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Contents lists available at ScienceDirect

Collegian
journal homepage: www.elsevier.com/locate/coll

Caring for women through early pregnancy loss: Exploring nurses’

experiences of care
Georgia Griffina,∗ , Margaret Ngulubea , Victoria Farrella , Yvonne L. Haucka,b
a
Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, 374 Bagot Road, Subiaco, Western Australia 6008,
Australia
b
School of Nursing, Midwifery and Paramedicine, Curtin University, Kent Street, Bentley, Perth, Western Australia 6102, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Early pregnancy loss is a common experience globally yet little is known about nurses’
Received 17 January 2020 experiences of providing early pregnancy loss care to women.
Received in revised form 19 August 2020 Aims: Study aims were to explore the experiences of nurses providing this care, what assists and chal-
Accepted 23 August 2020
lenges them and their perceptions of how they could be better supported.
Available online xxx
Methods: A qualitative descriptive design was employed.
Findings: Twenty-five registered nurses completed in-depth interviews. Thematic analysis revealed four
Keywords:
themes and nine subthemes: (1) Caring for all needs (Prioritising physical needs, Acknowledging emo-
Early pregnancy loss
Emotion work
tional needs, Offering explanations and information, Respecting individuality); (2) Caring through the
Emotional labour journey; (3) Working with challenges (Managing the environment, Tendering time); and (4) Reflecting
Gynaecology on the role (Recognising their good work, Valuing experience and knowledge, Facing the impact of care).
Miscarriage Discussion: Valuable insight revealed the complexity of the nurses’ work and the emphasis they place
Nurse on emotional care. Comparisons can be made to Hochschild’s concepts of emotional labour and emotion
Qualitative descriptive work. It is suggested that the nurses’ gift emotion work to care for the women. However, in an outcomes-
based hospital environment, nurses can also be at risk of burnout.
Conclusion: Nurses must be supported by health organisations to continue their emotion work. Further
research into interventions to support nurses providing early pregnancy loss care, including trialling
Balint groups, are recommended.
© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Summary of relevance
Problem
There is limited knowledge of nurses’ experiences of providing
early pregnancy loss care to women.
What is already known
Health professionals can influence women’s experience of
early pregnancy loss care, recovery and future interactions
with care providers.
What this paper adds
Nurses perform complex and intense work in the face of
organisational challenges. They describe meeting the women’s
emotional needs as at the heart of their care and must
be supported to continue their emotion work. Insight into
nurses’ experiences should be used to develop interventions
to improve support for nurses.
∗ Corresponding author. Tel.: +61 8 6458 3014.
E-mail address: georgia.griffin@health.wa.gov.au (G. Griffin).
1. Introduction
Early pregnancy loss is a common experience amongst women
globally, estimated to occur in 11–22% of pregnancies (Ammon
Avalos, Galindo, & Li, 2012). Early pregnancy loss is defined as the
loss of a pregnancy at less than 20 weeks gestation (Queensland
Clinical Guidelines, 2018). For those women who seek medical
care during early pregnancy loss, interactions with caregivers and
the care itself can influence their experience, recovery and future
interactions with care providers (Due, Obst, Riggs, & Collins, 2018).
Research shows that women perceive good care as emotionally
sensitive and individualised (Bellhouse, Temple-Smith, Watson, &
Bilardi, 2019; Due et al., 2018; Evans, Lloyd, Considine, & Hancock,
2002; Murphy & Merrell, 2009). Who cares for women during
pregnancy loss, nurse or midwife, varies dependant on where the
woman presents, the treatment she requires, her gestation and the
healthcare facility itself. For women presenting at less than twenty
weeks’ gestation to hospitals and through emergency departments
in Australia, nurses are typically the frontline of care (Edwards,
Birks, Chapman, & Yates, 2018).

https://doi.org/10.1016/j.colegn.2020.08.011
1322-7696/© 2020 Australian College of Nursing Ltd. Published by Elsevier Ltd.

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2. Literature review
Nurses are tasked with not only maintaining each woman’s
physical safety during an early pregnancy loss, but also meeting
her emotional needs (Murphy & Merrell, 2009). Despite its fre-
quency, early pregnancy loss often has significant psychological
and physical implications for women and families. Psychological
distress, anxiety and isolation, amongst other long term sequalae,
can accompany the loss of the expected child (Radford & Hughes,
2015; Stratton & Lloyd, 2008). Up to 20% of women experience mod-
erate depressive symptoms in the first four to six weeks following
an early pregnancy loss while up to 32% experience anxiety. Both
conditions typically resolve within one year (Farren et al., 2018).
Further, 25–39% of women exhibit symptoms of post-traumatic
stress disorder within one month of early pregnancy loss (Farren
et al., 2018). The duration of these symptoms have not been estab-
lished (Farren et al., 2018). Balancing these emotional needs with
physical needs and organisational demands can make the provision
of early pregnancy loss care a challenging role (Murphy & Merrell,
2009).
