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International Journal of Nursing Practice 2015; 21: 102–106
RESEARCH PAPER
Application of the triage assessment system for psychological assessment for pregnant women with a deadly fetal abnormality Xiao-yan Yu MS Vice Director, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Yin Hu BS Senior Nurse, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Ya-cen Li BS Senior Nurse, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Su-wen Feng MS Head Nurse, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Accepted for publication August 2013 Yu X, Hu Y, Li Y, Feng S. International Journal of Nursing Practice 2015; 21: 102–106 Application of the triage assessment system for psychological assessment for pregnant women with a deadly fetal abnormality To explore suitable scales to assess psychological status of pregnant women whose fetuses have grave deformities, a face-to-face interview guided by the Triage Assessment System (TAS) was conducted. Also, a questionnaire of the Impact of Event Scale-Revised (IES-R) was obtained in 44 pregnant women diagnosed with a fetal deformity. Percentages and non-parametric Spearman correlations were used to analyse the scores of the two scales. The total score of TAS ranged from 3 to 26, with a mean of 9.93; and the total score of IES-R ranged from 5 to 63, with a mean of 40.36. The total score and the two subscales of each scale were significantly correlated (P < 0.05). The TAS subscale of emotion and IES-R subscale of intrusion were not significantly correlated, with r = 0.24 (P = 0.11). Combined use of TAS and IES-R can make up for each other’s deficiencies and guide the clinician to make individual interventions during screening and treatment. Key words: fetal abnormality, pregnant women, psychological assessment, triage assessment system.
INTRODUCTION
Correspondence: Xiao-yan Yu, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, #2 Xueshi Road, Hangzhou City, Zhejiang Province 310006, China. Email: yuxy@ zju.edu.cn © 2014 Wiley Publishing Asia Pty Ltd
The World Health Organization estimates that the overall perinatal mortality rate in low-income countries in 2000 was 61 per 1000 total births, and 10 per 1000 in highincome, more-developed countries.1 Various authors established that both parents suffer a period of intense mourning following a perinatal death, and even exhibit doi:10.1111/ijn.12293
Application of the triage assessment system
depressive symptoms.2 In a prospective study, in which 90% of women had a loss at 20 or fewer weeks of gestation, 26% of women had high or very high levels of depressive symptomatology 6 months after their loss.3 Sudden fetal abnormality after 20 weeks of the pregnancy, including fetal death and deadly deformity, can be an extremely devastating experience in the life of a woman and her family. According to a study in 2009, termination of pregnancy for fetal anomaly had significant psychological consequences for 20% of women up to 1 year later.4 These consequences result not only from the loss of the current baby, but also from their concern about any subsequent pregnancy. Timely psychological assessment is of great importance in applying effective measures for families to overcome psychological crisis and moderate couples’ psychological trauma. However, effective crisis intervention is dependent on accurate assessment. The Impact of Event Scale-Revised (IES-R), Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale are self-evaluated scales that are widely used in psychological assessment. However, the resulting accuracy of selfevaluated scales, to some extent, can be affected by multiple factors, such as knowledge, mood status, individual character of the participants and their willingness to participate. Previous study showed that errors commonly occur due to participants’ unwillingness and casualness, and a low return rate of useful questionnaires was a problem for self-evaluated scales.5 The Triage Assessment System (TAS) offers clinicians a framework for understanding clients’ reactions during a crisis intervention. To date, there is no specific instrument designed to evaluate psychological status for women with a deadly fetal deformity. The current study is first to explore the effectiveness and feasibility of the TAS for pregnant women with fetal abnormality, and compare it with the IES-R scale. Our objective was to guide medical workers in providing psychological intervention more accurately and individually, with the guidance of an effective assessment tool.
METHODS Participants Pregnant women diagnosed with deadly fetal deformity requiring pregnancy termination admitted in Women’s Hospital School of Medicine, Zhijiang University, a tertiary special hospital, from April 2009 to December 2010, were eligible to participate in the study. The inclusion criteria were as follows: (i) having a deadly fetal deformity
103
diagnosed by the medical diagnostic centre of a tertiary hospital; (ii) accepting induced labor as suggested; (iii) gestational age more than 20 weeks; (iv) willingness to participate in the study and provide signed informed consent; (v) be able to read Chinese; and (vi) no psychosomatic disease history. Consent was obtained before the study commenced. All respondents were asked to complete the survey within 3 days of admission. The interview was conducted by a trained senior nurse who was a member of study personnel and the entire procedure was guided by the TAS. The self-evaluated IES-R was administered anonymously by participants and collected immediately by the nurse. Participants’ sociodemographic and clinical information were obtained from interviews/questionnaires and from their case notes.
