Nurses' Awareness and Stress on Perinatal Bereavement Care


 Background: A descriptive study was conducted to examine nurses’ awareness and stress related to perinatal bereavement care (PBC), improving nurses’ capabilities related to PBC.Methods: 136 nurses who had experienced perinatal death at least once participated. Data were analyzed using descriptive statistics in SPSS version 25.0 for Windows. Nurses’ awareness was assessed in terms of three subdomains (attitudes, importance of policies related to PBC, and importance of training related to PBC). Results: The participants high scores for the attitude-related items of “giving sufficient time to bereaved parents to mourn for their dead baby” (4.54 points) and “nurses should treat bereaved parents with respect and dignity” (4.51 points), and they perceived a high level of importance for the policy-related items of “every staff member in the hospital should understand the policies relevant for PBC” and “when nurses feel emotional exhaustion, they should seek support” (4.58 points). Nurses’ stress was high when performing PBC in combination with a heavy workload (4.25 points) and when informing parents of a poor prognosis (4.25 points). Nurses’ attitude toward PBC was associated with the perceived importance of policies (r=0.40, p<.001), the perceived importance of PBC-related training (r=0.61, p<.001), and stress related to PBC (r=0.29, p<.001). Conclusions: Establishing hospital policies related to PBC and providing PBC training for nurses could positively affect nurses’ attitudes toward PBC. A stress management program for nurses could reduce the stress caused by PBC.


Background
The perinatal mortality rate, which is an index that re ects the public health and health status of mothers and newborns [1], was 3.5 per 1,000 total births in 2009 (total number, 1,546) and 2.8 per 1,000 total births in 2018 in South Korea (total number, 904), but the rate increases as mothers become older [2]. Although several de nitions are used for perinatal death based on the time of fetal death and postnatal death, the most common de nition includes deaths at more than 20 weeks of gestation and death within 28 days of birth [3].
Nurses are the closest caregivers to parents who experience perinatal death and are perceived as the most helpful medical staff [4]. Nurses' perceptions of caring activities related to perinatal death are related to their attitudes and education, as well as institutional policies [5]. That is, if a nurse has negative attitudes (e.g., fear and frustration) when treating a family who has suffered the death of a baby, it can result in a negative attitude toward the performance of care [6]. In contrast, knowledge and expertise with interventions related to parental mourning counseling can improve empathy and comprehension, helping to foster a positive nursing attitude that is helpful when performing actual nursing activities [5]. Nurses are also in uenced by the existence of policies and protocols related to death and nursing in the workplace [7]. Maintaining high-quality policies could help to build a mourning culture to support parents' and family members' experiences of bereavement [8]. In addition, when a baby dies in the hospital, nurses experience extreme stress when providing support for the parents or family [9][10][11]. Nurses feel guilty under these circumstances [12], and persistent stress in nurses associated with perinatal death could negatively affect their perceptions of caring for patients affected perinatal death [13].
Several studies on nurses' attitudes, perceptions, and stress related to perinatal bereavement care (PBC) have been conducted [10,[14][15][16], but no studies have investigated this topic in Korea. Therefore, this study examined nurses' awareness and stress related to PBC. These parameters were hypothesized to be correlated. This study therefore aimed to provide basic data for improving nurses' capabilities related to PBC.
De nition of terminology 1) Perinatal death has been de ned as an involuntary loss of pregnancy due to stillbirth (more than 20 weeks), or the death of a newborn within 28 days after delivery [17,18].

Research Design
This descriptive correlational research was conducted to identify nurses' awareness and stress related to PBC and to examine their relationships.

Research Participants
The participants of this study were nurses working at general hospitals in departments that deal with perinatal death. Participants were recruited through convenience sampling. The inclusion criteria were as follows: nurses working in the obstetrics and pediatric nursing units who had experienced at least one case of perinatal death. Nurses with less than 1 year of experience were excluded because perinatal bereavement was expected to be an infrequent experience. The sample size was calculated using G*Power version 3.10, with a signi cance level of 0.05, power of 0.90, and a moderate effect size of 0.3. The required number of samples was determined to be 109. The questionnaire was distributed to a total of 150 nurses, considering a possible dropout rate of 20%, and 148 participants participated in the study. Twelve responses were incomplete, so 136 questionnaires were ultimately analyzed.