McCreight (2005) presents pregnancy loss care as emotionally
intense work, suggesting that emotional labour is required of the
nurse. The term emotional labour, first coined by Arlie Hochschild
in 1983, refers to “the management of feeling to create a publicly
observable facial and bodily display” (Hochschild, 2003, p. 7). In
seeking to meet the needs of patients, families and colleagues, along
with organisational priorities, nurses must also manage their own
emotions (McCreight, 2005). Emotional labour can be an exhaust-
ing form of work, leading to stress, burnout and poor patient care
(Delgado, Upton, Ranse, Furness, & Foster, 2017).
Bolton (2000), alternatively, suggests that emotional labour
does not adequately capture the work that gynaecology nurses per-
form. She draws upon a second of Hochschild’s concepts, emotion
work, in which the individual conjures, moulds and suppresses feel-
ing as part of social exchange in their professional role (Bolton,
2000). The individual may gift this type of work to offer something
more to the social exchange.
Whereas, emotional labour has negative consequences for
nurses who may become drained and unable to continue their
work, offering emotion work as a gift can be rewarding and self-
protective from burnout and stress (Bolton, 2000). The challenge
of emotion work is that nurses provide care in an increasingly
outcomes-based culture, a model into which emotion work does
not readily fit (McCreight, 2005; Sawbridge & Hewison, 2013). Fur-
thermore, early pregnancy loss is a uniquely emotionally intense
experience for both woman and nurse (Murphy & Merrell, 2009).
It is vital to ensure that nurses are supported to ensure that
their emotion work does not develop into emotional labour as
they are pressed to produce more outcomes with less time and
resources.
Insight into nurses’ experiences of providing early pregnancy
loss care is useful to understand how they perceive their role. Iden-
tifying what assists them to provide care and what challenges them,
can inform recommendations to support the nurses’ own wellbeing
and skills. This study presents the findings of a qualitative descrip-
tive study of nurses’ experiences providing early pregnancy loss
care with the aim of providing such insight.
3. Methods
3.1. Aim
The aim of the study was to explore the experiences of nurses
providing early pregnancy loss care to women. Specifically, insight
was sought into what assists and challenges them in providing care,
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and their perceptions of how the health institution could better
support them.
3.2. Design
A qualitative descriptive design was employed to enable the
researchers to approach the data from a comprehensive holistic
perspective suitable to the study aim (Cesario, Morin, & Santa-
Donato, 2002). Qualitative description is well suited to capture
experiences of a health phenomenon, such as early pregnancy
loss care, at a surface level using participants’ own words and
stories and identifying common themes (Willis, Sullivan-Bolyai,
Knafl, & Cohen, 2016). Researchers “stay close to their data
and to the surface of words and events” utilising this design
(Sandelowski, 2000, p. 334). Additionally, qualitative description
produces a focused understanding of the participants’ experiences
which makes clear the contextual factors that shape those expe-
riences. This is specifically useful for practical recommendations
and future decision-making (Willis et al., 2016). To allow for the
discovery of new and unexpected information, data collection was
through semi-structured interviews, the data collection tool of
choice in qualitative description (Neergaard, Olesen, Andersen, &
Sondergaard, 2009).
3.3. Setting
This study was conducted in the public tertiary women’s hos-
pital in Western Australia. Provision of early pregnancy loss care
occurred primarily in one of four clinical areas — the emergency
centre, day surgery, recovery and the gynaecology ward. In this
setting, early pregnancy loss care is deemed as a nursing role while
midwives assume care for women greater than twenty weeks’
gestation. The term ‘care’ referred to care at any point along the
woman’s pregnancy loss journey including presentation to hospi-
tal, diagnosis, treatment and post-treatment.
3.4. Sample
A purposeful sampling approach was utilised to recruit a sample
with experience of the phenomenon representative of the broader
population, allowing for detailed, in-depth insight into the phe-
nomenon (Cresswell & Plano Clark, 2011). Flyers were posted in the
four clinical areas advertising the study. A research assistant also
attended the shift handovers to explain the study. Nurses volun-
teered on the wards or contacted the research team to participate.
A total of 25 registered nurses and registered nurse/midwives
who provided early pregnancy loss care (<20 weeks gestation) in
the emergency centre, day surgery, recovery or gynaecology ward
participated in the study. Participants reported an average of 12
years gynaecology nursing experience (ranging 1–42 years) and 26
years nursing experience (ranging 1–48 years). Of the 25 partici-
pants, seven worked in the emergency centre, eight in day surgery,
four in recovery and six in the gynaecology ward.
3.5. Data collection
Data was collected through one-on-one semi-structured inter-
views from September to November 2018. Interviews were
conducted by either one of two research assistants. One research
assistant also worked on the gynaecology ward. To avoid poten-
tial bias, she did not interview participants from this clinical
area. Before each interview, nurses were given an information let-
ter to read about the study. Each participant signed a consent
form to proceed with the interview. Nurses were assured that
they could withdraw from the study at any point. To acknowl-
edge their contribution to the research process, nurses were
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offered a certificate of participation for their professional portfo-
lio.
