How to Break Bad News to Pregnant Women Regarding the Viability of Their Fetus - Research Paper Example

? An observational study of the techniques used by health professionals when breaking bad news to pregnant women regarding the viability of their fetus. Question 1. (498 words) Which research methodology would be most suited to this research question? Justify your response. Research technically involves fact finding, analysis and evaluation. The main objective of any research is to gain new insights about an observable fact. Two basic methodologies are applied while researching a topic, namely, quantitative and qualitative approach. Quantitative research is based on estimating quantities as it is a deductive process which is used to test pre-specified concepts [Oak Ridge Associated Universities, ORAU(a)]. It is applicable to phenomena that are expressed as numbers or values. On the other hand, qualitative research primarily is an inductive process that is used to formulate a theory. In other words, quantitative data enumerates, therefore, involves numbers, while qualitative data explains and, therefore, involves words (Barnes et al., 2005). Qualitative methods can explain the reasons for human behaviour e.g., what people feel, how they think or do certain things but they do not indicate how many feel or think that way [ORAU(b)]. Since the results of qualitative research are considered as themes, they are not reported as percentages, or subjected to statistical analysis. To conduct a study of the techniques used by health professionals when breaking bad news to pregnant women regarding the viability of their fetus, qualitative methods are appropriate. As the topic is one that is difficult to convey quantitatively, qualitative methods would help gain adequate description or information. Also, qualitative methodology will help produce a meaningful report rich with detail and insights into participant health professionals’ experiences. Communicating bad news to patients is an inevitable task that all physicians face often in their clinical practice. Medical schools seldom provide them formal training in that area (Vandekieft, 2001). Informing patients about an unfavourable prenatal diagnosis is a growing challenge to health professionals given the increasing number of tests that are performed to determine the condition of the fetus (Guerra et al., 2011). In such cases as when a pregnant woman's ultrasound verifies some fetal abnormality or even fetal death, how the patient responds to the information would be influenced by her psychosocial context, such as how desperately she and/or her partner wanted the baby. Therefore, a common concern of the physician which makes breaking the news difficult is how the news will affect the patient. How the patients receive and deal with the news also depend on how the news is communicated to them (Guerra et al., 2011). If the task is to inform a pregnant woman about a fetal abnormality, some patients may desire full disclosure while some may not. Hence, the physician will have to individualise the manner of breaking the bad news as well as the information delivered, suited to the patient's desires or needs (Vandekieft, 2001). A qualitative research on the topic will help gain in-depth knowledge of aspects such as the physicians’ preferred settings for conveying the bad news, would better communication skills help, and how to offer hope and encouragement about what options are available etc. The underlying motives that ultimately direct the health professional’s way of communicating bad news are better understood by qualitative research. Question 2 (1108 words - excluding references) Provide an annotated bibliography of five published journal articles that you could use in a literature review for this project. Include the full references for each paper using APA Style. 1. Guerra FAR, Mirlesse V. & Baiao AER., 2011. Breaking bad news during prenatal care: a challenge to be tackled. Ciencia & SaudeColetiva, 16(5): 2361- 2367. The paper discusses how the now routine practice of ultrasound examination during prenatal stage has led to an increasing number of fetal malformations being detected which puts the health professionals in a quandary about how’s and where’s of revealing the same to the patient. The authors say that in fetal medicine bad news is frequent but communication of bad news does not form a part of medical school training. Based on their observations at a tertiary referral hospital for high risk pregnancies in Rio de Janeiro, the authors report that identifying the “emotional demands and cultural values attributed to motherhood by the woman can help the physician in this difficult task of helping her find ways to proceed with the pregnancy or even to interrupt it when possible.” The way in which such news is broken is important since patients generally continue to have bad memories of such news received by them on account of the insensitivity of the physician who communicated it to them. Therefore, the manner of conveying bad news should follow the principles of beneficence and non-maleficence. Furthermore, the physician because of his priviledged knowledge is in a position to give the necessary emotional support to the woman following the diagnosis. The authors are also of the view that despite a majority of pregnancies being normal, the physician should always be prepared to detect and to convey bad news since the production of the image and the discussion of it have to happen almost simultaneously. In contrast to laboratory test results, not much time is available to the physician/sonographer to add medical information before the revelation. According to the authors, conveying bad news over the telephone is to be avoided at all cost, and a personal face-to-face discussion is necessary. The presence of a companion or two can help both the patient and the physician. The authors conclude by saying that breaking bad news is a challenge to the creativity of the physician in the “true art of medicine”. 