Instruments The TAS The TAS was first presented by Myer and Williams in 1992, and became a popular psychological assessment instruments. It was applied by Zhou et al. for a rapid mental health assessment of the referral wounded and their family members in the Wenchuan earthquake. It was translated into a Chinese version and had highly reliability and validity.6 The TAS for crisis intervention includes three domains: affective, behavioural and cognitive. In the affective domain, reactions are: (i) anger/hostility; (ii) anxiety/fear; and (iii) sadness/melancholy. Behavioural reactions can be assessed as: (i) immobility; (ii) avoidance; and (iii) approach. Cognitive domains can be assessed as (i) transgression; (ii) threat; and (iii) loss. Clinicians assess clients’ reactions along all of these domains. A 6-point Likert scale indicates the extent of affective reactions in the client experience. Reactions are rated on a scale of 1 to 10, with 10 being the most severe reaction. The higher the score, the more direct the intervention needed. Total score of TAS ranges from 0 to 30. Low scores (3–12) indicate a recommendation for no treatment or a nondirective approach. Middle scores (13–23) indicate the need for clinicians to partner with clients to help resolve the crisis. When clients’ total score on the severity scales is high (24–30), a direct approach is needed. If any severity scale score of the three domains is 10, hospitalization is strongly recommended.7
The IES-R The IES-R was approved by Weiss and Marmar after they revised the Horowitz’s Impact of Events instrument in © 2014 Wiley Publishing Asia Pty Ltd
104
X Yu et al.
1997.8 It has been translated into German, French, Italian and many other languages, and has been widely used in clinical settings. The Chinese version of the IES-R was translated by Guo su-ran in 2007. Its Cronbach’s α was 0.89 and split-half reliability was 0.93, suggesting an effective instrument with good internal consistency and reliability. It comprises 22 items that measure symptoms of intrusion (dreams about the event), avoidance and numbing (effort to avoid reminders of the event) and hyperarousal (feeling watchful and on guard) with respect to a particular life-threatening event. Participants’ rate on a 5-point Likert scale the extent to which each item applies to their experiences during the preceding 7 days. The total score of the IES-R ranges from 0 to 88. Higher scores indicate greater impact of the event. The following response categories are suggested: 0–9 no depression, 10–14 minimal depression, 15–20 mild depression, 21– 30 moderate depression, 31–40 severe depression and 41–63 very severe depression.
Data analysis The Statistical Package for the Social Sciences (SPSS version 17.0, IBM Corporation, Armonk, NY, USA) was used for statistical analyses. Categorical variables were presented as numbers or percentages. Non-parametric Spearman correlation was used to assess the correlation between the results of the two scales. Statistical significance was assigned to any P < 0.05.
Ethical approval The study was approved by the Ethical Committee of Women’s Hospital School of Medicine, Zhejiang University. Written informed consent was obtained from all participants or their legally acceptable representatives.
RESULTS Sample characteristics A total of 44 pregnant women diagnosed with a deadly fetal deformity, which was confirmed in the hospital diagnostic centre, participated in the study and completed the questionnaire and the interview. The mean ages of the participants was 30.84 (SD = 4.14, ranging from 25 to 42) years, whereas the mean years of formal education were 14.51 (SD = 2.85, ranging from 9 to 19). All the participants were married and 35 women were employed. Seven were Buddhist whereas 37 claimed to have no religious affiliation. Regarding the current pregnancy, 29 were expected and the remaining 15 were unplanned. © 2014 Wiley Publishing Asia Pty Ltd
Thirty-five were primiparas and 9 were multiparas with 1 live child. At the time of participation in the study, the gestational age ranged from 20 to 39 weeks, with a mean of 29.5 weeks. Among them, 15 had the diagnosis of stillbirth confirmed and the remaining 29 fetuses were still alive on admission. The mean time interval between diagnosis and admission was 3.4 days (SD = 6.78, and ranging from 0.5 to 30).