An interview guide comprising six open-ended questions was
used to explore the study aims while allowing for the discovery or
new and unexpected information (see Table 1). Additional prompts
such as ‘tell me more about that’ or ‘can you give me an example’
were used to encourage the nurses to elaborate. Interviews were
audio-recorded and transcribed verbatim for analysis. Transcrip-
tion was conducted by a professional transcriber external to the
research team. Data collection and analysis were managed simulta-
neously, as thematic analysis in qualitative description emphasises
context and involves a non-linear process (Vaismoradi, Turunen, &
Bondas, 2013). Thus interviews were ceased once data saturation
was reached at 25 interviews.
3.6. Data analysis
Thematic analysis was performed on each interview using the
six-phase approach proposed by Braun and Clarke (2006) to allow
investigators to identify, analyse and report patterns from the data,
rich with detail. As such, interview transcripts were read closely
for apparent and critical meaning. A selection of key phrases and
codes were then developed to express the meaning of the key
phrases. Tentative themes were established by identifying the pat-
tern of the meaning in and beyond the transcript. Two members
of the research team independently analysed each transcript to
ensure credibility and trustworthiness. The relationship between
the themes and the data was verified by all investigators who met
regularly to discuss emerging themes and sub-themes until a con-
sensus decision was reached.
3.7. Rigour
Multiple strategies were incorporated into the study design to
ensure rigour. For dependability, thematic analysis was conducted
following Braun and Clarke’s approach to limit the influence of
subjectivity (Braun & Clarke, 2006; Korstjens & Moser, 2018). Fur-
thermore, thorough detail has been provided for the reader about
the research methodology and rationale to show dependability
(Korstjens & Moser, 2018). To ensure credibility, investigator trian-
gulation was employed (Korstjens & Moser, 2018). A minimum of
two researchers coded and conducted preliminary analysis of each
transcript independently before meeting to discuss and finalise
the themes and subthemes. The following findings include rich
description to enable the reader to judge transferability to their
own setting, demonstrating trustworthiness (Korstjens & Moser,
2018; Polit & Beck, 2014).
4. Ethics
Ethical approval was granted by the hospital Human Research
Ethics Committee (GEKO ID 26862).
5. Findings
Four themes and nine subthemes emerged from the data,
reflecting the nurses’ experiences of providing early pregnancy loss
care. Fig. 1 presents the four themes and nine subthemes, demon-
strating how each theme reveals a layer of the nurses’ experience
of her role when caring for a woman during early pregnancy loss.
Themes and subthemes are described in the following text. Sup-
porting quotes are included in italics. A numeric coding system
was used to maintain confidentiality. Each nurse was allocated a
code (1–25). A postfix was added to indicate clinical area (‘E’ for
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Table 1
Interview guide
Interview guide questions
1. What are the key aspects that you remember around being involved in
caring for women who experience early pregnancy loss?
2. What do you think assists you to provide care for women experiencing a
pregnancy loss up to 20 weeks?
3. What challenges you to provide care for women experiencing a pregnancy
loss up to 20 weeks?
4. How do you feel the hospital supports you as a nurse to care for women who
experience a pregnancy loss up to 20 weeks?
5. What do you think the hospital could do to improve support for nurses in
this role?
6. Is there anything else you’d like to share?
emergency centre, ‘D’ for day surgery, ‘R’ for recovery and ‘W’ for
gynaecology ward).
5.1. Theme 1: caring for all needs
Nurses described the provision of individualised holistic care.
This encompassed physical care, compassionate emotional care,
information provision and the individualised assessment of each
woman’s needs. Four subthemes reflect these interconnected
aspects of care provision.
5.1.1. Subtheme 1.1: prioritising physical needs
Nurses shared how they commenced care by assessing physi-
cal needs first. While compassionate holistic care was emphasised,
the woman’s safety must be established first. Invariably they will
come in because they’ve got pain, because they’ve got bleeding. Some-
times they’ve got both and yes we deal with the physical stuff first
(19E ). While stabilising the woman however, emotional needs
could not be neglected. Often the two aspects of care were inter-
twined. Nurses described giving hot packs for cramps as an act
of compassion. Another warned, you have to be careful that you’re
not medicating psychological pain. . . because your heart hurts versus
physical pain because of cramps (20R ).
5.1.2. Subtheme 1.2: acknowledging emotional needs
The provision of emotional care was described as at the heart of
the nurse’s role, encompassing acknowledgement of loss, compas-
sion, appreciating the experience, addressing guilt and involving
the support person. It’s above the paperwork, it’s above the drugs. . .
it’s above the management of the airway. . . it’s actually caring for them
(20R ).
