Contraception 89 (2014) 460 – 465
Original research article
Caring for women undergoing second-trimester medical termination of pregnancy☆ Inga-Maj Andersson a,⁎, Kristina Gemzell-Danielsson b , Kyllike Christensson c b
a Department of Women’s and Children’s Health, Karolinska Institutet Södersjukhuset, Stockholm, Sweden Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, WHO Centre, Karolinska University Hospital, Stockholm, Sweden c Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden Received 8 August 2013; revised 15 January 2014; accepted 19 January 2014
Abstract Objective: The objective was to explore the experiences and perceptions of nurses/midwives caring for women undergoing second-trimester medical termination of pregnancy (MTOP). Study design: The study had a qualitative design using semistructured interviews. It took place in three wards at one gynecological clinic in a general hospital in Stockholm. Twenty-one nurses/midwives with experience in second-trimester abortion care were interviewed following a semistructured interview guide. The interviews were recorded, transcribed verbatim and then analyzed using qualitative content analysis to identify common themes. Results: The analysis revealed two themes: “The professional self,” with six subthemes describing the experiences and perceptions described in terms of professional behavior, and “The personal self,” with four subthemes containing the experiences and perceptions described in terms of personal values. Conclusions: Taking care of women undergoing second-trimester MTOP is a task that requires professional knowledge, empathy and the ability to reflect on ethical attitudes and considerations. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. The feeling of supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second-trimester MTOP. The findings of this study support the need for training, mentoring and support by experienced colleagues to help nurses/midwives feel secure in their professional role in difficult situations and feel confident in their personal life situation. Implications statement: Taking care of women undergoing second-trimester MTOP is a task that requires professional knowledge and empathy. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. Mentorship from experienced colleagues and structured opportunities for reflection on ethical issues enable the nurses/midwives to develop security in their professional roles and also feel confident in their personal life situation. The feeling of doing something good for women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second-trimester MTOP. © 2014 Elsevier Inc. All rights reserved. Keywords: Abortion; Second trimester; Interview; Content analysis; Nurses; Midwives
1. Introduction High-quality professional care and a nonjudgemental approach have been shown to have a significant impact on women’s sense of security in abortion situations [1,2]. ☆
Acknowledgement of funding: The study was supported by grants from the Swedish Research Council, FAS, Karolinska Institutet and Stockholm City County/Karolinska Institutet (ALF). ⁎ Corresponding author. Tel.: +46702191038. E-mail address: [email protected] (I.-M. Andersson). 0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2014.01.012
Women undergoing termination of pregnancy (TOP) may be in a complex situation [3] with emotional and existential needs which require care based on experience and empathy [4]. During the last decade, medical methods for secondtrimester TOP have developed considerably. In contrast to early MTOP, which can be handled by the woman herself [5], second-trimester MTOP demands more involvement by health care providers, and the risk for complications increases with gestational length [6]. Second-trimester medical TOP (MTOP) has been shown to be as safe and effective as dilatation and evacuation [7],
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with less need for trained providers of surgical TOP. As a result, there is an increased use of MTOP worldwide. In Sweden, MTOP has replaced other methods for secondtrimester abortion. The same trend is seen across Europe and beyond. The regimen used in Sweden is the one recommended by the World Health Organization of 200 mg mifepristone followed 36 to 48 h later by an initial dose of 800 mcg of misoprostol administered vaginally and then repeated doses of 400 mcg misoprostol (orally or sublingually) until expulsion [8]. Paracetamol and nonsteroidal anti-inflammatory drugs are commonly used for pain treatment supplemented with intravenous morphine and sometimes paracervical blockade. Nurses or midwives frequently care for women undergoing second-trimester MTOP. However, so far, only a few studies have focused on the experiences of nurses/midwives providing care for women undergoing second-trimester MTOP [9], and a previous study among midwives [10] showed misgivings of working with late TOP reported by 35% of respondents. Therefore, with increasing use of second-trimester MTOP, increasing involvement of nurses/midwives in abortion care and most studies on health care providers’ experiences focusing on early MTOP, a deeper knowledge of factors that may influence the perception of nurses/midwives involved in care of second-trimester abortion seems warranted. The aim of the present study was thus to explore the experiences and perceptions of nurses/midwives caring for women undergoing second-trimester MTOP.
2. Material and methods A qualitative approach was used to gain a deeper understanding and capture the perceptions and experiences [11] of the nurses and midwives caring for women undergoing second-trimester TOP. 2.1. Participants Participants were recruited from three gynecological care units at a general hospital in Stockholm. Forty nurses and 10 midwives are employed in these wards and care for patients undergoing gynecological surgery or treatment as well as women undergoing second-trimester abortion. About 500 second-trimester (and total 2500) abortions are performed annually. Nurses/midwives are responsible for medication administration, care given during the process and fetus delivery. The participants’ varied ages and experiences from abortion care increased the possibility of revealing variations of the studied phenomena [11]. 2.2. Data collection Invitation to participate was given in six workplace meetings together with verbal and written information about
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the study. Twenty-one nurses/midwives interested in participating contacted the first author (I.M.A.) via mail, who interviewed them all. Interviews enable getting closer to the respondent’s views and ideas, especially when interviewing colleagues from the same cultural context [12]. In this study, the interviewer’s preunderstanding was acquired by earlier experiences with second-trimester abortion care. Individual interviews were used following a semistructured guide (Table 1) which included questions with the possibility to follow up the answers. A hypothetical case, about a young woman with a repeat second-trimester abortion who expressed emotional pain, was used to capture the respondent’s views on patient care. One pilot interview was videotaped, and the product was discussed with 10 fellow research students, resulting in more open questions. All interviews were conducted between April 2010 and July 2012 in a secluded site and lasted between 17 and 35 min. The interviews were recorded and transcribed verbatim. 2.3. Analysis Content analysis is a method that interprets reality by creating units of content related to the context being studied [13]. Thematic content analysis shares a commonality in content derived from texts from interviews with persons from a context [11,14]. Content analysis was used, originating from interviews in contexts well known to the researcher and the participants. We read the transcribed text several times to gain an overview of the content. Meaning units were identified and extracted from the transcribed text individually by two researchers (I.M.A. and K.C.) who then jointly gave the units codes to summarize the content [14]. We discussed the codes, and likely words and sentences were placed together in 14 categories to systematically and objectively describe patterns [15] in how the nurses and midwives expressed their feelings and thoughts. From the categories, two themes emerged: “The professional self” and “The personal self” (Table 2). The themes were discussed by the whole research team as well as in seminar sessions with other research fellow midwives. The study was approved by the Regional Ethical Review Board at Karolinska Institutet in Stockholm. Voluntary par-
Table 1 Questions from the interview guide Question How did it come that you chose to work in gynecology? How long have you cared for women undergoing late abortion? How do you like your work? What do you perceive as positively in care for late abortion? What do you perceive as difficult? What are a woman’s needs of you as a caregiver? What do you need to be able to provide/meet the need for care?
