Nurses’ physical and mental health require support after a traumatic event.
Editor’s note: This is an early release of a web exclusive article for the April 2021 issue of American Nurse Journal.
- Emergent obstetric events are frequent in the labor and delivery unit and can be traumatic for nurses.
- The stress of these events may progress to a level of grief that’s more powerful than a nurse’s current coping mechanisms.
- A debriefing protocol can help begin the healing process, which improves affected nurses’ physical and mental health.
Witnessing the miracle of life each day brings joy and passion to obstetric nurses, but maternal and infant complications or death can bring profound anguish. (See Maternal and infant complications.) When an emergent cesarean section is necessary, all available personnel on the labor and delivery (L&D) unit respond to prepare and transport the mother to the operating room for immediate delivery. Frequently, the infant is delivered within minutes and enters the world kicking and screaming. However, an infant who requires resuscitation may be admitted to the neonatal intensive care unit and with potential negative outcomes.
Other critical obstetric events include failed resuscitation of an infant born alive, an emergent maternal hysterectomy, or the death of a mother during or after delivery. Secondary traumatic stress Beck and Gable describe secondary traumatic stress (compassion fatigue) as a work hazard for L&D nurses. They found that after a traumatic incident, 63% of nurses experienced secondary traumatic stress and 25% met the criteria for post-traumatic stress disorder (PTSD). (See PTSD symptoms.) Secondary traumatic stress has many serious consequences and can progress to grief.
When an infant or maternal complication leads to death, not just the parents or spouse grieve. Anyone close to the loss can experience the stages of grief. Grief is an individualized reaction with unique emotions for each person. However, unhealthy grieving can lead to depression, mental exhaustion, and damage to family relationships and friendships. It also can result in nurses leaving the specialty. Beck and Gable assert that a grief debriefing strategy can help protect nurses from physical and mental exhaustion and reduce these negative effects.
Maternal and infant complications
Labor and delivery nurses may encounter a number of complications that can lead to secondary traumatic stress.
• According to Holmer and colleagues, approximately 15% of all pregnancies have obstetric complications.
• National Center for Health Statistics data indicate that approximately 6 out of 1,000 fetuses die between 28 weeks’ gestation and 7 days after birth.
• According to Aziz and colleagues, approximately 10% of newborns need help to begin breathing and 1% require advanced neonatal resuscitation.
According to Dismukes and Smith, post-event debriefing began in aviation over 40 years ago as part of flight crew training. Aviation instructors acted as moderators to help crew members analyze and assess their techniques and performance. Healthcare debriefing includes carefully reviewing the events surrounding an incident. Jaramillo and colleagues explain that although nurses know how to respond to critical clinical situations, they don’t learn the coping mechanisms needed to manage their emotions and stress response after these events. Unmanaged stress can interfere with care delivery, create safety concerns, and result in negative patient outcomes.
Speaking about the event can clear up misunderstandings and remove blame, and professional counseling can help staff feel stronger and begin healing. Ultimately, the freedom to express emotions openly provides opportunities to decompress and defuse tension.
Education about grief, including the symptoms of secondary traumatic stress and the role of debriefing, can help nurses navigate these events. In addition, guidelines should be available to ensure consistency in the debriefing process.
A charge nurse or supervisor can start preparing for a debriefing as soon as the situation begins to stabilize. A safe place, such as an empty nursery, call room, or patient room far from patients, can help ensure privacy. Participants should include the team members who worked together in the crisis.
Part of preparation can include formulating a plan to discuss team performance, identify areas that didn’t go well, and plan for improvement. Before the debriefing begins, the facilitator can explain its purpose (to help staff heal) and that each person’s grief may manifest differently. Some may cry; others may express feelings of denial, anger, or shock; and still others may be unable to move or think.
Gather the staff involved in the stressful event in an appropriate space, acknowledge what happened, and give everyone an opportunity to share how they’re feeling. Discuss what went well and what can be improved for next time. Close out the debriefing by summarizing the conversation and providing an opportunity for follow-up.
Throughout the crisis and in the weeks after, nurses should watch for severe stress symptoms in themselves and each other. If a peer shows signs of anxiety or emotional breakdown, nurses should notify their manager. Speaking directly with others who’ve experienced critical maternal events can provide empathy and understanding.
Foreman suggests creating a self-care packet as a resource that can be handed out to staff after a crisis. The packet can include information about the stages of grief, PTSD symptoms, and resources for local counseling services that specialize in secondary traumatic stress. Other self-care items in the packet could include poetry, a journal, creative coloring pages, relaxation techniques (such as breathing exercises), and healthy eating and activity choices, as well as advice on coping mechanisms to avoid (such as alcohol).