Nurses described conveying empathy and compassion in myr-
iad ways, such as offering a symbolic gift. We’d give them a
little heart and I just say this is a little heart from us to acknowl-
edge that little heartbeat you’ve lost (15E ). Others utilised physical
touch or allowed themselves to be vulnerable with the woman.
If they cry I can cry with them and I think that’s very important for
patients as well, give them a hug, tell them we’re sorry (9E ). Many
described a responsibility to appreciate the meaning of the experi-
ence and address perceived guilt. [I] tell them. . . there is nothing
they’ve done or haven’t done that caused the miscarriage so they
don’t feel guilty. . . it’s a lot more common than what they think
(23E ).
Care was not about the woman alone. The nurse sought to
involve the support person in care by delegating simple tasks, such
as applying hot packs. This was seen as an act of caring for the
support person also.
5.1.3. Subtheme 1.3: offering explanations and information
The nurses perceived their role when caring for women expe-
riencing early pregnancy loss to involve information provision and
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Fig. 1. Nurses experiences of providing early pregnancy loss care to women: Themes and subthemes.

offering explanations. They felt that the women expected informa-
tion. They do want far more information than they ever, ever wanted
before (22W ).
Information was tailored and reflected the context of the
woman’s journey, the clinical setting and the woman’s individ-
ualised needs. For example, nurses on the gynaecology ward
described providing information about outpatient and commu-
nity resources while nurses in the emergency centre described
explaining treatment options. We will just give them all the
knowledge they need to deal with whatever’s happening to them
(15E ).
As with the content, information delivery was personalised to
the individual and setting. Just taking your time and explaining things
slowly and being, understanding that there’s a lot of information
(18W ).
5.1.4. Subtheme 1.4: respecting individuality
To provide holistic care, nurses described assessing each
woman’s unique needs to offer care suited to the individual woman.
While each loss was valued by the nurses, they reflected on
how women expressed their emotions differently. Some women
are very accepting. . .other women are incredibly distressed. . . their
reactions can be extremely varied and so making sure you can. . .
connect with women on all those different emotional kind of levels
(7E ).
Nurses respected the loss in the context of its meaning to the
woman and her family, acknowledging that factors such as obstet-
ric history or gestational age could influence a woman’s emotional
needs. Over 12, 13, 14 weeks there’s an actual little baby. . . they can
physically see. . . their emotional needs are slightly different because
they’re holding a baby. Under 12, 12 weeks it’s still a pregnancy loss
(13W ).
5.2. Theme 2: caring through the journey
The nurses cared for women across a range of clinical settings:
the emergency centre, day surgery, recovery and the gynaecology
ward. Care was shaped by the clinical setting in which it was deliv-
ered. The nurses were aware that the woman’s experience of care
may not be isolated to their specific clinical area. It’s like a flow chart,
it follows on. . . they’ve gone to EC [emergency centre], they’ve seen
certain people there, they come up to us, they have the treatment up
here, we follow it on with the booklets, the little keepsake (17D ).
The hospital admission too was perceived as only a discrete
component of the woman’s journey. Nurses demonstrated an
awareness of the role in preparing the women to return to every-
day life following discharge. You have to think about that person and
how they’re going to be when they go home. . . we give them you know
the brochures or the numbers or. . . whatever it is they need (1W ).
Many also reflected that the woman may be returning to a soci-
etal context that does not validate the woman’s loss or in which
miscarriage is taboo. Women feel, especially if the pregnancy is early,
their loss is not as important as if they lost their baby at 30 weeks for
example, and that society and the community don’t see it as valid at
6 weeks (7E ). Nurses attempted to prepare the woman to face chal-
lenges posed by returning to everyday life. I feel my role is to equip
them to go out and face people when they have to tell them about their
loss. So often I will say have you told people, what have you told them
(9E ).
5.3. Theme 3: working with challenges
Nurses identified challenges to the provision of holistic care
and how, at times, they felt their care was inhibited by these. The
environment and time constraints were recurrent challenges.

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5.3.1. Subtheme 3.1: managing the environment
The nurses described the environment in which they deliver
care. Maintaining a safe secure space was described as an act of
caring. What do I do? Provide a secure environment, so you don’t have
traffic going in and out of the room. Give them quiet if they want quiet
(16D ).
Maintaining this safe space was presented as an often emotive
challenge. Recovery and day surgery nurses could find themselves
caring for women experiencing early pregnancy loss in a shared
space with newborn babies and mothers following caesarean sec-
tion. One nurse described, so there’s a huge dichotomy of feelings, the
happy experience and vocalisations accordingly and then you have
the extreme sadness and grief that families experience after pregnancy
loss. . . how do you deal with that (4D ).
Where they were not able to obtain control over the environ-
ment, the nurses prioritised transfer to another ward or discharge
to home. Process them as fast as you can, get them comfortable
physically. . . and get them back to privacy where you can pull the
curtains and grieve and go home and do what you need to do (20R ).