Scores of TAS and IES-R in women with deadly fetal deformity The total score of TAS ranged from 3 to 26, with a mean of 9.93. Of the 44 participants, 29 women had an assessment score ranging from 3 to 12 (65.9%); 14 women’s scores ranged from 13 to 22 (31.8%); and 1 woman’s score was 26 (2.3%). Meanwhile, the total score of IES-R ranged from 5 to 63, with a mean of 40.36. Among them, 6 women had a score ranging from 15 to 20 (13.6%), 8 women’s scores ranged from 21 to 30 (18.2%), 9 women’s scores ranged from 31 to 40 (20.5%) and 21 women’s scores ranged from 41 to 63 (47.7%). Table 1 shows the details of these scores.
The correlation between the scores of TAS and IES-R Table 2 shows the relationship between the total score and each domain of TAS and IES-R. The total score of the two scales and the scores of two subscales were significantly correlated (P < 0.05). However, the TAS subscale of emotion and the IES-R subscale of intrusion were not found to have significant correlation, with r = 0.24 (P = 0.11). Table 1 Score of the TAS and IES-R Scale and its subscale
Minimum Maximum Mean SD
Total score TAS Emotion subscale Cognition subscale Behaviour subscale Total score IES-R Avoidance subscale Intrusion subscale Hyperarousal subscale
3 1 1 1 5 3 1 1
24 10 9 7 82 29 24 30
9.93 5.67 3.88 2.27 3.45 2.15 2.59 1.68 40.36 17.62 15.18 6.68 12.93 5.23 12.25 6.87
IES-R, Impact of Event Scale-Revised; TAS, Triage Assessment System.
Application of the triage assessment system
105
Table 2 The relationship between the two scales and their subscales TAS IES-R Total score IES-R Avoidance subscale Intrusion subscale Hyperarousal subscale
Correlation coefficient Sig. (two-tailed test) Correlation coefficient Sig. (two-tailed test) Correlation coefficient Sig. (two-tailed test) Correlation coefficient Sig. (two-tailed test)
Total score TAS
Emotion subscale
Cognition subscale
Behaviour subscale
0.36 0.01 0.33 0.02 0.32 0.03 0.40 0.00
0.30 0.04 0.29 0.05 0.24 0.11 0.31 0.03
0.38 0.00 0.39 0.00 0.36 0.01 0.35 0.01
0.39 0.00 0.31 0.03 0.33 0.02 0.40 0.00
IES-R, Impact of Event Scale-Revised; Sig., significant; TAS, Triage Assessment System.
DISCUSSION Fetal deformity can be caused by many factors, such as heredity, environment, medication and even mentality.9 The couple with a fetal deformity often will be facing double tensions regarding the loss of the current fetus and the concerns for a subsequent pregnancy. Perinatal loss due to abnormality leads to severe psychological disadjustment and also often puts great strains on the marital or partner relationship, as Gausia et al. have shown.10 In our study, the TAS scale showed that 34.1% of women had a score above 13, indicating the need for clinicians to partner with them to help resolve the crisis. The IES-R showed that about 68.2% had a score higher than 30, which indicates severe to very severe depression, according to the interpretation of the scale. Although the percentage of women with severe problems was not identical between scales, both scales indicated that stress was common in women with fetal deformity and that psychosocial assessment played an important role for screening. The IES-R, as a self-assessed scale, is one of the most widely used self-report instruments for the assessment of psychological crisis. When compared with TAS among our participants, we found the greatest relation between the total score and two of the three subscales scores of TAS and the IES-R. These results might be due to the characteristics of our population, possibly being too introverted to communicate with the clinicians openly. The TAS is an assessment scale that aimed to evaluate the patient psychological status from affective, behavioural and cognitive domains, and is considered to be
comprehensive, accurate and simple. However, it is not only the scale useable for screening. One of the important features is that it directly translates into focusing treatment when it is needed. That means the victim will be given the most quick and suitable management for her psychological concern guided by the score of TAS. And also, as the severity of the reaction varies throughout the crisis event and treatment, clinicians could adjust the treatment to meet clients’ needs, according to the re-assessment TAS results. Our reseach found that TAS represents a strength, as a clinician-assessed scale, first used to evaluate the psychological status of pregnant women diagnosed with a deadly fetal deformity. The combined use of TAS and IES-R can make up for each instrument’s deficiencies and guide the clinician to make more individual interventions during screening and treatment.
CONFLICT OF INTEREST STATEMENT None.