The patient and family’s primary nurse may require extra help. Foreman suggests giving the primary nurse a bereavement day as time to grieve and process what happened. To ensure the nurse feels supported, a peer who was involved in the event can call to check in
the next day and once a week for a month.
Nurses who experience secondary traumatic stress may encounter intrusion, avoidance, and arousal symptoms similar to post-traumatic stress disorder (PTSD).
• Distressing dreams
• Reliving the traumatic event
• Avoiding situations similar to the traumatic event
• Avoiding thoughts about the event
• Suppressing feelings about the event
• Exaggerated startle reflex
• Sleep disturbances
• Irritability or anger
• Difficulty concentrating
Source: Beck and Gable 2012
Coping skills and support
Working in L&D can be one of the most rewarding areas of nursing, but emergent events with poor outcomes can be traumatic. Obstetric nurses require strong coping skills and a good support system. An updated debriefing protocol and follow-up techniques will help
decrease secondary traumatic stress and improve nurses’ physical and mental health.
Ahken S, Peprah MK, Chen I, Wen SW, Black A. Cesarean sections for abnormal fetal heart tracings: Setting appropriateness indicators based on neonatal outcome. Obstet Gynecol. 2017;129(5):S145. doi:10.1097/01.AOG.0000514721.96759.98
Alliance for Innovation on Maternal Health. Support after a severe maternal event patient safety bundle. 2015. safehealthcareforeverywoman.org/aim/patient-safety-bundles/support-after-a-severe-maternal-event-patient-safety-bundle-aim
Aziz K, Lee HC, Escobedo MB, et al. Part 5: Neonatal resuscitation 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Pediatrics. 2021;147(suppl 1):e2020038505E. doi:10.1542/peds.2020-038505E
Beck CT, Gable RK. A mixed methods study of secondary traumatic stress in labor and delivery nurses. J Obstet Gynecol Neonatal Nurs. 2012;41(6):747-60. doi:10.1111/j.1552-6909.2012.01386.x
Clark SL, Hamilton EF, Garite TJ, Timmins A, Warrick PA, Smith S. The limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia. Am J Obstet Gynecol. 2017;216(2):163.e1-6. doi:10.1016/j.ajog.2016.10.009
Dismukes RK, Smith GM. Facilitation and Debriefing in Aviation Training and Operations. New London, England: Routledge; 2016.
Foreman S. Developing a process to support perinatal nurses after a critical event. Nurs Womens Health. 2014;18(1):61-5. doi:10.1111/1751-486X.12094
Gregory ECW, Drake P, Martin JA. Lack of change in perinatal mortality in the United States, 2014-2016. NCHS Data Brief. 2018;316:1-8.
Holmer H, Oyerinde K, Meara JG, Gillies R, Liljestrand J, Hagander L. The global met need for emergency obstetric care: A systematic review. BJOG. 2015;122(2):183-9. doi:10.1111/1471-0528.13230
Jaramillo K, Krenzischek DA, Anderson M, Baroya J, Thibeault J. Adverse event debriefing. J Perianesth Nurs. 2018;33(4):E39. doi:10.1016/j.jopan.2018.06.088
Montefiore, Albert Einstein College of Medicine. Communication for obstetric and perinatal events (COPE). safehealthcareforeverywoman.org/wp-content/uploads/3-Readiness-COPE-Communication-for-Obstetric-and-Perinatal-Events-Resource-Guide-Use-this-version-1.pdf
Pallas J. The acute incident response program: A framework guiding multidisciplinary responses to acutely traumatic or stress-inducing incidents in the ED setting. J Emerg Nurs. 2020;46(5):579-89. doi:10.1016/j.jen.2020.05.016
Rivera-Chiauzzi E, Lee C. Debriefing after adverse outcomes: An opportunity to improve quality and patient safety. Contemporary OB/GYN. January 27, 2016. contemporaryobgyn.net/view/debriefing-after-adverse-outcomes-opportunity-improve-quality-and-patient-safety
Thompson J, Olyaei A, Skeith A, Caughey A. 969: Cesarean prevalence rates overtime by maternal characteristics. Am J Obstet Gynecol. 2019;220(1):S624
Wienclaw RA. Grief and bereavement. Grief & Bereavement—Research Starters Sociology. 2016;3(1):1-7.
Amy LePard is a labor and delivery RN at Summa Health System in Akron, Ohio, and a faculty member at Kent State University, Geauga, Ohio.