Understanding Emergency Care For Miscarriage: A Qualitative Study

Study Purpose/Question

Did the study have a clear purpose/research question?

Yes/no – Yes

Explain – The researcher has clearly mentioned in the title as well as in the introduction that the purpose of this research was to understand how emergency care respond to the event of miscarriage and how such a response shapes the experiences of women who have had miscarriage (MacWilliams et al 2016, Pg 504-505, para 1).

Does it present relevant literature in relation to the problem/issue to be studied?

Yes/no – Yes

Explain – The researcher has reviewed relevant literature in the starting of the article. Researcher has defined the miscarriage, and then the researcher has given relevant statistics about it with proper reference. Researcher has further referred miscarriage to be a significant event in the life of a woman resulting in traumatic feelings while the emergency department focuses on just medical management of the event. Researcher has further referred that waiting times are long in the emergency department and the lack of empathetic attitude and supportive care has been reported in the relevant literature (MacWilliams et al 2016, Pg 504-505, para1-3).

Does it use a critical approach in reviewing relevant literature (ie: does it demonstrate comparing and contrasting of information)?

Yes/no – Yes

Explain – In the discussion section, the researcher has compared and contrasted the results of his study with other qualitative studies which explored the miscarriage experience among women. The researcher has discussed that other studies also report miscarriage experience among women as a loss of life or loss of their baby. It was a major setback for women and had severe consequences in their lives; but the health personnel were found insensitive to what women experienced; and even referred to the lost baby as “stuff”, “thing”, “tissue” and other such insensitive remarks. Thus the researcher found his study as very consistent with other qualitative studies conducted with similar research questions (MacWilliams et al 2016, Pg 509-510).

Does it identify any gaps in the literature?

Yes/no – Yes

Explain – The researcher have identified the gaps in the Introduction section, after reviewing the relevant literature. According to researcher, the literature provides clinical knowledge regarding physical diagnosis and treatment of women with miscarriage, but there are gaps regarding qualitative exploration of women’s experiences (MacWilliams et al 2016, Pg 505, para 1).

Does it provide a sound justification for doing the study?

Yes/no – Yes

Explain – In the Introduction section researcher told the gravity of the problem by giving data that 20 percent of pregnancies result in miscarriage. Researcher has then reviewed the relevant literature and identified gaps in literature. Thus the researcher justified that his study is aimed at addressing gaps in literature of a very important issue (MacWilliams et al 2016, Pg 504, para 1).

Background/Literature Review

Is there a statement regarding ethics approval?

Yes/no – Yes

Explain – The researcher has stated clearly in the starting of Methods section, that he has taken ethics approval from the health researcherity of the Halifax Regional Municipality in Nova Scotia, Canada (MacWilliams et al 2016, Pg 505, para 3).

Is there a statement regarding informed consent?

Yes/no – Yes

Explain – A letter was given to the eligible participants prior to the discharge by staff nurse or physician. The letter had clear information about the research. It was also mentioned that interviews of participants will be recorded and published, however their identity will be kept anonymous. The phone numbers and e-mail address were mentioned in the letter. Those who were interested called on the given numbers or wrote e-mails to participate in the study. Thus informed consent for participation in research was taken and the researcher has clearly mentioned this in the article (MacWilliams et al 2016, Pg 505, para 5-6).

What are the other relevant ethical issues addressed?

Explain – The identity of participants was kept anonymous. Pseudonyms were given to the participants to mask their identities. Second ethical issue was of beneficence. Community support resources were provided to the participants (MacWilliams et al 2016, Pg 506, para 2).

 List any other relevant ethical issues you think as important Explain – Another relevant ethical issue is to be empathetic and sensitive while interviewing participants (Henderson  & Mathew 2016).

 Explain why the above 4 ethical aspects are important

Explain – The above mentioned 4 ethical aspects are important for research because there are some moral and social obligations of researchers. First of all, researchers are obliged to respect the rights and dignity of participants. Second they should avoid imposing any risks or burdens on participant. Third they should research in a way to improve quality of medical/ healthcare. Finally they should research for the beneficence of society including participants. (Faden et al 2013).

What was the chosen methodology for this study?

Explain – The chosen methodology for this research is ‘interpretive phenomenology’ which is a form of qualitative research. The tools/ methods used were semi-structured face to face interview. The data was analysed using hermeneutics and thematic analysis. (MacWilliams et al 2016, Pg 504, Abstract)

Is this choice suitable for answering the research problem/question?

Yes/no – Yes

Explain – The choice of methodology is suitable for answering research question because the research involves detailed and in-depth analysis of women’s experiences during emergency care when they had miscarriage. Phenomenology is a philosophy which is based on how researchers make sense of the world and phenomena’s around them and how they bracket out the preconceptions regarding their understanding of that world/ phenomena (Bryman 2012). It involves; a series of common-sense constructs different from positivism, and stream of thoughts regarded as interpretivism. This methodology enables the researcher to grasp the subjective meanings of social actions (Bryman 2012).