ROLE OF THE FUNDING SOURCE The design and conduct of the study, collection, management, analysis and interpretation of the data, and preparation, review and approval of the manuscript were jointly supported by a Grant Y200804076 from education scientific research foundation project of Zhejiang Province, a Grant 2009A130 from medicine scientific research foundation project of Zhejiang Province and a Grant 2013RCA017 Zhe Jiang Provincial medical platform backbone talents program. © 2014 Wiley Publishing Asia Pty Ltd
106
X Yu et al.
ACKNOWLEDGEMENTS We acknowledge our Research Consultant, Dr Luo Hong, from the Department of Psychological Medicine, Hangzhou 3rd Hospital, for comments on the research and for help in writing the paper. We also thank Dr Hu Jianbo for statistical advice, and we express our gratitude to the nurse colleagues and the subjects who participated in the study.
REFERENCES 1 World Health Organization. Neonatal and perinatal mortality: Country, regional and global estimates, 2006. 2 Badenhorst W, Hughes P. Psychological aspects of perinatal loss. Best Practice & Research Clinical Obstetrics & Gynaecology 2007; 21: 249–259. 3 Janssen HJ, Cuisinier MC, Hoogduin KA, de Graauw KP. Controlled prospective study on the mental health of women following pregnancy loss. American Journal of Psychiatry 1996; 153: 226–230. 4 Korenromp MJ, Page-Christiaens GC, van den Bout J, Mulder EJ, Visser GH. Adjustment to termination of pregnancy for fetal anomaly: A longitudinal study in women at
© 2014 Wiley Publishing Asia Pty Ltd
5
6
7 8
9
10
4, 8, and 16 months. American Journal of Obstetrics and Gynecology 2009; 201: 160–167. Wu J, Zhai J, Liu X. Application of nurse-administered psychological assessment scale for patients early after trauma in the wounded after earthquake. Journal of Shanghai Jiaotong University(Medical Science) 2008; 1383–1385. Zhou W, Hu J, Hu S, Wei N, Huang M, Xu Y. Application of the triage assessment system for a rapid assessment of mental health of the referral wounded and their family members in Wenchuan earthquake. Chinese Journal of Preventive Medicine 2008; 11: 798–801. Myer RA, Conte C. Assessment for crisis intervention. Journal of Clinical Psychology: In Session 2006; 62: 959–970. Weiss DS, Marmar CR. The impact of event scale-revised. In: Wilson JP, Keane TM (eds). Assessing Psychological Trauma and PSTD. New York: Guilford Press, 1997; P399– P411. Zhu K, Ren R. Research progress of factors related to birth defect and interventional measures. Medical Recapitulate 2011; 17: 116–118. Gausia K, Moran AC, Ali M, Rader D, Fisher C, Koblinsky M. Psychological and social consequences among mothers suffering from perinatal loss: Perspective from a low income county. BMC Public Health 2011; 11: 451–460.
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International Journal of Nursing Practice 2015; 21: 102–106
RESEARCH PAPER
Application of the triage assessment system for psychological assessment for pregnant women with a deadly fetal abnormality Xiao-yan Yu MS Vice Director, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Yin Hu BS Senior Nurse, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Ya-cen Li BS Senior Nurse, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Su-wen Feng MS Head Nurse, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
Accepted for publication August 2013 Yu X, Hu Y, Li Y, Feng S. International Journal of Nursing Practice 2015; 21: 102–106 Application of the triage assessment system for psychological assessment for pregnant women with a deadly fetal abnormality To explore suitable scales to assess psychological status of pregnant women whose fetuses have grave deformities, a face-to-face interview guided by the Triage Assessment System (TAS) was conducted. Also, a questionnaire of the Impact of Event Scale-Revised (IES-R) was obtained in 44 pregnant women diagnosed with a fetal deformity. Percentages and non-parametric Spearman correlations were used to analyse the scores of the two scales. The total score of TAS ranged from 3 to 26, with a mean of 9.93; and the total score of IES-R ranged from 5 to 63, with a mean of 40.36. The total score and the two subscales of each scale were significantly correlated (P < 0.05). The TAS subscale of emotion and IES-R subscale of intrusion were not significantly correlated, with r = 0.24 (P = 0.11). Combined use of TAS and IES-R can make up for each other’s deficiencies and guide the clinician to make individual interventions during screening and treatment. Key words: fetal abnormality, pregnant women, psychological assessment, triage assessment system.