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Table 2 Examples of meaning units, condensed meaning units, codes and theme Meaning unit
Condensed meaning units
Codes
Theme
I also have strategies… therefore I never look for example, on the fetus when it … I look at the umbilical cord when it comes out, and so, different strategies to not see … so I have not changed my mind in the abortion issue as well but I have changed a bit. This that you become a little more humble and well, yes it can… unwanted pregnancy, and they are very relieved and happy that you get to do it in week 20
I have strategies, for example, I never look at the fetus, I look at the umbilical cord when it comes out in order not to see. I have not changed my mind on the issue of abortion, but I have amended to be a bit more humble … to have more understanding.
The fetus
The professional self
Reflection
The personal self
ticipation was confidential, and informed consent was obtained by the interviewer before the interview.
3. Results Seventeen nurses and four midwives, aged 25 to 59 years, with experience of abortion care ranging from 2 months to 17 years participated in the study (Table 3). The analysis revealed two themes: “The professional self,” with six subthemes describing the experiences and perceptions described in terms of professional behavior, and “The personal self,” with four subthemes containing the experiences and perceptions described in terms of personal values. The themes cross over each other in some aspects, especially regarding competence among the participants.
4. The professional self 4.1. Being familiar with the process Having clinical knowledge of second-trimester MTOP was described as important. Knowing you were competent gave strength and a sense of security, which made it easier to communicate calmly and in a secure manner. The nurses/ midwives who were less experienced sometimes felt that they transferred their own anxiety to the women when complications or unexpected events or reactions occurred. “If you feel confident in your role and know the process, you feel comfortable with the situation and convey a sense of security." (no 11)
Participants expressed a need for technical training to create more of a sense of their own competency in nursing situations. 4.2. Balancing objective information
Table 3 Demographic information about the participants Participant no
Nurse/midwife
Age
Years as nurse/midwife
Experience from abortion care
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Nurse Nurse Nurse Midwife Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Midwife Midwife Midwife Nurse Nurse a Nurse Nurse a
50 46 27 31 35 37 26 25 27 26 28 25 49 32 41 56 46 59 37 42 34
25 13 3 6/3 9 2 2 1 2 2 3 1 18 1 22/16 5/28 3/1 15 8 10 6
5 years 10 years 2 years 2 months 8 months 2 years 2 years 1 year 10 months 7 months 1,5 years 9 months 17 years 10 months 12 years 10 years 3 years 15 years 6 years 10 years 4 years
a
Midwife student.
Detailed information was provided to create a sense of security in the woman before and during the procedure. The nurse/midwife sometimes used communication strategies to decrease stress caused by emotionally difficult information. The participants did not want to scare the woman about the pain or lie. “You can’t say how it will feel physically, how painful it will be." (no 2)
When the woman was not fluent in Swedish, it was considered important to have an interpreter. 4.3. Finding ways for pain treatment The midwives’/nurses’ professional experience of caring for patients with pain made them keen to provide women with adequate pain treatment. Some described a sense of powerlessness when they were unable to find an optimal method to relieve severe pain. Wishes emerged about broadening the competencies of the midwives to apply a more effective pain treatment — paracervical block — that today is usually limited to use by doctors. Pain assessment tools were used for the physical pain; pain of a mental and existential
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nature was regarded as immeasurable. Therapeutic use of professional presence, listening and communication was a way for the nurses/midwives to attempt to provide satisfactory pain relief. “Whatever you give it doesn’t help … The best thing is to do nothing, just be there and listen." (no 19)
4.4. Looking for the woman’s needs Several nurses/midwives believed that women with different personalities need different kind of care, and the nurses/midwives stated that they had developed an ability to perceive different personalities and adapt their care to the woman's wishes. The ability to understand the underlying causes of women's reactions had been developed over the years by being able to sense the atmosphere and the specific needs for the woman and to understand even nonverbal communication. To convey the involvement of the woman, a permissive attitude to the women to express their inner feelings and openness to questions were consistently seen as foundational skills. Communication could be inhibited if the woman did not express her thoughts and feelings. The nurses/midwives tried to establish closer contact in these situations by lightening the mood, recalling some personal life experience or giving body contact. “Sometimes they want to have it in a certain way, but you can’t know that before you ask. I feel that it’s really important that you try to find out what the woman wants.” (no 7)
4.5. Handling the fetus Handling the fetus was one of the most difficult aspects. The nurses/midwives wanted to treat it with dignity. In the few cases where the fetus had shown signs of life, the nurse/ midwife described how they did not abandon it until all signs of life had disappeared. The majority of participants found fetal vital signs unpleasant but had found ways to handle it to reduce discomfort and/or to disconnect their own thoughts. “I have strategies, for example, I never look at the fetus, I look at the umbilical cord when it comes out in order not to see." (no 19)
Women who terminated their pregnancy because of malformation were routinely offered a chance to say goodbye. Other women were shown the fetus if they asked. Opinions that only the woman can decide about the fetus and that looking at the fetus can make the situation even worse for the woman were expressed by the participants. 4.6. Needing time for reflection The nurses/midwives perceived needs in both the health care organization and in themselves. The desire for increased resources was specified, as this would provide more time for the women by taking care of fewer patients at a time and
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increase opportunities for regular reflection/debriefing. Support from colleagues and time for personal reflection were seen as opportunities for developing the ability to find solutions to gain valuable practical knowledge and the ability to move on. “The most important thing is to talk about it, especially with my colleagues” (no 8)
