Was it caring? Did it make a difference?

1. Was it caring? Did it make a difference? The Couples Miscarriage Healing Project

2. Couples Miscarriage Healing Project Kristen M. Swanson, RN, PhD, FAAN Anthippy Petras, MSW Hsien-Tzu Chen, RN, PhD Danuta Wojnar, RN, PhD Rosalie Houston, RN, MN Susan Sandblom, ARNP, MN Jeannette Quaeck, RN, MN Appalachia Martine, RN, BSN Helga Fridjonsdottir, RN, PhD Alyson Shapiro, PhD Christopher Graham, PhD

3. 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

4. Couples Miscarriage Healing Project Overall Purpose: 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.

5. Non-probability sampling • health care providers • print & radio ads • posters • www, word of mouth • participant referral

6. Enrollment Criteria • unplanned, unexpected, loss of pregnancy • < 20 wks gestation at loss 3. no more than 12 weeks since loss • heterosexual couples • if married, any age • if in committed relationship, both 18 or older • both partners willing to participate 8. able to communicate in English (written and spoken) 9. geographically accessible

7. Sample • 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

8. nurse self combined control Randomized Experimental Design 1 5 11 weeks X X X X X X Phone screen randomized X X X t1 t4 t2 t3 0 Baseline 16 52 6 weeks

9. 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:

10. Nurse Caring Nurse counseling sessions with 84 couples in their homes at 1 week 5 weeks 11 weeks

11. Intervention Framework Process: Caring Theory Content: Miscarriage Model (Swanson, 1983, 1986, 1991, 1993, 1999a, 1999b)

12. Maintaining belief: sustaining faith in the other’s capacity to come through events or transitions and face a future with meaning. Enabling: facilitating the other’s passage through events or transition by providing support, information, and validation. Caring is a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility. healing Swanson Caring Theory Being with: being emotionally present to the other. Doing for:doing for others as they would do for themselves if were at all possible. Knowing: striving to understand an event as it has meaning in the life of the other. Recipient’s feeling capable Being with Enabling valued CARING Maintaining belief hopeful healing understood valued safe and comforted capable understood Doing for Knowing safe and comforted Kristen M. Swanson, RN, PhD, FAAN

13. Miscarriage Model SESSION 1 – 1 week Coming 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 weeks Sharing 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 weeks Getting 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

14. Questions: • 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?

15. Quantitative data: Paired T-tests Repeated Measures MANOVA • Qualitative data: Content analysis Methods:

16. Barrett-Lenard Relationship Inventory: Empathy subscale only • Swanson Caring Professional Scale: Compassionate Healer Competent Practitioner Measures:

17. Was the nurse who took care of you? Competent Practitioner Positive Informative Clinically competent An attentive listener Centered on you Technically skilled Respectful of you Comforting Understanding Personal Caring Supportive Aware of your feelings Visibly touched by your experience Able to offer you hope Compassionate Healer

18. Were there within couple differences in nurse ratings? No differences

19. Was there a difference over time in how couples rated the nurses as caring, compassionate, competent, or empathetic? • No differences in empathy based on time, gender, or nurse. • No differences in caring, competence, or compassion based on gender or nurse. • There were, however, differences in caring, compassion, and competence over time. • Repeated measures MANOVA: Gender (2) X Nurse (2) X Time (3)

20. Nurse Caring over three sessions

21. Nurse Compassion and Competence over three sessions

22. 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?

23. healing Maintaining Belief uplifting Session 3 ready to move on Session 2 Session 1 understand my mate Knowing nurse understands getting connected nurse compassion Being with open up feelings Doing for 54 codes comforting 16 categories skilled nurse well run session Enabling informative helpful more needed Failing to do for ineffective intervention ineffective nurse Content Analysis Inductive content analysis Deductive comparison 5 caring & 1 non-caring processes 2067 statements about nurse counseling sessions

24. Enabling informative helpful 5 Caring and 1 non-Caring Processes 16 Categories • Doing for well run session competent nurse comforting • Being with compassionate nurse opened up feelings • Knowing getting connected understand my mate Nurse is understanding • Maintaining belief healing uplifting ready to move on • Failing do-for more needed ineffective intervention ineffective nurse

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

26. What percent of women experienced each caring process?

27. What percent of men experienced each caring process?

28. 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…)

29. LOSS 64% 47% 36% Feelings Right after Counseling LOSS 45% 21% 21% Women Men

30. 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.

31. 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.

32. 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.

33. Conclusion Caring was delivered as intended

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

35. Two Questions: Treatment Outcomes Is there a difference in rate of resolution of grief and depression based on gender or treatment condition?

36. 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

37. Individual Couple Treatment Analysis: Multi-level Modeling 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 Assumptions

38. Results

39. Bayesian Odds Ratios BO = Bayesian Odds Ratio P = 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)

40. Treatments vs Controlcontrolling for time since loss andhistory of treatment for depression, anxiety, or grief

41. Thank you