2. Lalor JG, Devane D & Begley CM., 2007. Unexpected diagnosis of fetal abnormality: women's encounters with caregivers. Birth, 34(1):80-88. This paper has investigated the experiences of women upon meeting caregivers following the diagnosis of fetal anomaly at the routine second trimester ultrasound scan. The study was conducted on a purposive sample of 38 women at low risk of fetal abnormality in Ireland and who eventually were diagnosed with a fetal abnormality in a tertiary referral centre. The women were subjected to an in-depth interview within 4-6 weeks of the diagnosis. The women's encounters with their physicians yielded outcomes such as information sharing, getting expert opinion, an explanation of the anomaly, availability of written information, and continued service of the caregiver. The study also found that the women desired to have more information and prompt referral to the fetal medicine specialist for confirmation of the diagnosis, following the diagnosis of a possible anomaly. It was observed that continuance of the same caregiver and empathy from staff were much valued by the patients. The authors’ conclusion from their study is that the technique of communicating unfavourable fetal diagnosis to pregnant women is very important and has a lot of scope for improvement. Their suggestion is that health professionals should be specifically trained to break bad news sensitively to a vulnerable population. 3. Menezes MA., 2010. Life on the front line: exploring personal and professional impacts on healthcare professionals working with fetal anomaly. Ph D Thesis, The University of Melbourne. Web. 15 September 2011. The numerous antenatal screening and diagnostic tests currently available for pregnant women are capable of revealing information about the fetus, and identifying potential anomalies at the prenatal stage. Exploring the interface between prenatal testing technology and society, some studies have tried to investigate the impact of a diagnosis of a fetal anomaly in pregnancy in women. Given the paucity of information on the experiences of healthcare professionals working in a similar setting – of conducting prenatal tests and providing emotional support to the patients diagnosed with fetal anomaly-- the author has tried to find out if working with fetal anomaly has an impact on healthcare professionals and to identify supports used and/or needed, if any. Using a qualitative approach, the author conducted in-depth interviews on 40 healthcare professionals (11 physicians and 29 allied health professionals) working in fetal medicine settings in Melbourne. The study revealed that working with fetal anomaly had a significant personal and professional impact on the participants. As disclosed by the participants, the impact was greater when they were pregnant themselves. The phenomena of ‘burnout’ and compassion fatigue was evident in the participants. They, however, could not ask for, or appear to need support, in order not to seem vulnerable. Yet the participants generally found their job to be fulfilling. 4. Vandekieft GK., 2001. Breaking bad news. Am Fam Physician, 64(12):1975-1979. This paper presents a detailed discussion of issues pertaining to breaking bad news by physicians in clinical practice. It explains in detail the reasons that make breaking bad news very difficult for the physician. The author provides general guidelines that could serve as the basis for delivering bad news most compassionately and effectively. The points mentioned are advance preparation, building a therapeutic relationship with the patient, good communication skills, dealing with patient and family reactions, and encouraging and validating emotions. 5. Van der Zalm JE & Byrne PJ., 2006. Seeing baby: women's experience of prenatal ultrasound examination and unexpected fetal diagnosis Journal of Perinatology 26: 403–408. doi:10.1038/sj.jp.7211540 This investigation describes the perceptions of women undergoing a routine prenatal ultrasound scan and their experience of receiving an unexpected fetal diagnosis. Thirteen women were recruited to this study to form a convenience sample. The women indicated that they were alert to verbal and nonverbal expressions from health care professionals about what was seen on the US screen and sensed information through the verbal and nonverbal communication cues in the room. They admitted to being disconcerted by the silence of the ultrasound examiner. According to the authors, for an ultrasound examination to be satisfactory to the patient and also to build up a good patient-examiner rapport, “the examiner must (1) speak directly to the woman being examined; (2) have eye contact with the woman being examined; (3) ensure the woman is physically comfortable during the examination; (4) respond to questions openly and honestly; (5) provide face-to-face interpretation of the US process and results; (6) be sensitive to a woman's unspoken needs; and, (7) ensure a personal support person is available if requested”. It should however be borne in mind that although sonographers may be capable of providing a fetal diagnosis, current practices do not allow them to discuss the finding with the mother. Based on their findings from this study, the authors recommend that prenatal ultrasound examiners should be encouraged to prepare women for the probable but unlikely event of unexpected findings prior to beginning the examination. Patients should also be told what to expect during and after the ultrasound examination. It should also be made clear to them that the sonographer is unable to give results of the examination; and, that only a physician can make a diagnosis based on the ultrasound findings. Question 3 (269 words) What recruitment process would