Was it caring? Was it caring? Did it make a difference?Did it make a difference?

The Couples The Couples Miscarriage Healing Miscarriage Healing

ProjectProject

Couples Miscarriage Healing Project

Kristen M. Swanson, RN, PhD, FAANAnthippy Petras, MSW

Hsien-Tzu Chen, RN, PhDDanuta Wojnar, RN, PhDRosalie Houston, RN, MN

Susan Sandblom, ARNP, MNJeannette Quaeck, RN, MN

Appalachia Martine, RN, BSNHelga Fridjonsdottir, RN, PhD

Alyson Shapiro, PhDChristopher Graham, PhD

During the first year after miscarriage, when couples engage in mutual sharing about their loss women report their interpersonal and sexual relationships become closer than before the miscarriage. (Swanson, 2003)

1 out of 6 pregnancies end in miscarriage

To compare the effects of nurse caring, self-caring, combined caring, and control (no intervention) on the emotional healing, integration of loss, and couple well-being of women and their male mates during the first year after miscarrying.

Couples Miscarriage Healing Project

Overall Purpose:

Non-probability sampling

• health care providers

• print & radio ads

• posters

• www, word of mouth

• participant referral

Enrollment Criteria

1. unplanned, unexpected, loss of pregnancy2. < 20 wks gestation at loss3. no more than 12 weeks since loss4. heterosexual couples5. if married, any age6. if in committed relationship, both 18 or older7. both partners willing to participate8. able to communicate in English (written and spoken)9. geographically accessible

• 341 Couples enrolled • up to 12 weeks post loss (M = 4.5 + 3.3 wks)

• Gestational age (M = 9.8 + 3.1 wks).

• Maternal age (M = 32.4 + 6.0 yrs)

• Paternal age (M = 33.9 + 6.7 yrs )

• 85% Caucasian, ~ 90% some college

Sample

Randomized Experimental Design

Phonescreen

randomized

nurse

self

combined

control

t2 t3t4

1 5 11 weeks

t1

weeks 6 16 52

X X X

X X X

X X X

0 Baseline

1.1. To describe the extent to which the nurse counseling sessions were perceived as caring by couples.

2. To describe how women and men felt about their miscarriage right after participating in counseling sessions.

Two goals for this presentation:Two goals for this presentation:

Nurse Caring Nurse Caring

Nurse counseling sessions with 84couples in their homes at

1 week5 weeks 11 weeks

Intervention FrameworkIntervention Framework

Process: Caring TheoryProcess: Caring Theory

Content: Miscarriage ModelContent: Miscarriage Model

(Swanson, 1983, 1986, 1991, 1993, 1999a, 1999b)

KnowingKnowing Doing for Doing for

Kristen M. Swanson, RN, PhD, FAAN

Being with:Being with: being emotionally present to being emotionally present to the other.the other.Knowing:Knowing: striving to understand an event as striving to understand an event as

it has meaning in the life of the other.it has meaning in the life of the other.

Doing forDoing for: doing for others as they would do doing for others as they would do for themselves if were at all possible.for themselves if were at all possible.

Enabling:Enabling: facilitating the other’s passage facilitating the other’s passage through events or transition by providing through events or transition by providing support, information, and validation.support, information, and validation.

Maintaining belief:Maintaining belief: sustaining faith in the sustaining faith in the other’s capacity to come through events other’s capacity to come through events or transitions and face a future with or transitions and face a future with

meaning.meaning.Recipient’s

feeling

EnablingEnablingBeing withBeing with

Maintaining beliefCARINGCARING

healinghealing

valuedvalued

understoodunderstood

safe and safe and comfortedcomforted

capablecapable

healingunderstoodunderstoodvaluedvaluedsafe and safe and comfortedcomfortedcapablecapablehopefulhopeful

Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility.

Swanson Caring TheorySwanson Caring Theory

Miscarriage Model

SESSION 1 – 1 weekComing to know – confusing painful process of balancing mounting evidence of impending loss against hopes for a healthy pregnancy outcome

Losing and Gaining – identifying what was lost and / or gained through miscarriage

SESSION 2 – 6 weeksSharing the loss – determining just who is and not available to share in and validate the loss

Going Public – facing the fertile world as a no longer expectant parent

SESSION 3 – 11 weeksGetting Through It – identifying when the good times in the day begin to outweigh the bad

Trying Again – making plans to conceive again while dealing with the ongoing fears of future loss

• If caring is what we claimed we delivered, what would couples say they received?