The wish for education about fetal development revealed the need for reflections centered on the fetus’ capacity or noncapacity to survive an abortion as well as discussions about attitudes about women’s rights and abortion. 5. The personal self 5.1. Conflicting duty and behavior An effort was made to treat everyone equally regardless of the reason for the MTOP, and it was considered important to care for the individual rather than adhere to principles. To behave neutrally and withhold personal opinions appeared to be an important approach. In cases where the woman seemed tough or unconcerned, some nurses/midwives noted that it was difficult to maintain their views on women’s abortion rights. Thoughts about TOP being used as a method of contraception existed among a few of the participants, even if this was something that they did not actually want to speak about openly. One midwife expressed sorrow for the waste of life regarding the abortion of healthy fetuses by healthy women in contrast to women struggling with infertility problems. Care for second-trimester terminations was seen as a necessity despite this injustice. “I felt it was a waste, too bad that no one could adopt it.” (no 17)
Commitment to women's rights and commitment to improve abortion care led participants to feelings of involvement in the women's struggle, and thus abortion care was perceived as important both for their own beliefs and to society at large. 5.2. Dealing with emotions Feelings of relief, gratitude and joy in a job well done were presented as well as more negative feelings. Carrying emotions inside to prevent those emotions from taking the upper hand in a situation was a way for the nurses/midwives to deal with their own feelings. Emotions such as anger and outrage were perceived as forbidden emotions. Feelings of grief, sorrow and sadness were shared with the women without crying. “I would never ever show, it’s just a thought in my brain. I’m there as a nurse not as a private person” (no 5)
5.3. Identifying oneself with the woman The participants of fertile age sometimes identified themselves with the women experiencing fetal malformation
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and imagined the sadness that could have afflicted them in the same situation. Before ultrasound screening in her first pregnancy, one nurse revealed that she felt concern related to women she had met who had terminated their pregnancy because of fetal malformation. “I have no children but… this is my picture, you see miscarriages, complications and when things go wrong… you feel scared” (no 3)
Identifying with the feelings of the woman’s parents was mentioned by some of the older participants who were thinking about their own daughters. 5.4. Developing inner safety and maturity From experiences with other areas of women’s health together with the nurses/midwives own life situations, the personal maturity of the nurses/midwives was described as developing inner safety and maturity. An inner confidence and an increased understanding of women’s varied situations were developed. These were inherent in and obtained from nursing competence and ethical thinking. The young nurses had actively sought positions in gynecology to gain experience for further training as a midwife. The nurse’s/ midwife’s particular ethical standpoint on second-trimester MTOP became more nuanced over the years. Increased awareness of their own emotions could be seen as a maturing process. “Even though it's a really difficult situation, I'm incredibly happy to have experienced this. I think you develop a lot as a person and you become stronger." (no 14)
6. Discussion This study explores the experiences and perceptions of nurses/midwives caring for women undergoing secondtrimester MTOP. The included participants are deemed as a representative sample of staff in Swedish gynecological wards, with varying theoretical knowledge and experiences from nursing and midwifery care. The analysis revealed two themes: “The professional self” and “The personal self.” A conflict can be seen between the themes: what the nurses/ midwives must do as part of their professional obligations and what they would like to do based on their inner feelings and thoughts. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. The sense supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing MTOP. Data showed multiple meanings in the studied context and can be seen as not mutually exclusive and therefore crossing over the themes and subthemes [13]. The participants were well aware that professional care, with a nonjudgmental attitude and respect during TOP, is important for
the woman’s ongoing well-being [16]. Contradictions in opinions, attitudes and emotions were expressed by some participants, especially when referring to cases in advanced gestational length. This is consistent with previous findings showing that nurses’ willingness to care for patients electing TOP for fetal anomaly decreases with gestational length [17]. The opinion that young women look upon abortion as a justified right [18] to terminate a pregnancy owing to media scare stories about contraceptive side effects [19] is in accordance with previous studies and mirrors the sociocultural influence in Sweden. The participants found it hard to talk about their job with relatives, afraid of being misunderstood, which mirrors previous findings [20] about hesitation to talk about involvement in second-trimester abortion care. However, at the same time, they wanted to raise public awareness about secondtrimester MTOP to improve abortion care. Increased understanding of women’s various circumstances was developed with greater experience, but not the standpoint towards TOP, which is consistent with earlier studies [18] about midwives’ experiences. Nurses involved with TOP care are in need of mentorship [20], and team support is seen as a coping strategy [9]. Debriefing and ethical discussions with more experienced colleagues and counselors helped the participants in the present study to grow in their professional role. With increased experience in second-trimester abortion care, the participants relied on intuitive understanding which had grown over time [21]. A second-trimester MTOP includes fetus delivery, and midwives no doubt have more experience than nurses in dealing with the care of the woman, the fetus and the related physical pain. Development was seen among the nurses/ midwives in perception and understanding of situations. This ranged from novice to expert [21] according to experiences from other areas in women’s health care as well as own life situations. All of the nurses/midwives considered the pain and the desire to provide adequate pain treatment to the women as difficult and hard to handle. Caring for patients with pain has been described [22] as a challenging task; the nurse has to find complementary strategies to reduce pain when pharmacological treatment is not enough. The nurses/ midwives in the present study used their professional competence to relieve pain by being present and listening to the women. The feeling of a lack of power in pharmacological pain treatment is worrying since, according to an earlier study [23], successful pain relief was reported as one important factor in the nurses’ sense of empowerment and overall well-being and frustration was reported when pain was unrelieved. Multiple individualized care strategies to relieve pain are essential for the experienced nurse to meet the woman’s needs [21]. Earlier studies [18,20] have shown that handling the aborted fetus, particularly in later gestational weeks, is an emotionally hard task for the nursing staff. This may be more pronounced among those nurses who lack clinical experience, in line with a report on attitudes among physicians [24]