INTRODUCTION
Correspondence: Xiao-yan Yu, Obstetrics and Gynecology, Women’s Hospital School of Medicine, Zhejiang University, #2 Xueshi Road, Hangzhou City, Zhejiang Province 310006, China. Email: yuxy@ zju.edu.cn © 2014 Wiley Publishing Asia Pty Ltd
The World Health Organization estimates that the overall perinatal mortality rate in low-income countries in 2000 was 61 per 1000 total births, and 10 per 1000 in highincome, more-developed countries.1 Various authors established that both parents suffer a period of intense mourning following a perinatal death, and even exhibit doi:10.1111/ijn.12293
Application of the triage assessment system
depressive symptoms.2 In a prospective study, in which 90% of women had a loss at 20 or fewer weeks of gestation, 26% of women had high or very high levels of depressive symptomatology 6 months after their loss.3 Sudden fetal abnormality after 20 weeks of the pregnancy, including fetal death and deadly deformity, can be an extremely devastating experience in the life of a woman and her family. According to a study in 2009, termination of pregnancy for fetal anomaly had significant psychological consequences for 20% of women up to 1 year later.4 These consequences result not only from the loss of the current baby, but also from their concern about any subsequent pregnancy. Timely psychological assessment is of great importance in applying effective measures for families to overcome psychological crisis and moderate couples’ psychological trauma. However, effective crisis intervention is dependent on accurate assessment. The Impact of Event Scale-Revised (IES-R), Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale are self-evaluated scales that are widely used in psychological assessment. However, the resulting accuracy of selfevaluated scales, to some extent, can be affected by multiple factors, such as knowledge, mood status, individual character of the participants and their willingness to participate. Previous study showed that errors commonly occur due to participants’ unwillingness and casualness, and a low return rate of useful questionnaires was a problem for self-evaluated scales.5 The Triage Assessment System (TAS) offers clinicians a framework for understanding clients’ reactions during a crisis intervention. To date, there is no specific instrument designed to evaluate psychological status for women with a deadly fetal deformity. The current study is first to explore the effectiveness and feasibility of the TAS for pregnant women with fetal abnormality, and compare it with the IES-R scale. Our objective was to guide medical workers in providing psychological intervention more accurately and individually, with the guidance of an effective assessment tool.
METHODS Participants Pregnant women diagnosed with deadly fetal deformity requiring pregnancy termination admitted in Women’s Hospital School of Medicine, Zhijiang University, a tertiary special hospital, from April 2009 to December 2010, were eligible to participate in the study. The inclusion criteria were as follows: (i) having a deadly fetal deformity
103
diagnosed by the medical diagnostic centre of a tertiary hospital; (ii) accepting induced labor as suggested; (iii) gestational age more than 20 weeks; (iv) willingness to participate in the study and provide signed informed consent; (v) be able to read Chinese; and (vi) no psychosomatic disease history. Consent was obtained before the study commenced. All respondents were asked to complete the survey within 3 days of admission. The interview was conducted by a trained senior nurse who was a member of study personnel and the entire procedure was guided by the TAS. The self-evaluated IES-R was administered anonymously by participants and collected immediately by the nurse. Participants’ sociodemographic and clinical information were obtained from interviews/questionnaires and from their case notes.
Instruments The TAS The TAS was first presented by Myer and Williams in 1992, and became a popular psychological assessment instruments. It was applied by Zhou et al. for a rapid mental health assessment of the referral wounded and their family members in the Wenchuan earthquake. It was translated into a Chinese version and had highly reliability and validity.6 The TAS for crisis intervention includes three domains: affective, behavioural and cognitive. In the affective domain, reactions are: (i) anger/hostility; (ii) anxiety/fear; and (iii) sadness/melancholy. Behavioural reactions can be assessed as: (i) immobility; (ii) avoidance; and (iii) approach. Cognitive domains can be assessed as (i) transgression; (ii) threat; and (iii) loss. Clinicians assess clients’ reactions along all of these domains. A 6-point Likert scale indicates the extent of affective reactions in the client experience. Reactions are rated on a scale of 1 to 10, with 10 being the most severe reaction. The higher the score, the more direct the intervention needed. Total score of TAS ranges from 0 to 30. Low scores (3–12) indicate a recommendation for no treatment or a nondirective approach. Middle scores (13–23) indicate the need for clinicians to partner with clients to help resolve the crisis. When clients’ total score on the severity scales is high (24–30), a direct approach is needed. If any severity scale score of the three domains is 10, hospitalization is strongly recommended.7
The IES-R The IES-R was approved by Weiss and Marmar after they revised the Horowitz’s Impact of Events instrument in © 2014 Wiley Publishing Asia Pty Ltd
104
X Yu et al.