5.3.2. Subtheme 3.2: tendering time
Time was an asset valued by the nurses, enabling them to pro-
vide comprehensive holistic care, and it was something given to
the woman as an act of caring itself. It’s a sensitive time, we need
to give time to the patient (9E ). In time poor, busy clinical settings,
managing time was a challenge.
They do take up a lot more time than people give them credit for. . .
it’s just a minor procedure and surgically it probably is, but the
emotional and physical support that the patient needs pre-op and
post-op can sometimes be equivalent if not more as a patient having
more extensive surgery (6D ).
Nurses identified methods by which they tendered time. Some
referred care to other members of the multidisciplinary team such
as pastoral care, some asked colleagues to help care for other
patients and some accepted their work would not be completed
within the allocated shift hours that day. One nurse reflected that
she frequently worked over time. If you have a lady that. . . breaks
down you know you could be in there for an hour. . . we just have to
cater for it (25E ).
5.4. Theme 4: reflecting on the role
When describing their role, nurses explored their own percep-
tions of early pregnancy loss care. They reflected on the experience
and knowledge that enables them to provide care. When asked to
reflect on how the role challenges them, they speculated on how
their role may affect others.
5.4.1. Subtheme 4.1: recognising their good work
Nurses described a pride in and responsibility for the care they
provided women. The care is only as good as the nurse giving it, isn’t
it? (10D ). Many reflected on a meaning and satisfaction drawn from
caring for women, stating they felt that they do a good job.
What I enjoy doing, and sometimes the rewards afterwards. . . The
amount of emotion that these people have and how grateful. . . I’ve
given them a bearable delivery. . . It’s going to be horrible regardless
but if you can make it a little bit better then it’s like a good death isn’t
it (13W ).
Often the nurses described their ability to care for the woman as
an innate quality or gift while others viewed the role as a privilege.
I feel I have a gift for them, I’ve never lost a baby but I just feel empathy
(9E ).
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5.4.2. Subtheme 4.2: valuing experience and knowledge
Nurses valued experience as an asset to their practice. They drew
upon clinical experience caring for women experiencing early preg-
nancy loss. The more times you probably do it the better you get at it
(5D ). However, they also valued broader clinical experience in fields
such as midwifery or mental health. One nurse found her palliative
care background helpful. I’m quite good at this and dying situations
and talking about this (2W ).
Personal life experience was also valued, including experiences
of pregnancy loss, pregnancy and motherhood. I’ve had a miscar-
riage, I understand, I’ve had children. I remember being young and
wanting a family so to me I feel I have the empathy to share their
sadness and to reassure and encourage (10D ).
The nurses valued education and assumed responsibility for
their own learning. Some described learning from colleagues’ expe-
riences to improve their own practice. I listen to my colleagues. . .
they’ll have seen a lot more things than me so I listen in what they say
and how they deliver things and encompass it into my nursing care
(11D ). Others perceived themselves as role models with experience
and knowledge to share, taking pride in their ability to support their
colleagues.
5.4.3. Subtheme 4.3: facing the impact of care
Nurses reflected that while they themselves were not emotion-
ally affected by the role, other nurses may find it challenging or
distressing. I think other people find it quite challenging and quite
upsetting, so a bit more counselling’d be quite good. . . let’s have a
group once a month or something like that (13W ). The opportunity to
use groups to debrief and learn from others was shared by a number
of nurses.
Some prioritised their own self-care or acknowledged the
potential personal burden of the role. When you work in this area
often. . . how do you take care of your own mental health with it,
because it is sad news and you think. . . this can really build up (25E ).
Improved emotional support for staff and informal debriefs were
suggested to support those who may be challenged by the role.
I think probably the staff occasionally being able to debrief here. . .
Providing time for staff to perhaps sit down with each other or with
someone running the show to you know whether it’s someone from
psych med or social work or you know to say you know “how are
you girls feeling” (8E ).
6. Discussion
This study offers unique insight into nurses’ experiences of pro-
viding early pregnancy loss care and their perceptions of the care
they provide. Thematic analysis of their interviews revealed the
complexity of the nurses’ work. While the nurses addressed the
physical needs of the women first, the emphasis of their care as they
described it, was on emotional needs. This is supported by three
international studies which also found nurses strongly valued the
emotional care they provided when providing perinatal loss care
or broader gynaecology care (Bolton, 2000; Gergett & Gillen, 2014;
McCreight, 2005).
The nurses in this study also shared the reality of emotive and
stressful challenges and how they adapted, for example expediting
a woman’s transfer because she is being cared for in the presence of
a crying newborn. Despite the complexities and challenges of the
role, the nurses did not describe burnout. They continually reflected
on their good work, conveying pride and confidence. This sense of
satisfaction may suggest that the nurses are performing emotion
work when they provide early pregnancy loss care. For example,
they described taking time away from themselves by working over-
time in order to gift their attention to women. This aligns with
the findings of Bolton’s (2000) qualitative study with gynaecology
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nurses, where she asserts that performing emotion work can be
rewarding and self-protective from burnout and stress.