• Right after receiving counseling, how did women and men feel about their miscarriage?

QuestionsQuestions:

• Quantitative data: Paired T-tests Repeated Measures MANOVA

• Qualitative data: Content analysis

Methods:Methods:

• Barrett-Lenard Relationship Inventory: Empathy subscale only

• Swanson Caring Professional Scale: Compassionate Healer

Competent Practitioner

Measures:Measures:

PositiveInformativeClinically competent An attentive listenerCentered on youTechnically skilledRespectful of you

ComfortingUnderstandingPersonalCaringSupportiveAware of your feelingsVisibly touched by your experienceAble to offer you hope

Competent Practitioner

Compassionate Healer

Was the nurse who took care of you?

Session 1 Session 2 Session 3 Mean N Std. sig Mean N Std. sig Mean N Std. sig Caring Total W 71.36 83 4.498 .954 70.11 38 7.274 .087 70.08 36 6.465 .380 (possible range 18 – 75) M 71.40 83 4.997 71.84 38 4.110 70.94 36 5.466 Compassionate Healer W 38.06 84 2.748 .842 37.49 39 4.248 .141 37.56 36 4.252 .280 (possible range 8 – 40) M 38.13 84 2.583 38.46 39 2.584 38.31 36 2.528 Competent Practitioner W 33.55 78 2.111 .715 33.23 35 2.658 .462 32.91 35 2.418 .832 (possible range 7 – 35) M 33.65 78 2.094 33.51 35 2.092 32.80 35 3.008 Empathy W 52.23 84 5.893 .272 51.08 38 7.057 .740 53.19 37 5.778 .142 (possible range 10 – 60) M 51.50 84 4.988 51.39 38 5.989 51.62 37 6.452

No differences

Were there within couple differences in nurse ratings?

Was there a difference over time in how couples rated the nurses as caring, compassionate, competent, or empathetic?

Repeated measures MANOVA: Gender (2) X Nurse (2) X Time (3)

1. No differences in empathy based on time, gender, or nurse.

2. No differences in caring, competence, or compassion based on gender or nurse.

3.3. There were, however, differences in caring, There were, however, differences in caring, compassion, and competence over time.compassion, and competence over time.

Nurse Caring over three sessions

70.4

70.6

70.8

71

71.2

71.4

71.6

71.8

72

72.2

1 2 3

Counseling Session

Caring

time (p = .009)

Nurse Compassion and Competence over three sessions

32.5

33

33.5

34

34.5

35

35.5

36

36.5

37

37.5

38

38.5

39

1 2 3

Counseling Sessions

Scores

Compassionate Healertime (p = .04)

Competent Practitionertime (p = .01)

Qualitative Prompts

• In one word or phrase how would you describe the counseling session?

• Any additional comments about the session would be most appreciated.

• In one word or phrase how do you feel about the miscarriage now?

Ses

sio

n 3

Ses

sio

n 2

Ses

sio

n 1

2067 statements about nurse counseling

sessions

Content AnalysisContent Analysis

Failing to do for

Doing for

Being with

Knowing

Enabling

MaintainingBelief

5 caring & 1 non-caring

processes

uplifting

healing

ready tomove on

understand my mate

nurse understands

getting connected

comforting

skilled nurse

well run session

helpful

ineffective intervention

more needed

ineffective nurse

nurse compassion

open up feelings

informative

Inductive content analysis Deductive comparison

54 codes

16 categories

• Knowinggetting connected

understand my mate

Nurse is understanding

• Being withcompassionate nurse

opened up feelings

• Doing forwell run session

competent nurse

comforting

• Enablinginformative

helpful

• Failing do-formore needed

ineffective intervention

ineffective nurse

• Maintaining beliefhealing

uplifting

ready to move on

5 Caring and 1 non-Caring Processes16 Categories

How many individuals made at least one statement indicating the counseling was caring?

Session1 Session2 Session3 N % N % N % WOMEN Caring 161 95.3 78 92.9 74 88.1 Failure to do for 1 0.6 1 1.1 4 4.8 Blank 7 4.1 5 6.0 6 7.1 Total 169 100.0 84 100.0 84 100.0 MEN Caring 152 89.9 68 81.0 65 77.3 Failure to do for 3 2.2 1 1.1 3 3.6 Blank 14 8.3 15 17.9 19 22.6 Total 169 100.0 84 100.0 84 100.0

What percent of women experienced What percent of women experienced each caring process?each caring process?