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who had little experience from second-trimester TOP. Second-trimester abortion care is carried out exclusively in hospital settings in Sweden where the nurses/midwives receive their in-service training. In the present study, some of the nurses/midwives reported negative feelings connected to experiences of handling the fetus and formed strategies to handle hard situations according to similar findings from a previous study [20]. Nevertheless, they felt that the importance of their work was worth overcoming the unpleasant feelings. In contrast to MTOP, second-trimester surgical TOP may be more physically and emotionally difficult for the nursing staff to handle because of the handling of fetal parts instead of a complete fetus [25]. For the woman undergoing second-trimester MTOP, seeing the fetus could produce emotional distress [26] that requires support from health care providers. At the same time, viewing the fetus is often appreciated by women/couples who have undergone TOP for fetal abnormality [27]. In those cases, the nurses/ midwives indicated that they made an effort to meet the woman's or couple's wishes. Since this is a qualitative study, performed in a capital city with fewer midwives compared with nurses being interviewed, the results only reflect this context. The transferability can be referred to likely sociocultural settings but not in global contexts with different abortion care regulations. Credibility is strengthened by discussions about the findings with the target group who confirmed the findings. The main investigator’s preunderstanding of the context may have facilitated the respondent’s interest in pain, and pain treatment may have influenced respondents in highlighting painmanagement-related problems more than they might have done without that knowledge. This study highlights the emotions raised from experiences from second-trimester care among Swedish nurses/ midwives. The findings support the need for training, mentoring and support by experienced colleagues to help nurses/ midwives in feeling confident and competent in their professional role and confident in their personal life situation. We recommend more scheduled time for reflection and for ethical as well as theoretical discussions. Acknowledgment The authors are grateful to the nurses who participated in the study. None of the authors have any conflict of interests in connection to the manuscript. I.M.A. designed, performed, analyzed and wrote the paper. K.C. analyzed the paper together with I.M.A. K.G.D. had overall responsibility for the funding, design and production of the paper. All the authors were involved in the discussions and manuscript writing. References [1] Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients’ perceptions of care. J Fam Plann Reprod Health Care 2001;27 (2):72–7.
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[2] Murphy F, Jordan S, Jones L. Care of women having termination of first-trimester pregnancy. Br J Nurs 2000;9(21):2235–40. [3] Halldén B-M, Christensson K, Olsson P. Early abortion as narrated by young Swedish women. Scand J Caring Sci 2009;23:243–50. [4] Liljas Stålhandske M, Makenzius M, Tydén T, Larsson M. Existential experiences and needs related to induced abortion in a group of Swedish women: a quantitative investigation. J Psychosom Obstet Gynecol 2012;33(2):53–61. [5] Kopp Kallner H, Fiala C, Gemzell-Danielsson. Assessment of significant factors accepting acceptability of home administration of misoprostol for medical abortion. Contraception 2012;85:394–7. [6] Gemzell-Danielsson K, Lalitkumar S. Second trimester medical abortion with mifepristone-misoprostol and misoprostol alone: a review of methods and management. Reprod Health Matters 2008;16(31 suppl): 162–72. [7] Lohr PA, Hayes JL, Gemzell-Danielsson K. Surgical versus medical methods for second trimester induced abortion. Cochrane Database Syst Rev 2008;1 CD006714. [8] Cheng L. (2008) Surgical versus medical methods for second-trimester induced abortion: RHL commentary. The WHO Reproductive Health Library; Geneva: World Health Organization. [9] Gallagher K, Porock D, Edgley A. The concept of “nursing” in the abortion services. J Adv Nurs 2010;66(4):849–57. [10] Lindström M, Jacobsson L, Wulff M, Lalos A. Midwive’s experiences of encoutering women seeking an abortion. J Psychosom Obstet Gynecol 2007;28(4):231–7. [11] Patton QM. Qualitative evaluation and research methods. 2nd ed. Newsbury Park, London, New Dehli: Sage Publications Inc.; 1990. [12] Holloway I, Wheeler S. (2002) Qualitative research in nursing second edition. Cornwall: MPG Books Ltd. [13] Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105–12. [14] Krippendorff K. Content analysis. An introduction to its methodology. London: Sage Publications; 2004. [15] Barroso, Sandelowski. Classifying the findings in qualitative studies. Qual Health Res 2003;13:905–25. [16] Walker S. A nurse-led service for termination of pregnancy. Prof Nurse 2000;15(8):506–9. [17] Marek MJ. Nurses’ attitudes toward pregnancy termination in the labor and delivery setting. J Obstet Gynecol Neonatal Nurs 2004;33(4): 472–9. [18] Halldén B-M, Lundgren I, Christensson K. Ten Swedish midwives’ lived experiences of the care of teenagers’ early induced abortions. Health Care Women Int 2011;32:420–44. [19] Falk G, Ivarsson A-B, Brynhildsen J. Teenagers’ struggles with contraceptive use — what improvements can be made? Eur J Contracept Reprod Health Care 2010;15:271–9. [20] Nicholson J, Slade P, Fletcher J. Termination of pregnancy services: experiences of gynaecological nurses. J Adv Nurs 2010;66(10):2245–56. [21] Benner P. From novice to expert. Am J Nurs 1982:402–7. [22] Quinlan-Colwell AD. Understanding the paradox of patient pain and patient satisfaction. J Holist Nurs 2009;27(3):177–82. [23] Blondal K, Halldorsdottir S. The challenge for caring for patients in pain: from the nurse’s perspective. J Clin Nurs 2009;18:2897–906. [24] Ingerslev MD, Diness BR, Norup M. Attitudes towards abortion among trainees in obstetrics/gynecology and clinical genetics. ACTA Obstet Gynecol Scand 2011;91:256–9. [25] Harries J, Lince N, Constant D, Hargey A, Grossman D. The challenges of offering public second trimester abortion services in South Africa: health care provider’s perspectives. J Biosoc Sci 2012;44:197–208. [26] Mukkavaara I, Öhrling K, Lindberg I. Women’s experiences after an induced second trimester abortion. Midwifery 2012;28:720–5. [27] Geerinck-Vercammen CR, Kanhai HHH. Coping with termination of pregnancy for fetal abnormality in a supportive environment. Prenat Diagn 2003;23:543–8.