Research Tools
Nurses' Awareness of PBC After translation, the tool developed by Chan et al. [5] (Nurses' Attitudes towards Perinatal Bereavement Support; NAPBS) was used in this study (supplementary le 1). This self-reporting tool contains a total of 25 questions that respondents answer on a 5-point Likert score, ranging from "I do not agree at all" to "I strongly agree." This tool consists of three subdomains: attitude (13 items), importance of policies related to PBC (4 items), and importance of training related to PBC (8 items). Higher scores correspond to more positive attitudes toward PBC or a greater recognition of the importance of policies or training related to PBC. Chan et al. [5] reported that Cronbach's α was .92 for the total items, and .86, .83, .90. for the three subdomains of attitude, importance of policies, and importance of training, respectively. In the current study, Cronbach's α was .87 for the total items, and .73, .67, and .90. for the three subdomains, respectively.

Nurses' Stress Related to PBC
The tool developed by Jang was used in this study after revision (supplementary le 2) [19]. This tool is composed of 29 questions in four domains, consisting of 6 items on di culties in providing care for patients affected by perinatal death, 5 items on lack of knowledge, 10 items on inadequacies of the environment and systems for handling perinatal death, and 8 items on psychological di culties. The items in this tool are answered using a 5-point Likert score from "I do not agree at all (1 point)" to "I strongly agree (5 points)," with higher scores indicating high levels of stress. For all items, Jang [19] reported that Cronbach's α was .87, while in the current study, Cronbach's α was .89.

General Characteristics
The questionnaires were developed in this study (supplementary le 3). Information was gathered on participants' demographic characteristics, including their level of education, whether they were religious, and their marital status. Additionally, information was collected on their personal experiences, such as their workplace, total career experience and experience at their current workplace, personal bereavement experience, and experiences of PBC. They were also asked about whether they had received training on PBC. These factors were hypothesized to be associated with nurses' perceptions and stress related to PBC.

Research Procedures
Author's Approval for Use of the Research Tool The developer of the NAPBS tool, Moon-Fai Chan, approved its use in this study.

Forward Translation
The original tool was rst translated into Korean by a translation expert at the Language Education Center of OO University. The translation was then reviewed by three experts (one nurse who is a native speaker of Korean and uent in both Korean and English, as well as two maternity nursing professors). They determined whether there was any need for corrections due to the accuracy of the initial translation and cultural differences. The translation did not focus on translating individual words and their meanings into Korean; instead, the core concepts were emphasized [20], with the goal that the end product would not feel like a translated tool. As such, it was adjusted to t the socio-cultural situation and medical institutions in Korea Reverse Translation A written translation was again conducted (reverse translation) into English by the nurse. The reverse translator is uent in both Korean and English, and is a nurse currently working in the United States. The previous three experts who participated in the rst translation reviewed the equivalence between the reverse translation and the original version to nalize the translation.

Review of Expert Committee Members (content validity)
The content validity of the translated tool was examined by 10 nursing experts. The survey was conducted once from July 1 to July 15. 2019. The experts included one nursing professor, four head nurses with 10 years or more of experience in the delivery room or neonatal intensive care unit, and ve staff nurses with 7 years or more in the relevant departments mentioned above.
They were asked to assess the validity of each item as 1 point for "never valid," 2 points for "not valid," 3 points for "valid," and 4 points for "very valid." All 25 items had a content validity index of 0.8 or higher, and were selected for inclusion in the nal version.

Preliminary Study
Prior to study, the translated Korean version of the NAPBS was preliminarily tested among 10 nurses working at hospitals located in Seoul and Gyeonggi Province. Thereafter, the Korean version of the tool was nalized.

Data Collection
After receiving IRB approval from S University Hospital (IRB No. B-1908/561-305), data were collected from September 1 to September 31, 2019. After obtaining permission from o cials at seven general hospitals in Seoul and Gyeonggi-do, where the data were collected, potential participants received an explanation about the study purpose and procedures with a written protocol, and a questionnaire was distributed to nurses who voluntarily chose to participate. The participants provided written informed consent, and the collected data were encrypted and processed in a way that respected the con dentiality of the participants.

Data analysis
Data were analyzed using SPSS for Windows version 25.0 (IBM Corp., Armonk, NY, USA). The speci c analytical methods were as follows.
1. General characteristics and the main variables of the study were analyzed using descriptive statistics (mean, standard deviation, frequency, and percentage).
2. Nurses' awareness (attitude, importance of policies, and importance of training related to PBC) and PBC-related stress according to their general characteristics were analyzed using the independent t-test and one-way analysis of variance. If necessary, the Scheffé test was conducted as a post hoc test.
3. The relationships among the three subdomains of awareness and stress were analyzed by Pearson correlation coe cients. All tests used a signi cance level of 0.05.

Results
General Characteristics of the Participants  Speci cally, the highest scores were reported for "It is important to nd support when feeling emotional exhaustion" (4.58 points), "I think we need enough time for bereaved parents to mourn" (4.54 points), and "I will treat bereaved parents with respect and dignity" (4.51 points) ( Table 2).