However, Bolton (2000) also warns that emotion work does not
readily fit into an increasingly outcomes-based healthcare model.
In her British qualitative study of gynaecology nurses, Bolton (2000)
concluded that the nurses’ work was a combination of emotion
work and emotional labour, terming it ‘emotionful’. Emotion work
may be self-protective and rewarding because nurses are able to
gift the management of their emotions. However, emotional labour
requires the nurse to manage their emotions to meet the demands
of their role. This may have negative consequences for nurses who
can become drained and unable to continue their work (Bolton,
2000). Care must be taken by the health institution that emo-
tion work does not transition into emotional labour as nurses are
pressed to produce more outcomes with less time and resources
(Bolton, 2000).
When asked how they could be better supported by the health
institution, the nurses in this study denied needing any emotional
support. However, they frequently referred to “other” nurses on
whom the role may be taking an emotional toll. These anonymous
others were attributed with various experiences. For example, they
were described as needing a break from the work or benefiting from
support to debrief. Riley and Weiss (2016) found that health profes-
sionals coped with the negative consequences of emotional labour
through conscious and unconscious psychological processes, such
as projection.
Attributing one’s own feelings or experiences onto others,
termed projection, has been identified as a common unconscious
coping mechanism amongst nurses to distance themselves from a
stressor, such as providing early pregnancy loss care (Abeni et al.,
2014; Sullivan, 2009). While it may be a useful short-term coping
mechanism, it is not a long-term healthy coping mechanism and
leads to less adaptive functioning (Abeni et al., 2014). Deriving sat-
isfaction from one’s work and reflecting on personal psychological
processes are recommended as protective factors against burnout
from emotion work (Abeni et al., 2014; Riley & Weiss, 2016).
A number of the nurses in this study specifically described group
sessions as a means to share their experiences and debrief. Simi-
larly, McCreight (2005), in her study of Northern Irish gynaecology
nurses providing perinatal loss care, observed that the nurses
appeared to benefit from the opportunity to share their experi-
ences and personal narrative during the interviews conducted for
the study. They were able to use the opportunity to reflect on their
experiences, professional skills and coping mechanisms in a mean-
ingful way. McCreight suggested further opportunities to share
their narrative may be beneficial for nurses while warning that
there was a strong risk of the nurses’ needs being marginalised by
the hidden nature of emotional labour (2005).
The nurses also described a desire for group sessions as an
opportunity to learn from each other’s experiences, a learning tech-
nique they strongly valued. An example of such an intervention is
a Balint group in which health professionals present cases from
their clinical practice which the group then discusses with guid-
ance from a facilitator (Green, Searle, Hannah, & Robertson, 2017).
The purpose is not to solve the case, but to reflect on the health
professional-patient interaction (Green et al., 2017; Yazdankhah-
fard, Haghani, & Omid, 2019).
Balint groups were initially conceived of for general practi-
tioners, however they have also been evaluated amongst medical
students, psychiatrists and other doctors (Yazdankhahfard et al.,
2019). In the Australian context, Balint groups have been shown
to facilitate medical students’ reflection on clinician-patient inter-
actions (Parker & Leggett, 2012, 2014). Rabinowitz, Kushnir, and
Ribak (1996) introduced Balint groups to primary care nursing
as an intervention for professional burnout. More recently Balint
groups have been successfully trialled with mental health nurses
Please cite this article in press as: Griffin, G., et al. Caring for women through early pregnancy loss: Exploring nurses’ experiences of
care. Collegian (2020),
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07, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
in England (Green et al., 2017). Positive outcomes reported include
improved self-efficacy, reduced levels of stress and burnout, and a
safe space for reflection (Green et al., 2017; Rabinowitz et al., 1996;
Yazdankhahfard et al., 2019). However, willingness from partici-
pants to engage with and learn the Balint group process is necessary
for the intervention to be effective (Parker & Leggett, 2014). Balint
groups may be a novel approach to support the nurses’ current emo-
tion work while offering a safe space for them to reflect on their
practice and own psychological wellbeing. Further research into
Balint groups for this cohort of nurses in their challenging role of
supporting women with an early pregnancy loss is recommended.
6.1. Limitations
Findings of this study reflect the experiences of nurses working
in one metropolitan health service in one Australian state. In keep-
ing with qualitative research, rich description has been provided
to enable the reader to determine transferability of the findings to
different clinical contexts (Polit & Beck, 2014).
7. Conclusion
This study provides valuable insight into the experiences of
nurses caring for women during early pregnancy loss. The nurses in
this study described the provision of comprehensive holistic care
with an emphasis on meeting women’s emotional needs. They also
described the challenges they faced, the journey along which the
women received care and how they saw their role. Apparent from
their reflections is the complexity and emotional demand of their
work. In the current outcomes-based health care climate, this emo-
tion work that nurses feel they gift to women may transition into
emotional labour if not appropriately recognised and supported
and may contribute to nurse burnout and compromised clinical
care. Further research into interventions such as Balint groups to
better support nurses caring for women experiencing early preg-
nancy loss are recommended. Nurses must be supported in their
emotion work by health institutions, to continue to provide safe
and compassionate care for women at this vulnerable time in their
lives.
