Little research has been done on secondary traumatic stress in nurses, especially in perinatal nurses, and even less has been studied on the best methods to prepare nurses in their education on how to provide trauma-informed care. Secondary traumatic stress is defined as "the natural consequent behaviors and emotions resulting from knowledge about a traumatized event experienced by a significant other. This stress results from helping or wanting to help a traumatized or suffering person" (Figley, 1995, p. 10). Trauma-informed care is defined as "a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors" (Hopper, Bassuk, & Olivet, 2010, p. 82).

Simwaka et al. (2014) identified the importance of nurses being able to provide adequate emotional support for women who experience a perinatal loss. However, there is a significant gap in the literature on how to prepare nurses for that practice (Meisenhelder & Gibson, 2015). As nursing students are rarely exposed to parents undergoing an unexpected perinatal loss in their clinical practicum experiences, it is important to evaluate educational strategies to prepare nursing students for such care.

Raising students' awareness of secondary traumatic stress as related to perinatal loss will encourage supportive self-care and care of colleagues during these trying times. In a mixed-methods study, Beck and Gable (2012) identified that 35 percent of labor and delivery nurses experience at least a moderate level of elevated secondary traumatic stress symptoms. Similarly, in a mixed-methods convergent parallel design study, Beck, Cusson, and Gable (2017) identified that 49 percent of neonatal intensive care nurses scored moderate to severe secondary traumatic stress levels. Simulation and interprofessional education serve as excellent options for students to get exposed to these experiences while also receiving support on how to cope with them.

The Institute of Medicine (2011) has called for radical transformation to include more interprofessional education in preparation of health care practitioners. The only simulation and debriefing activity to prepare nursing students for unanticipated perinatal outcome care was published by Knight, Dailey, and Currie (2015), who reported anecdotal results of valuable learning while conducting no formal evaluation of the activity. Knight et al. noted that students were emotionally distressed as the learning activity may have triggered memories of personal or family losses.

This study proposed to provide and evaluate the effectiveness of a similar learning activity for unanticipated perinatal grief topics with a larger group of students. The study used simulation resources and involved experts available to the faculty in addition to a mother who had experienced an intrauterine fetal demise. Knowing that it would be emotionally draining for the mother and panel to recount their experiences, the investigators chose to use prerecorded simulations and expert panel debriefing methods in addition to a formalized evaluation and the provision of emotional support for students as recommended by Knight et al.

METHOD

Sample and Setting

The proposal for this parallel-convergent mixed-methods study was approved by the university's institutional review board prior to conducting the learning activity and study. In preparation for the learning activity, four simulations were created and recorded by the research team of faculty with perinatal and simulation specialty expertise. The simulations of four scenarios on unanticipated perinatal outcome cases demonstrated initial treatment and communication skills for patients and families experiencing a threatened abortion (miscarriage), preterm labor, and intrauterine fetal demise, as well as a perinatal nurse experiencing symptoms of secondary traumatic stress. An interprofessional panel was invited to the campus for the learning activity; the panel included a chaplain, a social worker, an obstetrical RN, a mental health nurse, and a mother who experienced an intrauterine fetal demise. Study personnel not involved in the class (teaching or grading) explained the study to the students.

Students (n = 54) were informed that, based on previous research, this learning activity might elicit emotional responses and that if they felt they needed to leave the room, a nurse would be available to provide support. A member of the research team who was not the class professor distributed and collected the survey from each student. Surveys were sealed and analyzed after the course was completed, and participation did not impact the students' grades.

Nursing students were in a baccalaureate program at a large university in the northeast United States. The sample was largely female (88.9 percent), ranging from 20 to 24 years old. Participants were 77.8 percent white, 7.4 percent black, 11.2 percent Hispanic, and 3.8 percent Asian.

Instruments and Debriefing

A 10-question survey was developed using multiple-choice questions and a Likert scale to assess the students' acquisition of content and communication knowledge and techniques, rate their degree of emotional response, evaluate fidelity and applicability to practice, and reflect on thoughts, feelings, and perceptions related to the learning activity. Questions were designed to give researchers insight into the students' experience with the prerecorded simulations, debriefing with the expert panel, emotional response, and provision of emotional support.

