retrospective, descriptive study was to examine the sociodemographic factors and referral triggers for perinatal-neonatal palliative and supportive care services for women enrolled in a newly developed perinatal-neonatal palliative and supportive care program.

METHODS

Data were collected from medical records of 135 women enrolled in the program. Triggers for referral to the program were classified as fetal, maternal, or prenatal complications.

RESULTS

A diverse sample of women were enrolled in the program. Most infants survived to birth and discharge from the hospital. Two-thirds of referrals were related to infant complications and 34% were for multiple complications (fetal, maternal, and/or prenatal). Triggers for referral to the program were not related to sociodemographic characteristics of women.

IMPLICATIONS FOR PRACTICE

A comprehensive list of triggers that include maternal and prenatal complications, in addition to infant complications, may ensure at-risk women and infants, are enrolled in perinatal-neonatal palliative and supportive care programs early in pregnancy, regardless of sociodemographic factors.

IMPLICATIONS FOR RESEARCH

Prospective research on the effectiveness of perinatal-neonatal palliative and supportive care programs in diverse populations of women is needed. This includes the examination of family health outcomes and provider perspectives.