Original research article
Caring for women undergoing second-trimester medical termination of pregnancy☆ Inga-Maj Andersson a,⁎, Kristina Gemzell-Danielsson b , Kyllike Christensson c b
a Department of Women’s and Children’s Health, Karolinska Institutet Södersjukhuset, Stockholm, Sweden Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, WHO Centre, Karolinska University Hospital, Stockholm, Sweden c Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden Received 8 August 2013; revised 15 January 2014; accepted 19 January 2014
Abstract Objective: The objective was to explore the experiences and perceptions of nurses/midwives caring for women undergoing second-trimester medical termination of pregnancy (MTOP). Study design: The study had a qualitative design using semistructured interviews. It took place in three wards at one gynecological clinic in a general hospital in Stockholm. Twenty-one nurses/midwives with experience in second-trimester abortion care were interviewed following a semistructured interview guide. The interviews were recorded, transcribed verbatim and then analyzed using qualitative content analysis to identify common themes. Results: The analysis revealed two themes: “The professional self,” with six subthemes describing the experiences and perceptions described in terms of professional behavior, and “The personal self,” with four subthemes containing the experiences and perceptions described in terms of personal values. Conclusions: Taking care of women undergoing second-trimester MTOP is a task that requires professional knowledge, empathy and the ability to reflect on ethical attitudes and considerations. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. The feeling of supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second-trimester MTOP. The findings of this study support the need for training, mentoring and support by experienced colleagues to help nurses/midwives feel secure in their professional role in difficult situations and feel confident in their personal life situation. Implications statement: Taking care of women undergoing second-trimester MTOP is a task that requires professional knowledge and empathy. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. Mentorship from experienced colleagues and structured opportunities for reflection on ethical issues enable the nurses/midwives to develop security in their professional roles and also feel confident in their personal life situation. The feeling of doing something good for women's rights bridges the difficulties nurses/midwives face in caring for women undergoing second-trimester MTOP. © 2014 Elsevier Inc. All rights reserved. Keywords: Abortion; Second trimester; Interview; Content analysis; Nurses; Midwives
1. Introduction High-quality professional care and a nonjudgemental approach have been shown to have a significant impact on women’s sense of security in abortion situations [1,2]. ☆
Acknowledgement of funding: The study was supported by grants from the Swedish Research Council, FAS, Karolinska Institutet and Stockholm City County/Karolinska Institutet (ALF). ⁎ Corresponding author. Tel.: +46702191038. E-mail address: [email protected] (I.-M. Andersson). 0010-7824/$ – see front matter © 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.contraception.2014.01.012
Women undergoing termination of pregnancy (TOP) may be in a complex situation [3] with emotional and existential needs which require care based on experience and empathy [4]. During the last decade, medical methods for secondtrimester TOP have developed considerably. In contrast to early MTOP, which can be handled by the woman herself [5], second-trimester MTOP demands more involvement by health care providers, and the risk for complications increases with gestational length [6]. Second-trimester medical TOP (MTOP) has been shown to be as safe and effective as dilatation and evacuation [7],
I.-M. Andersson et al. / Contraception 89 (2014) 460–465
with less need for trained providers of surgical TOP. As a result, there is an increased use of MTOP worldwide. In Sweden, MTOP has replaced other methods for secondtrimester abortion. The same trend is seen across Europe and beyond. The regimen used in Sweden is the one recommended by the World Health Organization of 200 mg mifepristone followed 36 to 48 h later by an initial dose of 800 mcg of misoprostol administered vaginally and then repeated doses of 400 mcg misoprostol (orally or sublingually) until expulsion [8]. Paracetamol and nonsteroidal anti-inflammatory drugs are commonly used for pain treatment supplemented with intravenous morphine and sometimes paracervical blockade. Nurses or midwives frequently care for women undergoing second-trimester MTOP. However, so far, only a few studies have focused on the experiences of nurses/midwives providing care for women undergoing second-trimester MTOP [9], and a previous study among midwives [10] showed misgivings of working with late TOP reported by 35% of respondents. Therefore, with increasing use of second-trimester MTOP, increasing involvement of nurses/midwives in abortion care and most studies on health care providers’ experiences focusing on early MTOP, a deeper knowledge of factors that may influence the perception of nurses/midwives involved in care of second-trimester abortion seems warranted. The aim of the present study was thus to explore the experiences and perceptions of nurses/midwives caring for women undergoing second-trimester MTOP.
2. Material and methods A qualitative approach was used to gain a deeper understanding and capture the perceptions and experiences [11] of the nurses and midwives caring for women undergoing second-trimester TOP. 2.1. Participants Participants were recruited from three gynecological care units at a general hospital in Stockholm. Forty nurses and 10 midwives are employed in these wards and care for patients undergoing gynecological surgery or treatment as well as women undergoing second-trimester abortion. About 500 second-trimester (and total 2500) abortions are performed annually. Nurses/midwives are responsible for medication administration, care given during the process and fetus delivery. The participants’ varied ages and experiences from abortion care increased the possibility of revealing variations of the studied phenomena [11]. 2.2. Data collection Invitation to participate was given in six workplace meetings together with verbal and written information about
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the study. Twenty-one nurses/midwives interested in participating contacted the first author (I.M.A.) via mail, who interviewed them all. Interviews enable getting closer to the respondent’s views and ideas, especially when interviewing colleagues from the same cultural context [12]. In this study, the interviewer’s preunderstanding was acquired by earlier experiences with second-trimester abortion care. Individual interviews were used following a semistructured guide (Table 1) which included questions with the possibility to follow up the answers. A hypothetical case, about a young woman with a repeat second-trimester abortion who expressed emotional pain, was used to capture the respondent’s views on patient care. One pilot interview was videotaped, and the product was discussed with 10 fellow research students, resulting in more open questions. All interviews were conducted between April 2010 and July 2012 in a secluded site and lasted between 17 and 35 min. The interviews were recorded and transcribed verbatim. 2.3. Analysis Content analysis is a method that interprets reality by creating units of content related to the context being studied [13]. Thematic content analysis shares a commonality in content derived from texts from interviews with persons from a context [11,14]. Content analysis was used, originating from interviews in contexts well known to the researcher and the participants. We read the transcribed text several times to gain an overview of the content. Meaning units were identified and extracted from the transcribed text individually by two researchers (I.M.A. and K.C.) who then jointly gave the units codes to summarize the content [14]. We discussed the codes, and likely words and sentences were placed together in 14 categories to systematically and objectively describe patterns [15] in how the nurses and midwives expressed their feelings and thoughts. From the categories, two themes emerged: “The professional self” and “The personal self” (Table 2). The themes were discussed by the whole research team as well as in seminar sessions with other research fellow midwives. The study was approved by the Regional Ethical Review Board at Karolinska Institutet in Stockholm. Voluntary par-
Table 1 Questions from the interview guide Question How did it come that you chose to work in gynecology? How long have you cared for women undergoing late abortion? How do you like your work? What do you perceive as positively in care for late abortion? What do you perceive as difficult? What are a woman’s needs of you as a caregiver? What do you need to be able to provide/meet the need for care?