Ethical statement
The submitted manuscript does involve human research. Ethi-
cal approval was granted by the hospital Human Research Ethics
Committee (GEKO ID 26862). The submitted manuscript does not
involve animal research.
Conflict of interest
None.
CRediT authorship contribution statement
Georgia Griffin: Methodology, Investigation, Formal analysis,
Data curation, Writing - original draft. Margaret Ngulube: Inves-
tigation, Formal analysis, Writing - original draft. Victoria Farrell:
Conceptualization, Methodology, Formal analysis, Writing - review
& editing. Yvonne L. Hauck: Supervision, Resources, Formal anal-
ysis, Writing - review & editing.
Acknowledgements
We would like to thank the nurses for graciously sharing their
experiences. The authors have no funding to disclose. This work was
G Model
COLEGN-739; No. of Pages 7 ARTICLE IN PRESS
G. Griffin et al. / Collegian xxx (2020) xxx–xxx
supported and funded by King Edward Memorial Hospital. There
was no external funding for this study.
References
Abeni, M. S., Magni, M., Conte, M., Mangiacavalli, S., Pochintesta, L., Vicenzi, G.,
et al. (2014). Psychological care of caregivers, nurses and physicians: A study of
a new approach. Cancer Medicine, 3(1), 101–110. http://dx.doi.org/10.1002/
cam4.163
Ammon Avalos, L., Galindo, C., & Li, D. (2012). A systematic review to calculate
background miscarriage rates using life table analysis. Birth Defects Research
Part A: Clinical and Molecular Teratology, 94(6), 417–423. http://dx.doi.org/10.
1002/bdra.23014
Bellhouse, C., Temple-Smith, M., Watson, S., & Bilardi, J. (2019). “The loss was
traumatic. . .some healthcare providers added to that”: Women’s experiences
of miscarriage. Women and Birth, 32(2), 137–146. http://dx.doi.org/10.1016/j.
wombi.2018.06.006
Bolton, S. C. (2000). Who cares? Offering emotion work as a ‘gift’ in the nursing
labour process. Journal of Advanced Nursing, 32(3), 580–586. http://dx.doi.org/
10.1046/j.1365-2648.2000.01516.x
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative
Research in Psychology, 3(2), 77–101. http://dx.doi.org/10.1191/
1478088706qp063oa
Cesario, S., Morin, K., & Santa-Donato, A. (2002). Evaluating the level of evidence of
qualitative research. Journal of Obstetric, Gynecologic & Neonatal Nursing, 31,
708–714. http://dx.doi.org/10.1177/0884217502239216
Cresswell, J. W., & Plano Clark, V. L. (2011). Designing and conducting mixed methods
research (2nd edn). Thousand Oaks, CA: Sage.
Delgado, C., Upton, D., Ranse, K., Furness, T., & Foster, K. (2017). Nurses’ resilience
and the emotional labour of nursing work: An integrative review of empirical
literature. International Journal of Nursing Studies, 70, 71–88. http://dx.doi.org/
10.1016/j.ijnurstu.2017.02.008
Due, C., Obst, K., Riggs, D. W., & Collins, C. (2018). Australian heterosexual women’s
experiences of healthcare provision following a pregnancy loss. Women and
Birth, 31(4), 331–338. http://dx.doi.org/10.1016/j.womb.2017.11.002
Edwards, S., Birks, M., Chapman, Y., & Yates, K. (2018). Bringing together the
‘Threads of Care’ in possible miscarriage for women, their partners and nurses
in non-metropolitan EDs. Collegian, 25(3), 293–301. http://dx.doi.org/10.1016/
j.colegn.2017.09.004
Evans, L., Lloyd, D., Considine, R., & Hancock, L. (2002). Contrasting views of staff
and patients regarding psychosocial care for Australian women who miscarry:
A hospital-based study. Australian and New Zealand Journal of Obstetrics and
Gynaecology, 42(2), 155–160. http://dx.doi.org/10.1111/j.0004-8666.2002.
00155.x
Farren, J., Mitchell-Jones, N., Verbakel, J. Y., Timmerman, D., Jalmbrant, M., &
Bourne, T. (2018). The psychological impact of early pregnancy loss. Human
Reproduction Update, 24(6), 731–749. http://dx.doi.org/10.1093/humupd/
dmy025
Gergett, B., & Gillen, P. (2014). Early pregnancy loss: Perceptions of healthcare
professionals. Evidence Based Midwifery, 12, 29–34. Retrieved from http://rcm.
redactive.co.uk/ebm/volume-12-2014/volume-12-issue-1/early-pregnancy-
loss-perceptions-of-healthcare-professionals/
Green, A., Searle, E., Hannah, L., & Robertson, M. (2017). How to make Balint groups
relevant for mental health nurses. Mental Health Practice, 21(2), 18–21. http://
dx.doi.org/10.7748/mhp.2017.e1202
Hochschild, A. R. (2003). The managed heart: Commercialization of human feeling.