1997.8 It has been translated into German, French, Italian and many other languages, and has been widely used in clinical settings. The Chinese version of the IES-R was translated by Guo su-ran in 2007. Its Cronbach’s α was 0.89 and split-half reliability was 0.93, suggesting an effective instrument with good internal consistency and reliability. It comprises 22 items that measure symptoms of intrusion (dreams about the event), avoidance and numbing (effort to avoid reminders of the event) and hyperarousal (feeling watchful and on guard) with respect to a particular life-threatening event. Participants’ rate on a 5-point Likert scale the extent to which each item applies to their experiences during the preceding 7 days. The total score of the IES-R ranges from 0 to 88. Higher scores indicate greater impact of the event. The following response categories are suggested: 0–9 no depression, 10–14 minimal depression, 15–20 mild depression, 21– 30 moderate depression, 31–40 severe depression and 41–63 very severe depression.
Data analysis The Statistical Package for the Social Sciences (SPSS version 17.0, IBM Corporation, Armonk, NY, USA) was used for statistical analyses. Categorical variables were presented as numbers or percentages. Non-parametric Spearman correlation was used to assess the correlation between the results of the two scales. Statistical significance was assigned to any P < 0.05.
Ethical approval The study was approved by the Ethical Committee of Women’s Hospital School of Medicine, Zhejiang University. Written informed consent was obtained from all participants or their legally acceptable representatives.
RESULTS Sample characteristics A total of 44 pregnant women diagnosed with a deadly fetal deformity, which was confirmed in the hospital diagnostic centre, participated in the study and completed the questionnaire and the interview. The mean ages of the participants was 30.84 (SD = 4.14, ranging from 25 to 42) years, whereas the mean years of formal education were 14.51 (SD = 2.85, ranging from 9 to 19). All the participants were married and 35 women were employed. Seven were Buddhist whereas 37 claimed to have no religious affiliation. Regarding the current pregnancy, 29 were expected and the remaining 15 were unplanned. © 2014 Wiley Publishing Asia Pty Ltd
Thirty-five were primiparas and 9 were multiparas with 1 live child. At the time of participation in the study, the gestational age ranged from 20 to 39 weeks, with a mean of 29.5 weeks. Among them, 15 had the diagnosis of stillbirth confirmed and the remaining 29 fetuses were still alive on admission. The mean time interval between diagnosis and admission was 3.4 days (SD = 6.78, and ranging from 0.5 to 30).
Scores of TAS and IES-R in women with deadly fetal deformity The total score of TAS ranged from 3 to 26, with a mean of 9.93. Of the 44 participants, 29 women had an assessment score ranging from 3 to 12 (65.9%); 14 women’s scores ranged from 13 to 22 (31.8%); and 1 woman’s score was 26 (2.3%). Meanwhile, the total score of IES-R ranged from 5 to 63, with a mean of 40.36. Among them, 6 women had a score ranging from 15 to 20 (13.6%), 8 women’s scores ranged from 21 to 30 (18.2%), 9 women’s scores ranged from 31 to 40 (20.5%) and 21 women’s scores ranged from 41 to 63 (47.7%). Table 1 shows the details of these scores.
The correlation between the scores of TAS and IES-R Table 2 shows the relationship between the total score and each domain of TAS and IES-R. The total score of the two scales and the scores of two subscales were significantly correlated (P < 0.05). However, the TAS subscale of emotion and the IES-R subscale of intrusion were not found to have significant correlation, with r = 0.24 (P = 0.11). Table 1 Score of the TAS and IES-R Scale and its subscale
Minimum Maximum Mean SD
Total score TAS Emotion subscale Cognition subscale Behaviour subscale Total score IES-R Avoidance subscale Intrusion subscale Hyperarousal subscale
3 1 1 1 5 3 1 1
24 10 9 7 82 29 24 30
9.93 5.67 3.88 2.27 3.45 2.15 2.59 1.68 40.36 17.62 15.18 6.68 12.93 5.23 12.25 6.87
IES-R, Impact of Event Scale-Revised; TAS, Triage Assessment System.