M mean, SD Standard deviation
Regarding the nurses' stress, the overall average score was 112.16 (± 13.46) points. The items with the highest scores were "caring for a dying newborn along with a heavy workload" (4.25 points) and "telling parents that their neonate has a poor prognosis" (4.25 points) ( Table 3). However, no factor showed a signi cant relationship with nurses' PBC-related stress (Table 4).

Relationships between Nurses' Awareness and Stress Related to PBC
The three subdomains of PBC awareness were all correlated with each other (r = 0.29-0.61).
Nurses' stress related to PBC was correlated with their attitude toward PBC (r = 0.29, p < .001) and their perceived importance of training on PBC (r = 0.38, p < .001) ( Table 5).

Discussion
Since 91.2% of nurses-the overwhelming majority of the participants in this study-had not received training on bereavement care, it is urgently necessary to address nurses' educational needs related to PBC.
Regarding nurses' awareness of PBC, each of the three subdomains can be considered separately. First, regarding attitudes toward PBC, nurses showed a positive attitude toward giving the parents su cient time for the bereavement process, but they seemed to hesitate and worry about showing the dying baby to the parents. This is similar to the nding of a previous study [21] that nurses felt con icted about whether to accept or reject parents' request to see their dead baby. However, in a systematic review, Kingdon et al. [22] reported that showing parents their dead baby and giving them the chance to hold the baby could help in the parents' bereavement process. No guideline or protocol currently exists regarding whether parents can view or photograph their dead baby in Korea; therefore, culturally-speci c conversations among health professionals are needed to address this issue. Regarding policies, nurses showed a high level of recognition of the importance of all staff members understanding policies related to PBC, which supports the ndings of Chan et al. [23]. Third, in relation to awareness of training, nurses placed the highest importance on seeking support when they were emotionally exhausted. This nding is similar to the results of a previous study [24], in which nurses working in the neonatal intensive care unit sought social support as their coping mechanism. Furthermore, this supports the result that nurses had the strongest demand regarding stress and exhaustion among the palliative nursing education needs [25].
In regard to nurses' stress related to PBC, the ndings of high levels of stress when informing parents of a poor prognosis and coping with PBC in combination with a heavy workload are consistent with those of previous studies on nurses caring for dying adults [26][27][28], and neonates in the neonatal intensive care unit [19]. Therefore, administrative efforts are needed in the hospital setting to improve the e ciency of the distribution of nurses' workload and to provide spaces for parents to mourn when perinatal death occurs.
Regarding the relationships of general characteristics to nurses' awareness, it was found that previous training on PBC was related to a positive attitude toward PBC, consistent with the ndings of Chan et al. [5], which emphasizes the importance of nurse training on PBC. Nurses were more aware of the importance of policies when their departments had a clear policy about bereavement care, which is similar to the nding of Wi and Kang [29], indicating that policies or protocols should be established to improve nurses' recognition and performance of bereavement care. In this study, there was an unclear relationship between the frequency of PBC and the perceived importance of training for PBC. A possible interpretation may be that as nurses came to have more experiences of PBC, they perceived PBC training as more important or valuable or became increasingly aware of the di culties and their lack of con dence regarding PBC. Further research is needed to con rm the relationships of nursing con dence and perceived di culties with the number of PBC experiences.
The three domains of nurses' awareness of PBC-attitude, importance of policies, and importance of training-were found to be closely related. Therefore, positive effects on the performance of PBC may occur as a result of supporting nurses' attitude and related policies and providing training or education on PBC. In addition, it appears that nurses performing PBC are vulnerable to high levels of psychological stress due to their busy workload, regardless of whether they have a positive attitude towards PBC. Medical institutions and hospitals should therefore establish clear policies and nurse support programs related to PBC. Since nursing care is continued after discharge for patients who experience perinatal death, further research on nurses working in the community setting is recommended.
The limitations of this study are as follows. First, participants were selected using convenience sampling, which could interfere with the generalizability of the results to all nurses, especially since variations exist in hospital policies, departmental characteristics, and patient severity. Moreover, the Korean version of the NAPBS used in this study was translated and used for the rst time. Based on qualitative research into Korean nurses' awareness of PBC, the domains of the tool will be reexamined, and possibly reconstructed, in the future.

Conclusions
Nurses' awareness of PBC was higher if they had received training on perinatal death and if relevant policies had been clearly established at their workplace. More positive attitudes toward PBC were associated with higher stress. Therefore, clear policies for PBC should be implemented, and relevant education programs for nurses should be developed. In order to reduce nurses' stress related to perinatal death, institutional efforts are necessary to prevent nurses from becoming exhausted and to support nurses in the PBC.