Ethics

How were potential participants identified?

Explain – The participants were identified in emergency departments of two community hospitals and one tertiary care hospital in Nova Scotia, Canada. The eligible participants were 18 years or older English speaking women who underwent treatment in emergency department after suspecting miscarriage. The eligible participants were given a letter for their informed consent by staff nurse or general practitioners. The posters advertising the research were also pasted at suitable places in the department to attract the attention of participants. (MacWilliams et al 2016, Pg 505, para 4-6)

Were the targeted participants appropriate?

Yes/no – Yes

Explain – The targeted patients were appropriate as the study was intended to capture the experiences of women who underwent miscarriage and seek care in emergency department of hospitals. (MacWilliams et al 2016, Pg 504, para 1).

Were the participants adequately described?

Yes/no – Yes

Explain – The researcher has described the patients in detail including their age, background, parity, gestational age at the time of miscarriage, obstetrical histories, and also the time between loss and interview (MacWilliams et al 2016, Pg 505, para 6, table 1).

Outline the types of methods used to gather data (information) in this study:

Explain – The information was gathered using semi-structured face to face interviews. The duration of interview was 45-90 minutes. Interviews were audio recorded and were then transcribed verbatim (MacWilliams et al 2016, Pg 506, para 2).

Do these methods match the chosen methodology?

Yes/no – Yes

Explain – The semi-structured interviews of about one hour duration are apt for an interpretive phenomenology methodology. The semi-structured nature and long duration allows an in-depth understanding of the matter at hand which is required for interpretive phenomenology (Tuohy et al 2013).

Do the researchers adequately describe the setting in which the study took place?

Yes/no – Yes

Explain – The article has clearly described that setting was emergency departments of one tertiary care hospital and two community hospitals in Halifax regional municipality in Nova Scotia, Canada. (MacWilliams et al 2016, Pg 505, para 3).

Do the researchers identify any personal ideas, experiences or knowledge that might influence the study?

Yes/no – Yes

Explain why this is important. The researcher has identified his own personal ideas as well as personal ideas of participants. The personal ideas of researcher may induce a bias in the study as it appears from the tone of the study that researcher was already having a belief that health personnel at emergency care do not empathise with the women who underwent miscarriage. This belief got strengthened after talking to participants and knowing their personal ideas, experiences and knowledge. (MacWilliams et al 2016, Pg 509, last para).

Study Methodology

How was the data analysed in this study?

Explain – The data was analysed using interpretive phenomenology. It was a process of continuous interpretation, reflection and going back to data again and again. It also involved triangulation of data gathered from various sources. (MacWilliams et al 2016, Pg 506, para 3)

Is this the type of analysis one would expect for Qualitative Research?

Yes/no – Yes

Explain – The qualitative research involves in-depth analysis of qualitative data. There is generally a huge amount of data which requires frequent revisits while analysing. The data is generally collected from various primary as well as secondary sources; which should talk to each other and this is done by triangulation. Final analysis should have some depth as well as meaning in it. (Bryman 2012)

Did the researchers continue recruiting people to the study until data saturation was reached?

Yes/no – Yes

Explain – The researcher has mentioned that eight participants were selected after sampling. They were interviewed, data was collected and analysed. After analysis the data was found to be sufficient or in other words saturation of data was reached and so no new participants were recruited (MacWilliams et al 2016, Pg 506, para 1)

Did the researchers collect data from more than one source? If so, what were they?

Yes/no – Yes

Explain – The researchers collected data from 8 study participants where they recorded the interviews as well as took field notes for non-verbal cues. They also compared and contrasted the primary data with secondary data sources (MacWilliams et al 2016, Pg 506, para 2).

Did the researchers provide the participants with the opportunity to check the research findings?

Yes/no – Yes

Explain – The participants were followed-up through a telephone conversation to check the research findings (MacWilliams et al 2016, Pg 504, para 3, last line).

Explain how the above 3 points contribute to the trustworthiness of the overall research findings.

Explain – A qualitative research cannot be fully objective as being subjective is the hallmark of it. But to maintain rigour in qualitative research, the researchers should be reflective of it where they should reflect themselves on their results as well as ask their study participants to reflect on the results (Bengough & Hannes 2017).

What were the main findings of this study? (provide dot point summary from the article)

• Being pregnant meant life for women and miscarriage was experienced like a loss of life in the lives of these women.
• They opted to seek emergency care when they felt something wrong with their pregnancy.
• The healthcare personnel in emergency care did not perceive miscarriage as trauma.
• Women with miscarriage needed an acknowledgement of their loss as loss of life.
• After miscarriage, the world was not same for the women, and there was hopelessness.
• Women with miscarriage felt marginalised in emergency care.