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Table 2 Examples of meaning units, condensed meaning units, codes and theme Meaning unit
Condensed meaning units
Codes
Theme
I also have strategies… therefore I never look for example, on the fetus when it … I look at the umbilical cord when it comes out, and so, different strategies to not see … so I have not changed my mind in the abortion issue as well but I have changed a bit. This that you become a little more humble and well, yes it can… unwanted pregnancy, and they are very relieved and happy that you get to do it in week 20
I have strategies, for example, I never look at the fetus, I look at the umbilical cord when it comes out in order not to see. I have not changed my mind on the issue of abortion, but I have amended to be a bit more humble … to have more understanding.
The fetus
The professional self
Reflection
The personal self
ticipation was confidential, and informed consent was obtained by the interviewer before the interview.
3. Results Seventeen nurses and four midwives, aged 25 to 59 years, with experience of abortion care ranging from 2 months to 17 years participated in the study (Table 3). The analysis revealed two themes: “The professional self,” with six subthemes describing the experiences and perceptions described in terms of professional behavior, and “The personal self,” with four subthemes containing the experiences and perceptions described in terms of personal values. The themes cross over each other in some aspects, especially regarding competence among the participants.
4. The professional self 4.1. Being familiar with the process Having clinical knowledge of second-trimester MTOP was described as important. Knowing you were competent gave strength and a sense of security, which made it easier to communicate calmly and in a secure manner. The nurses/ midwives who were less experienced sometimes felt that they transferred their own anxiety to the women when complications or unexpected events or reactions occurred. “If you feel confident in your role and know the process, you feel comfortable with the situation and convey a sense of security." (no 11)
Participants expressed a need for technical training to create more of a sense of their own competency in nursing situations. 4.2. Balancing objective information
Table 3 Demographic information about the participants Participant no
Nurse/midwife
Age
Years as nurse/midwife
Experience from abortion care
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Nurse Nurse Nurse Midwife Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Nurse Midwife Midwife Midwife Nurse Nurse a Nurse Nurse a
50 46 27 31 35 37 26 25 27 26 28 25 49 32 41 56 46 59 37 42 34
25 13 3 6/3 9 2 2 1 2 2 3 1 18 1 22/16 5/28 3/1 15 8 10 6
5 years 10 years 2 years 2 months 8 months 2 years 2 years 1 year 10 months 7 months 1,5 years 9 months 17 years 10 months 12 years 10 years 3 years 15 years 6 years 10 years 4 years
a
Midwife student.
Detailed information was provided to create a sense of security in the woman before and during the procedure. The nurse/midwife sometimes used communication strategies to decrease stress caused by emotionally difficult information. The participants did not want to scare the woman about the pain or lie. “You can’t say how it will feel physically, how painful it will be." (no 2)
When the woman was not fluent in Swedish, it was considered important to have an interpreter. 4.3. Finding ways for pain treatment The midwives’/nurses’ professional experience of caring for patients with pain made them keen to provide women with adequate pain treatment. Some described a sense of powerlessness when they were unable to find an optimal method to relieve severe pain. Wishes emerged about broadening the competencies of the midwives to apply a more effective pain treatment — paracervical block — that today is usually limited to use by doctors. Pain assessment tools were used for the physical pain; pain of a mental and existential
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nature was regarded as immeasurable. Therapeutic use of professional presence, listening and communication was a way for the nurses/midwives to attempt to provide satisfactory pain relief. “Whatever you give it doesn’t help … The best thing is to do nothing, just be there and listen." (no 19)
4.4. Looking for the woman’s needs Several nurses/midwives believed that women with different personalities need different kind of care, and the nurses/midwives stated that they had developed an ability to perceive different personalities and adapt their care to the woman's wishes. The ability to understand the underlying causes of women's reactions had been developed over the years by being able to sense the atmosphere and the specific needs for the woman and to understand even nonverbal communication. To convey the involvement of the woman, a permissive attitude to the women to express their inner feelings and openness to questions were consistently seen as foundational skills. Communication could be inhibited if the woman did not express her thoughts and feelings. The nurses/midwives tried to establish closer contact in these situations by lightening the mood, recalling some personal life experience or giving body contact. “Sometimes they want to have it in a certain way, but you can’t know that before you ask. I feel that it’s really important that you try to find out what the woman wants.” (no 7)
4.5. Handling the fetus Handling the fetus was one of the most difficult aspects. The nurses/midwives wanted to treat it with dignity. In the few cases where the fetus had shown signs of life, the nurse/ midwife described how they did not abandon it until all signs of life had disappeared. The majority of participants found fetal vital signs unpleasant but had found ways to handle it to reduce discomfort and/or to disconnect their own thoughts. “I have strategies, for example, I never look at the fetus, I look at the umbilical cord when it comes out in order not to see." (no 19)
Women who terminated their pregnancy because of malformation were routinely offered a chance to say goodbye. Other women were shown the fetus if they asked. Opinions that only the woman can decide about the fetus and that looking at the fetus can make the situation even worse for the woman were expressed by the participants. 4.6. Needing time for reflection The nurses/midwives perceived needs in both the health care organization and in themselves. The desire for increased resources was specified, as this would provide more time for the women by taking care of fewer patients at a time and
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increase opportunities for regular reflection/debriefing. Support from colleagues and time for personal reflection were seen as opportunities for developing the ability to find solutions to gain valuable practical knowledge and the ability to move on. “The most important thing is to talk about it, especially with my colleagues” (no 8)