Application of the triage assessment system
105
Table 2 The relationship between the two scales and their subscales TAS IES-R Total score IES-R Avoidance subscale Intrusion subscale Hyperarousal subscale
Correlation coefficient Sig. (two-tailed test) Correlation coefficient Sig. (two-tailed test) Correlation coefficient Sig. (two-tailed test) Correlation coefficient Sig. (two-tailed test)
Total score TAS
Emotion subscale
Cognition subscale
Behaviour subscale
0.36 0.01 0.33 0.02 0.32 0.03 0.40 0.00
0.30 0.04 0.29 0.05 0.24 0.11 0.31 0.03
0.38 0.00 0.39 0.00 0.36 0.01 0.35 0.01
0.39 0.00 0.31 0.03 0.33 0.02 0.40 0.00
IES-R, Impact of Event Scale-Revised; Sig., significant; TAS, Triage Assessment System.
DISCUSSION Fetal deformity can be caused by many factors, such as heredity, environment, medication and even mentality.9 The couple with a fetal deformity often will be facing double tensions regarding the loss of the current fetus and the concerns for a subsequent pregnancy. Perinatal loss due to abnormality leads to severe psychological disadjustment and also often puts great strains on the marital or partner relationship, as Gausia et al. have shown.10 In our study, the TAS scale showed that 34.1% of women had a score above 13, indicating the need for clinicians to partner with them to help resolve the crisis. The IES-R showed that about 68.2% had a score higher than 30, which indicates severe to very severe depression, according to the interpretation of the scale. Although the percentage of women with severe problems was not identical between scales, both scales indicated that stress was common in women with fetal deformity and that psychosocial assessment played an important role for screening. The IES-R, as a self-assessed scale, is one of the most widely used self-report instruments for the assessment of psychological crisis. When compared with TAS among our participants, we found the greatest relation between the total score and two of the three subscales scores of TAS and the IES-R. These results might be due to the characteristics of our population, possibly being too introverted to communicate with the clinicians openly. The TAS is an assessment scale that aimed to evaluate the patient psychological status from affective, behavioural and cognitive domains, and is considered to be
comprehensive, accurate and simple. However, it is not only the scale useable for screening. One of the important features is that it directly translates into focusing treatment when it is needed. That means the victim will be given the most quick and suitable management for her psychological concern guided by the score of TAS. And also, as the severity of the reaction varies throughout the crisis event and treatment, clinicians could adjust the treatment to meet clients’ needs, according to the re-assessment TAS results. Our reseach found that TAS represents a strength, as a clinician-assessed scale, first used to evaluate the psychological status of pregnant women diagnosed with a deadly fetal deformity. The combined use of TAS and IES-R can make up for each instrument’s deficiencies and guide the clinician to make more individual interventions during screening and treatment.
CONFLICT OF INTEREST STATEMENT None.
ROLE OF THE FUNDING SOURCE The design and conduct of the study, collection, management, analysis and interpretation of the data, and preparation, review and approval of the manuscript were jointly supported by a Grant Y200804076 from education scientific research foundation project of Zhejiang Province, a Grant 2009A130 from medicine scientific research foundation project of Zhejiang Province and a Grant 2013RCA017 Zhe Jiang Provincial medical platform backbone talents program. © 2014 Wiley Publishing Asia Pty Ltd
106
X Yu et al.
ACKNOWLEDGEMENTS We acknowledge our Research Consultant, Dr Luo Hong, from the Department of Psychological Medicine, Hangzhou 3rd Hospital, for comments on the research and for help in writing the paper. We also thank Dr Hu Jianbo for statistical advice, and we express our gratitude to the nurse colleagues and the subjects who participated in the study.
REFERENCES 1 World Health Organization. Neonatal and perinatal mortality: Country, regional and global estimates, 2006. 2 Badenhorst W, Hughes P. Psychological aspects of perinatal loss. Best Practice & Research Clinical Obstetrics & Gynaecology 2007; 21: 249–259. 3 Janssen HJ, Cuisinier MC, Hoogduin KA, de Graauw KP. Controlled prospective study on the mental health of women following pregnancy loss. American Journal of Psychiatry 1996; 153: 226–230. 4 Korenromp MJ, Page-Christiaens GC, van den Bout J, Mulder EJ, Visser GH. Adjustment to termination of pregnancy for fetal anomaly: A longitudinal study in women at
© 2014 Wiley Publishing Asia Pty Ltd
5
6
7 8
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