0

10

20

30

40

50

60

70

Percent

Session 1 Session 2 Session 3

Maintain belief

Knowing

Being With

Doing For

Enabling

Fail to Do For

What percent of men experienced What percent of men experienced each caring process?each caring process?

0

10

20

30

40

50

60

70

Percent

Session 1 Session 2 Session 3

Maintain belief

Knowing

Being With

Doing For

Enabling

Fail to Do For

How did couples feel after counseling?How did couples feel after counseling?

• Healing (at peace, wanting to move on, optimistic…)

• Sad (grieving, disappointed, wish it did not happen…)

• Disrupted (family disrupted, part of us is gone…)

• Adrift (feeling lost, ambivalent, numb inside…)

• Resentful (remorseful, angry at God, annoyed…)

• Raw (painful burden, hovers in my life, helpless…)

Feelings Right after Counseling

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

complicated 23.1 22.7 14.7

sad 41.3 24.5 21.1

healing 35.5 52.7 64.2

1 2 30%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

complicated 13.3 10.7 6.2

sad 31.6 10.7 14.8

healing 55.1 78.6 79

1 2 3

Women Men

64% 47% 36%

LOSS

45% 21% 21%

LOSS

Summary: Feelings about Miscarriage

• 35.5% of women indicated they were healing after session 1 and 64.2% after session 3.

• 55.1% of men indicated they were healing after

session 1 and 79% after session 3.

• Since these analyses are only descriptive, we do not know if these increases are attributable to the healing effects of time or to our counseling sessions.

Qualitative Caring Summary

• In all three sessions the most commonly endorsed caring categories were Doing For, Enabling and Maintaining Belief.

• The majority of “failing to do for” statements focused on couples’ desires for more time, sessions, or support.

Quantitative Caring Summary

• Both nurses were rated as highly caring, compassionate, competent, and empathetic, with both partners rating nurses similarly.

• The highest competence, compassion, and caring ratings were at Session 2 possibly due to the nurse-couple relationship deepening, the content being more relevant, couples needing more caring, or the nurse being more responsive.

Conclusion

Caring was delivered as intended

Limitations

• These analyses are merely evaluative of the nurse counseling intervention and do not tell us anything about treatment outcomes.

Treatment Outcomes

Is there a difference in rate of resolution of grief and depression based on gender or treatment condition?

Two QuestionsTwo Questions:

Measures

Depression: CES-D (Radloff, 1977 )

Grief: Miscarriage Grief Inventory (Nikcevic et al, 1999)

Pure Grief Grief-Related Emotions Adjustment

Chronbach alphas ranged from .759 to .938

Analysis: Multi-level Modeling

Assumptions

1. Since all participants exist in the context of a couple relationship, each individual’s recovery is impacted by their partner’s recovery.

2. Since women and men were treated together, each couple’s recovery is impacted by their treatment condition.

3. Hence, the slope of each person’s recovery line is estimated based on their own scores over time, as influenced by their partner’s scores over time, as influenced by their assigned treatment condition

Treatment

Couple

Individual

Results

Bayesian Odds Ratios

BO = Bayesian Odds RatioP = Probability that slope is steeper than control

Evidence in Favor of Ho that Tx > control

RED INK = Substantial

BLUE INK = Strong (Kass and Raftery, 1995)

Treatments vs Controlcontrolling for time since loss

andhistory of treatment for depression, anxiety, or grief

  Self Caring Combined Caring Nurse Caring  Female Male Female Male Female Male

  BO P BO P BO P BO P BO P BO P

Pure Grief 7.1 .88 1.0 .50 3.1 .76 23.3 .96 5.3 .84 17.4 .95

Grf Rel Emots 3.5 .78 .29 .22 .54 .35 5.1 .84 2.6 .72 2.4 .70

Adjustment 2.6 .72 4.5 .82 1.5 .60 3.3 .77 3.0 .75 2.8 .74

Total Grief 5.4 .84 .92 .48 1.6 .61 11.5 .92 4.8 .83 8.3 .89

Depression 2.2 .69 .31 .24 1.5 .6 .21 .18 7.4 .88 1.3 .56

Thank you