The wish for education about fetal development revealed the need for reflections centered on the fetus’ capacity or noncapacity to survive an abortion as well as discussions about attitudes about women’s rights and abortion. 5. The personal self 5.1. Conflicting duty and behavior An effort was made to treat everyone equally regardless of the reason for the MTOP, and it was considered important to care for the individual rather than adhere to principles. To behave neutrally and withhold personal opinions appeared to be an important approach. In cases where the woman seemed tough or unconcerned, some nurses/midwives noted that it was difficult to maintain their views on women’s abortion rights. Thoughts about TOP being used as a method of contraception existed among a few of the participants, even if this was something that they did not actually want to speak about openly. One midwife expressed sorrow for the waste of life regarding the abortion of healthy fetuses by healthy women in contrast to women struggling with infertility problems. Care for second-trimester terminations was seen as a necessity despite this injustice. “I felt it was a waste, too bad that no one could adopt it.” (no 17)
Commitment to women's rights and commitment to improve abortion care led participants to feelings of involvement in the women's struggle, and thus abortion care was perceived as important both for their own beliefs and to society at large. 5.2. Dealing with emotions Feelings of relief, gratitude and joy in a job well done were presented as well as more negative feelings. Carrying emotions inside to prevent those emotions from taking the upper hand in a situation was a way for the nurses/midwives to deal with their own feelings. Emotions such as anger and outrage were perceived as forbidden emotions. Feelings of grief, sorrow and sadness were shared with the women without crying. “I would never ever show, it’s just a thought in my brain. I’m there as a nurse not as a private person” (no 5)
5.3. Identifying oneself with the woman The participants of fertile age sometimes identified themselves with the women experiencing fetal malformation
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and imagined the sadness that could have afflicted them in the same situation. Before ultrasound screening in her first pregnancy, one nurse revealed that she felt concern related to women she had met who had terminated their pregnancy because of fetal malformation. “I have no children but… this is my picture, you see miscarriages, complications and when things go wrong… you feel scared” (no 3)
Identifying with the feelings of the woman’s parents was mentioned by some of the older participants who were thinking about their own daughters. 5.4. Developing inner safety and maturity From experiences with other areas of women’s health together with the nurses/midwives own life situations, the personal maturity of the nurses/midwives was described as developing inner safety and maturity. An inner confidence and an increased understanding of women’s varied situations were developed. These were inherent in and obtained from nursing competence and ethical thinking. The young nurses had actively sought positions in gynecology to gain experience for further training as a midwife. The nurse’s/ midwife’s particular ethical standpoint on second-trimester MTOP became more nuanced over the years. Increased awareness of their own emotions could be seen as a maturing process. “Even though it's a really difficult situation, I'm incredibly happy to have experienced this. I think you develop a lot as a person and you become stronger." (no 14)
6. Discussion This study explores the experiences and perceptions of nurses/midwives caring for women undergoing secondtrimester MTOP. The included participants are deemed as a representative sample of staff in Swedish gynecological wards, with varying theoretical knowledge and experiences from nursing and midwifery care. The analysis revealed two themes: “The professional self” and “The personal self.” A conflict can be seen between the themes: what the nurses/ midwives must do as part of their professional obligations and what they would like to do based on their inner feelings and thoughts. Difficult situations that arise during the process are easier to handle with increased knowledge and experience. The sense supporting women's rights bridges the difficulties nurses/midwives face in caring for women undergoing MTOP. Data showed multiple meanings in the studied context and can be seen as not mutually exclusive and therefore crossing over the themes and subthemes [13]. The participants were well aware that professional care, with a nonjudgmental attitude and respect during TOP, is important for
the woman’s ongoing well-being [16]. Contradictions in opinions, attitudes and emotions were expressed by some participants, especially when referring to cases in advanced gestational length. This is consistent with previous findings showing that nurses’ willingness to care for patients electing TOP for fetal anomaly decreases with gestational length [17]. The opinion that young women look upon abortion as a justified right [18] to terminate a pregnancy owing to media scare stories about contraceptive side effects [19] is in accordance with previous studies and mirrors the sociocultural influence in Sweden. The participants found it hard to talk about their job with relatives, afraid of being misunderstood, which mirrors previous findings [20] about hesitation to talk about involvement in second-trimester abortion care. However, at the same time, they wanted to raise public awareness about secondtrimester MTOP to improve abortion care. Increased understanding of women’s various circumstances was developed with greater experience, but not the standpoint towards TOP, which is consistent with earlier studies [18] about midwives’ experiences. Nurses involved with TOP care are in need of mentorship [20], and team support is seen as a coping strategy [9]. Debriefing and ethical discussions with more experienced colleagues and counselors helped the participants in the present study to grow in their professional role. With increased experience in second-trimester abortion care, the participants relied on intuitive understanding which had grown over time [21]. A second-trimester MTOP includes fetus delivery, and midwives no doubt have more experience than nurses in dealing with the care of the woman, the fetus and the related physical pain. Development was seen among the nurses/ midwives in perception and understanding of situations. This ranged from novice to expert [21] according to experiences from other areas in women’s health care as well as own life situations. All of the nurses/midwives considered the pain and the desire to provide adequate pain treatment to the women as difficult and hard to handle. Caring for patients with pain has been described [22] as a challenging task; the nurse has to find complementary strategies to reduce pain when pharmacological treatment is not enough. The nurses/ midwives in the present study used their professional competence to relieve pain by being present and listening to the women. The feeling of a lack of power in pharmacological pain treatment is worrying since, according to an earlier study [23], successful pain relief was reported as one important factor in the nurses’ sense of empowerment and overall well-being and frustration was reported when pain was unrelieved. Multiple individualized care strategies to relieve pain are essential for the experienced nurse to meet the woman’s needs [21]. Earlier studies [18,20] have shown that handling the aborted fetus, particularly in later gestational weeks, is an emotionally hard task for the nursing staff. This may be more pronounced among those nurses who lack clinical experience, in line with a report on attitudes among physicians [24]