(MacWilliams et al 2016, Pg 504, Abstract).

Are the research findings presented in a way that is consistent with qualitative research?

Participants

Yes/no – Yes

Explain – The qualitative research require narratives, quotes, own words of participants and detailed presentation of data; simultaneously making it coherent and driving meaning out of it. In this particular research paper, the research findings were presented in the same consistent way as required in a qualitative research (Dowling & Cooney 2012). 

What were the limitations of this study? (limitations identified by the researchers and students are both acceptable)

Explain – One limitation as identified by researcher was that the gap between emergency department visit and study was 1-2 years. As a student I further link it to recall bias which might be a limitation of study. Second limitation as identified by researcher was that sample was homogeneous and all 8 of them from similar socio-economic background. Third limitation as identified by researcher was that sample size was small i.e. of only 8 participants. (MacWilliams et al 2016, Pg 510, para 6-7).

 Explain why they are limitations of the study?

• Recall bias may emerge when the duration between interview and the actual event is too long. The respondent may not recall some of the events or may recall them in a way the interviewer wants them to recall. Here interviewers own personal bias may be introduced (Shields et al 2016).
• A homogenous sample will direct the research towards a particular view-point, ignoring view-points of other heterogenous groups, thus may introduce bias in the research (Dowling 2012).
• A sample of 8 women is not representative of whole population or all the women who underwent miscarriage. The sample may be sufficient to generalise the results for a particular hospital, but results could not be generalised to larger populations (Dowling 2012).

Briefly discuss the implications of these findings for Nursing/Midwifery practice and/or patient care. Include a discussion about the transferability of the findings.

 Yes, the implications of such study are very relevant for Nursing/ Midwifery practice and patient care. Although the study had a small sample of only 8 participants, still the results could be generalised and be able to suggest nurses to be reflective and have some insight while dealing with patients of miscarriage. Nursing care should be a holistic approach, considering patient as a whole, taking into account her physical and social environment. A nurse should be able to collect social cues along with clinical cues. While making a plan of action, nurse should also be able to address emotional, psychological and social needs of a patient along with proper management of her clinical needs. A nurse should have the ability of clinical reasoning which is more than mere clinical judgement and is, “the process by which nurses (and other clinicians) collect cues, process the information, come to an understanding of a patient’s problem or situation, plan and implement interventions, evaluate outcomes, and reflect on and learn from the process” (Levett- Jones et al, 2010, Pg 516).

Overall, should the outcomes of this study be used to inform clinical practice?

Yes/no – Yes

Explain – Inspite of limitations, the research was able to maintain rigour of a qualitative research as explained previously. The results could be very well used to inform the clinical practice. Thus while conveying the message of miscarriage; the nurse should be empathetic towards the patient. The nurse should understand that it is a loss of life for the woman. May be the nurse should sit with patient for a while and hold her hand. The women should be proceeded to a counselling session where she should be counselled regarding upcoming physical symptoms and should be prepared mentally, emotionally and psychologically to handle the distress. (Thorne 2016)

 References –

Bengough, T., & Hannes, K. (2017). A storyline about what young researchers should know when engaged in qualitative research-viewing one’s own research through a reflective lens. European Congress of Qualitative Inquiry edition:1 location:Leuven date:7-10 February 2017

Bryman, A (2012): “Social Research Methods”, 4^th Edition, South-Asia Edition, New Delhi: Oxford University Press.

Dowling, M., & Cooney, A. (2012). Research approaches related to phenomenology: negotiating a complex landscape. Nurse Researcher, 20(2), 21-27.

Faden, R. R., Kass, N. E., Goodman, S. N., Pronovost, P., Tunis, S., & Beauchamp, T. L. (2013). An ethics framework for a learning health care system: a departure from traditional research ethics and clinical ethics. Hastings Center Report, 43(s1), S16-S27.

Henderson, K., & Mathew Byrne, J. (2016). Developing communication and interviewing skills. Skills for social work practice, 1-22.

Levett-Jones, T. (Ed.). (2013). Clinical reasoning: Learning to think like a nurse. Frenchs Forest, NSW: Pearson.

MacWilliams, K., Hughes, J., Aston, M., Field, S., & Moffatt, F. W. (2016). Understanding the Experience of Miscarriage in the Emergency Department. Journal of Emergency Nursing, 42(6), 504-512.

Shields, A. L., Shiffman, S., & Stone, A. (2016). Recall Bias: Understanding and Reducing Bias in PRO Data Collection. EPro: Electronic Solutions for Patient-Reported Data, 5.

Thorne, S. (2016). Interpretive description: Qualitative research for applied practice (Vol. 2). Routledge.

Tuohy, D., Cooney, A., Dowling, M., Murphy, K., & Sixsmith, J. (2013). An overview of interpretive phenomenology as a research methodology. Nurse Researcher, 20(6), 17-20.