you recommend to obtain an appropriate sample? To conduct a proper qualitative research, a systematic selection or sampling of appropriate persons to be interviewed is necessary. The study on the techniques used by health professionals to break bad news to pregnant women regarding the status of fetus following examination, basically seeks to understand the topic from the perspective of the physicians (or sonographers) involved in such a task. The most common qualitative methods applicable here are (1) in-depth interviews which are optimal for eliciting the individual health professional’s personal history, perspective and experiences regarding the techniques they prefer to use to accomplish the task most satisfactorily, and (2) focus groups which are helpful in obtaining data on the cultural norms of a group of health professionals that is engaged in the task being researched. Recruitment strategy for this study will essentially involve deliberate sampling that is, purposive or non-probability sampling. The sample unit will be determined by the characteristics of health professionals available for the study. For instance, health professionals generally having a busy schedule may not have the time for lengthy interviews. The number of people to be recruited will be flexible and subject to modification, also when new research questions or subpopulations that are important to the study emerge. Sampling will, therefore, continue until data saturation is attained that is, no new themes emerge from the data. Since the population is not homogeneous, and conducting research is a team effort, efforts will be made to involve a diverse group of health workers including indigenous or aboriginal health workers in the process of recruitment. Question 4 (360 words) What are the ethical considerations of the project? How would you best manage these? Ethical issues are involved in every kind of research. Ethics is mainly about doing good and avoiding harm to human participants of the research study (Orb et al., 2001). The appropriate ethical priniciple to follow during recruitment for the present qualitative study is to clearly explain the objectives of the project to potential study participants, that is, obtaining informed consent, is a must. Ethical review boards do exist to examine health related research proposals, yet it is the ultimate responsibility of the researcher to protect the participants. The well-established ethical principles include autonomy, beneficence and justice (Orb et al., 2001). However, ethical codes and guidelines may not address all the ethical issues that may crop up during the course of research. For example, a participant health professional having certain rigid religious beliefs might, during the course of interview, admit that he/she always avoids breaking the bad news of fetal abnormality to the mother at the prenatal stage, and allowing her to discover it after the baby is born and accept it as her misfortune (or even as an Act of God). In this situation, the researcher sees a definite unethical behaviour on the part of the health professional. A physician withholding bad news is actually interfering with patient autonomy since an honest disclosure of diagnosis and treatment options would allow the patient to make an informed healthcare decision that is consistent with her own values. However, Codes of Ethics do not stipulate how the researcher needs to respond to this. If the researcher includes this data in the report it may mean a violation of the ethical principle of justice, a crucial feature of which is avoiding exploitation and abuse of participants. On the other hand, by avoiding inclusion of this data the researcher would be demonstrating his/her “understanding and application of the principle of justice in qualitative research studies …..by recognising vulnerability of the participants and their contributions to the study” (Orb et al., 2001). When reporting such a case is beneficial in the view of the researcher, the names of people and places can be anonymised or fictionalised such that the principle of confidentiality is maintained while the principle of openness is upheld in all research dealings (McBride and Schostak, 2008) Question 5 (112 words) You are planning to apply for funding to undertake this project. Write a 100 word proposal to the funding body. As more and more sophisticated prenatal tests become routinely available, the number of fetal abnormalities detected could go up. The literature shows that physicians are both ill-prepared and unwilling to undertake the task of breaking the bad news about the viability of the fetus to the expectant mother. This is mainly because medical schools do not impart the necessary training for such a task. How the health professional conveys the news to the woman is important since it can make a lasting impact on the woman’s psyche. A project is proposed to be undertaken to understand the complexity of communication through a qualitative study of the techniques currently adopted by health professionals. References Barnes J, Conrad K, Demont-Heinrich C, et al., 2005. Generalizability and Transferability: Qualitative vs. Quantitative debate. Writing@CSU. Colorado State University. Web. 13 September 2011 McBride R & Schostak J., 2008. Chapter 3: Researching action and change. The Enquiry Learning Unit. Web. 14 September 2011. Oak Ridge Associated Universities, ORAU(a). Differences Between Qualitative and Quantitative Research Methods. Web. 13 September 2011. < http://www.orau.gov/cdcynergy/demo/content/activeinformation/tools/ toolscontent/soc_qual_quant_chart.htm> ORAU(b). Qualitative Research Methods. Web. 13 September 2011. Orb A, Eisenhauer L & Wynaden D., 2000. Ethics in qualitative research. Journal of Nursing Scholarship, 33(1): 93-96. Vandekieft GK., 2001. Breaking bad news. 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