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who had little experience from second-trimester TOP. Second-trimester abortion care is carried out exclusively in hospital settings in Sweden where the nurses/midwives receive their in-service training. In the present study, some of the nurses/midwives reported negative feelings connected to experiences of handling the fetus and formed strategies to handle hard situations according to similar findings from a previous study [20]. Nevertheless, they felt that the importance of their work was worth overcoming the unpleasant feelings. In contrast to MTOP, second-trimester surgical TOP may be more physically and emotionally difficult for the nursing staff to handle because of the handling of fetal parts instead of a complete fetus [25]. For the woman undergoing second-trimester MTOP, seeing the fetus could produce emotional distress [26] that requires support from health care providers. At the same time, viewing the fetus is often appreciated by women/couples who have undergone TOP for fetal abnormality [27]. In those cases, the nurses/ midwives indicated that they made an effort to meet the woman's or couple's wishes. Since this is a qualitative study, performed in a capital city with fewer midwives compared with nurses being interviewed, the results only reflect this context. The transferability can be referred to likely sociocultural settings but not in global contexts with different abortion care regulations. Credibility is strengthened by discussions about the findings with the target group who confirmed the findings. The main investigator’s preunderstanding of the context may have facilitated the respondent’s interest in pain, and pain treatment may have influenced respondents in highlighting painmanagement-related problems more than they might have done without that knowledge. This study highlights the emotions raised from experiences from second-trimester care among Swedish nurses/ midwives. The findings support the need for training, mentoring and support by experienced colleagues to help nurses/ midwives in feeling confident and competent in their professional role and confident in their personal life situation. We recommend more scheduled time for reflection and for ethical as well as theoretical discussions. Acknowledgment The authors are grateful to the nurses who participated in the study. None of the authors have any conflict of interests in connection to the manuscript. I.M.A. designed, performed, analyzed and wrote the paper. K.C. analyzed the paper together with I.M.A. K.G.D. had overall responsibility for the funding, design and production of the paper. All the authors were involved in the discussions and manuscript writing. References [1] Slade P, Heke S, Fletcher J, Stewart P. Termination of pregnancy: patients’ perceptions of care. J Fam Plann Reprod Health Care 2001;27 (2):72–7.
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[2] Murphy F, Jordan S, Jones L. Care of women having termination of first-trimester pregnancy. Br J Nurs 2000;9(21):2235–40. [3] Halldén B-M, Christensson K, Olsson P. Early abortion as narrated by young Swedish women. Scand J Caring Sci 2009;23:243–50. [4] Liljas Stålhandske M, Makenzius M, Tydén T, Larsson M. Existential experiences and needs related to induced abortion in a group of Swedish women: a quantitative investigation. J Psychosom Obstet Gynecol 2012;33(2):53–61. [5] Kopp Kallner H, Fiala C, Gemzell-Danielsson. Assessment of significant factors accepting acceptability of home administration of misoprostol for medical abortion. Contraception 2012;85:394–7. [6] Gemzell-Danielsson K, Lalitkumar S. Second trimester medical abortion with mifepristone-misoprostol and misoprostol alone: a review of methods and management. Reprod Health Matters 2008;16(31 suppl): 162–72. [7] Lohr PA, Hayes JL, Gemzell-Danielsson K. Surgical versus medical methods for second trimester induced abortion. Cochrane Database Syst Rev 2008;1 CD006714. [8] Cheng L. (2008) Surgical versus medical methods for second-trimester induced abortion: RHL commentary. The WHO Reproductive Health Library; Geneva: World Health Organization. [9] Gallagher K, Porock D, Edgley A. The concept of “nursing” in the abortion services. J Adv Nurs 2010;66(4):849–57. [10] Lindström M, Jacobsson L, Wulff M, Lalos A. Midwive’s experiences of encoutering women seeking an abortion. J Psychosom Obstet Gynecol 2007;28(4):231–7. [11] Patton QM. Qualitative evaluation and research methods. 2nd ed. Newsbury Park, London, New Dehli: Sage Publications Inc.; 1990. [12] Holloway I, Wheeler S. (2002) Qualitative research in nursing second edition. Cornwall: MPG Books Ltd. [13] Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105–12. [14] Krippendorff K. Content analysis. An introduction to its methodology. London: Sage Publications; 2004. [15] Barroso, Sandelowski. Classifying the findings in qualitative studies. Qual Health Res 2003;13:905–25. [16] Walker S. A nurse-led service for termination of pregnancy. Prof Nurse 2000;15(8):506–9. [17] Marek MJ. Nurses’ attitudes toward pregnancy termination in the labor and delivery setting. J Obstet Gynecol Neonatal Nurs 2004;33(4): 472–9. [18] Halldén B-M, Lundgren I, Christensson K. Ten Swedish midwives’ lived experiences of the care of teenagers’ early induced abortions. Health Care Women Int 2011;32:420–44. [19] Falk G, Ivarsson A-B, Brynhildsen J. Teenagers’ struggles with contraceptive use — what improvements can be made? Eur J Contracept Reprod Health Care 2010;15:271–9. [20] Nicholson J, Slade P, Fletcher J. Termination of pregnancy services: experiences of gynaecological nurses. J Adv Nurs 2010;66(10):2245–56. [21] Benner P. From novice to expert. Am J Nurs 1982:402–7. [22] Quinlan-Colwell AD. Understanding the paradox of patient pain and patient satisfaction. J Holist Nurs 2009;27(3):177–82. [23] Blondal K, Halldorsdottir S. The challenge for caring for patients in pain: from the nurse’s perspective. J Clin Nurs 2009;18:2897–906. [24] Ingerslev MD, Diness BR, Norup M. Attitudes towards abortion among trainees in obstetrics/gynecology and clinical genetics. ACTA Obstet Gynecol Scand 2011;91:256–9. [25] Harries J, Lince N, Constant D, Hargey A, Grossman D. The challenges of offering public second trimester abortion services in South Africa: health care provider’s perspectives. J Biosoc Sci 2012;44:197–208. [26] Mukkavaara I, Öhrling K, Lindberg I. Women’s experiences after an induced second trimester abortion. Midwifery 2012;28:720–5. [27] Geerinck-Vercammen CR, Kanhai HHH. Coping with termination of pregnancy for fetal abnormality in a supportive environment. Prenat Diagn 2003;23:543–8.