USA: University of California Press.
Please cite this article in press as: Griffin, G., et al. Caring for women through early pregnancy loss: Exploring nurses’ experiences of
care. Collegian (2020),
Downloaded https://doi.org/10.1016/j.colegn.2020.08.011
for Anonymous User (n/a) at National Library of Indonesia from ClinicalKey.com/nursing by Elsevier on April
07, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
7
Korstjens, I., & Moser, A. (2018). Series: Practical guidance to qualitative research.
Part 4: Trustworthiness and publishing. European Journal of General Practice,
24(1), 120–124. http://dx.doi.org/10.1080/13814788.2017.1375092
McCreight, B. S. (2005). Perinatal grief and emotional labour: A study of nurses’
experiences in gynae wards. International Journal of Nursing Studies, 42(4),
439–448. http://dx.doi.org/10.1016/j.ijnurstu.2004.07.004
Murphy, F., & Merrell, J. (2009). Negotiating the transition: Caring for women
through the experience of early miscarriage. Journal of Clinical Nursing, 18,
1583–1591. http://dx.doi.org/10.1111/j.1365-2702.2008.02701.x
Neergaard, M., Olesen, F., Andersen, R., & Sondergaard, J. (2009). Qualitative
description – the poor cousin of health research? BMC Medical Research
Methodology, 9, 52–56. http://dx.doi.org/10.1186/1471-2288-9-52
Parker, S. D., & Leggett, A. (2012). Teaching the clinical encounter in psychiatry: A
trial of Balint groups for medical students. Australasian Psychiatry, 20(4),
343–347. http://dx.doi.org/10.1177/1039856212447965
Parker, S. D., & Leggett, A. (2014). Reflecting on our practice: An evaluation of
Balint groups for medical students in psychiatry. Australasian Psychiatry, 22(2),
190–194. http://dx.doi.org/10.1177/1039856213517946
Polit, D., & Beck, C. (2014). Essentials of nursing research (8th edn). Sydney:
Lippincott Williams & Wilkins.
Queensland Clinical Guidelines. (2018). Early pregnancy loss. Queensland Health.
Document number MN17.29-V5-R22, 1–39. Retrieved from https://www.health.
qld.gov.au/ data/assets/pdf file/0033/139947/g-epl.pdf
Rabinowitz, S., Kushnir, T., & Ribak, J. (1996). Preventing burnout: Increasing
professional self efficacy in primary care nurses in a Balint group. American
Association of Occupational Health Nurses Journal, 44(1), 28–32. Retrieved from
https://search-proquest-com.kelibresources.health.wa.gov.au/docview/
1012767215?accountid=38630
Radford, E. J., & Hughes, M. (2015). Women’s experiences of early miscarriage:
Implications of nursing care. Journal of Clinical Nursing, 24, 1457–1465. http://
dx.doi.org/10.1111/jocn.12781
Riley, R., & Weiss, M. C. (2016). A qualitative thematic review: Emotional labour in
healthcare settings. Journal of Advanced Nursing, 72(1), 6–17. http://dx.doi.org/
10.1111/jan.12738
Sandelowski, M. (2000). Whatever happened to qualitative description? Research
in Nursing and Health, 23, 224–240. http://dx.doi.org/10.1002/nur.20362
Sawbridge, Y., & Hewison, A. (2013). Thinking about emotional labour of nursing –
supporting nurses to care. Journal of Health Organization and Management
Information, 27(1), 127–133. http://dx.doi.org/10.1108/14777261311311834
Stratton, K., & Lloyd, L. (2008). Hospital-based interventions at and following
miscarriage: Literature to inform a research-practice initiative. Australian and
New Zealand Journal of Obstetrics and Gynaecology, 48, 5–11. http://dx.doi.org/
10.1111/j.1479-828X.2007.00806.x
Sullivan, L. E. (Ed.). (2009). The SAGE glossary of the social and behavioural sciences.
USA: SAGE Publications.
Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic
analysis: Implications for conducting a qualitative descriptive study. Nursing
and Health Sciences, 15, 398–405. http://dx.doi.org/10.1111/nhs.12048
Willis, D. G., Sullivan-Bolyai, S., Knafl, K., & Cohen, M. Z. (2016). Distinguishing
features and similarities between descriptive phenomenological and
qualitative description research. Western Journal of Nursing Research, 38(9),
1185–1204. http://dx.doi.org/10.1177/0193945916645499
Yazdankhahfard, M., Haghani, F., & Omid, A. (2019). The Balint group and its
application in medical education: A systematic review. Journal of Education and
Health Promotion, 8(124), 1–7. http://dx.doi.org/10.4103/jehp.jehp 423 18