All students viewed all four simulations to instill discussion with the panel during debriefing. The interprofessional panel conducted an open-ended debriefing, and the mother on the panel shared her story of her personal loss of her daughter. As students asked questions in the debriefing, each member of the expert panel was able to share professional experiences with perinatal loss and offer suggestions for working with parents through these ordeals. Students were encouraged to ask questions, express their feelings and concerns, and ask for support as needed. Once debriefing was completed, students answered posttest questions to evaluate their acquisition of knowledge and communication techniques, applicability to practice, and fidelity of the simulation. Students also responded to open-ended statements describing their experience with this simulation related to their thoughts and feelings about unexpected fetal outcomes. Their responses were used for qualitative content analysis.

RESULTS

Quantitative Results

A Wilcoxon matched-pairs signed rank test was conducted to determine whether there was a difference in the acquisition of communication techniques preintervention and postintervention. There was a significant difference overall from pretest to posttest in how the students ranked their learning and acquisition of communication techniques (z = -6.005, p = .000). The results indicate that students reported they felt better prepared to communicate with patients who experienced an unexpected fetal demise gained knowledge of communication techniques through this simulation. Students identified that the simulations were realistic (94.3 percent), applicable to their practice (98.2 percent), and elicited strong emotional responses (71 percent) and that they felt emotionally supported (94.4 percent).

Future studies may consider evaluation of knowledge retention by repeating the posttest later in the semester or beyond. Although there was no assessment of long-term knowledge retention in this study, anecdotal information from course evaluations noted the learning activity was positive and memorable.

Qualitative Results

Three themes emerged from the content analysis of students' responses: 1) strong emotional response to the realistic scenarios, 2) personal stories shared by expert panel will help nursing students in future practice, and 3) students felt supported emotionally during the learning activity.

STRONG EMOTIONAL RESPONSE TO THE REALISTIC SCENARIOS

Students reported feeling very sad, nervous, and afraid to be "at a loss for words." One student stated, "I was blown away with how real it felt. There were points that I wanted to cry and I felt terrible for the family." The students recognized the transferability to other traumatic patient experiences when she shared, "I thought the simulations were realistic and provided insight as future nurses. I thought it was useful listening to what others said during the sim and thought about what I would have done."

PERSONAL STORIES SHARED BY EXPERT PANEL WILL HELP NURSING STUDENTS IN FUTURE PRACTICE

Students gained insight from the different perspectives and experiences that each panel member shared as this quote illustrates: "It was helpful to hear from a variety of different people on the panel. They all contributed different tips/techniques and thoughts about how to approach situations like these." Students felt that hearing personal stories added depth to the overall experience and would help them as a future nurse: "Listening to the personal account really made the scenario that much more real. I felt that I really could sympathize with the women and get a better understanding of what someone would be feeling or going through."

STUDENTS FELT SUPPORTED EMOTIONALLY DURING THE LEARNING ACTIVITY

Students wrote: "The panel was helpful in normalizing our intense feeling and reassuring ourselves in our ability to provide care, and enormous support from everyone in the room and from panel."

DISCUSSION

The interactive learning activity and panel debriefing were critical in making the scenarios real, giving students perspective, knowledge, and communication tools for use in their future practice. This study supports the need for the provision of such content on providing trauma-informed care and the recognition of secondary traumatic stress in practice for perinatal nurses (Beck & Gable, 2012; Beck et al., 2017). It answers the call by Decker et al. (2015) for providing realistic and applicable scenarios to promote nursing education. Significant results were identified for the acquisition of communication techniques, and the theme that personal stories will help nursing students in future practice emerged during the content analysis.

Besides the exemplar quotes presented, students found that they could take some key phrases that the experts suggested and incorporate them into practice. The mother who experienced a personal loss validated what nurses did that was helpful and what was not.

This research supports the use of this learning activity with nursing students and should be provided on a larger scale, potentially replicating this study in multiple sites with a larger sample. The activity has potential for use in the practice setting for new perinatal nurses who may not have had such content in their nursing education. The interprofessional nature of the learning activity models the collaborative team approach nursing students should expect to see in practice.

CONCLUSION

The sample of 54 nursing students demonstrated learning and acquisition of communication techniques (p = .000). Descriptive statistics demonstrate the simulations were realistic, applicable to their practice, and elicited strong emotional responses with participants feeling emotionally supported, filling the gap identified by Knight et al. (2015). Content analysis supported the quantitative results and found the personal stories of the expert panel to be applicable to practice, helping students gain strategies to incorporate into their practice. Evaluation of this innovative learning activity determined its applicability to academic settings, utilizing simulation and interprofessional resources so that learners can apply the knowledge and communication techniques into their caring behaviors while feeling supported to give such care and protecting themselves from secondary traumatic stress.

REFERENCES