QUALITY IMPROVEMENT PROJECT: PROVISION OF GRIEF COUNSELLING TO MOTHERS WHO HAVE LOST THEIR BABIES. It is a study under leadership and management course in nursing school. It provides enough details on quality improvement projects that can be done on hospital especially to postnatal mothers who has lost their children. It is a project that was done to reduce effects of bereavement on mothers that might lead to mental damage hence impact on quality of care in generally

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BY
ACHOKA CLIFFORD(BSCN)

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QUALITY IMPROVEMENT PROJECT: PROVISION OF GRIEF COUNSELLING TO
MOTHERS WHO HAVE LOST THEIR BABIES

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Contents
1.FOREWORD ..................................................................................................................................4
2.HOSPITAL MISSION AND VISION...............................................................................................5
3.IDENTIFICATION OF A PROBLEM FOR QUALITY IMPROVEMENT IN THE WARD................5
3.1 Definition .................................................................................................................................5
3.2 How Is It Related To Quality Care..............................................................................................5
3.3 Evidence That It Can Work........................................................................................................7
3.4 HOW IT IS IMPLIMENTED IN THE WARD............................................................................8
3.5 Strengths...................................................................................................................................8
3.6 GAPS IN THE UNIT................................................................................................................8
4. ANALYSIS OF THE CAUSE OF THE PROBLEM .........................................................................9
4.1 Root cause analysis ...................................................................................................................9
4.2 Counter measures to solve CQI problem area............................................................................11
4.3 Implementation of effective counter measures...........................................................................13
4.4 Effectiveness and standardization of countermeasures................................................................14
5. AIM STATEMENT......................................................................................................................14
6. RELEVANCE USING EVIDENCE BASED PRACTICE...............................................................14
7. RELATIONSHIP OF THE PROBLEM TO THE DIMENSIONS OF QUALITY..............................15
8. ANALYSIS OF THE PROBLEM AND ITS INFLUENCES ON PROCESS, OUTCOME ................16
9. EXECUTION OF QUALITY IMPROVEMENT USING A MODEL...............................................16
9.1 CQI problem area....................................................................................................................16
9.9 Situation analysis -EPISTEL....................................................................................................16
9.3. Countermeasures....................................................................................................................20
9.4 Implementation of effective counter measures...........................................................................20
9.5 Effectiveness of countermeasures.............................................................................................20
9.6 Standardization of countermeasures..........................................................................................20
X.ACTION PLAN............................................................................................................................20
XI. MONITORING AND EVALUATION.........................................................................................21
XII. STEPS TO BE TAKEN TO SUSTAIN IMPROVEMENTS .........................................................21
XIII. CONCLUSION........................................................................................................................22

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XIV. EVIDENCE OF IMPLEMENTATION IN THE WARD.............................................................22
XV.REFERENCES..........................................................................................................................23
1.FOREWORD
Health care quality is the degree to which health care services for individuals and populations
increase the likelihood of desired health outcomes(Understanding quality management,2016)
Quality of care plays an important role in describing the iron triangle of health care, which
defines the intricate relationships between quality, cost, and accessibility of health care within a
community (Carrol et.al ., 2012). Researchers measure health care quality to identify problems
caused by overuse, underuse, or misuse of health resources (Chassin., M.R.,1998). In 1999,
the Institute of Medicine released six domains to measure and describe quality of care in health
(Richardson.,William.,C (2000):
1. Safe – avoiding injuries to patients from care that is intended to help them.
2. Effective – avoiding overuse and misuse of care.
3. Patient-Centered – providing care that is unique to a patient's needs.
4. Timely – reducing wait times and harmful delays for patients and providers.
5. Efficient – avoiding waste of equipment, supplies, ideas and energy.
6. Equitable – providing care that does not vary across intrinsic personal characteristics
Quality improvement is defined “as systematic, data-guided activities designed to bring about
immediate improvement in health care delivery in particular settings” (Lynn et.al., 2007). A
quality improvement strategy is defined as “any intervention aimed at reducing the quality gap
for a group of patients representative of those encountered in routine practice” ( Shojania
et.al.,2004).

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2.HOSPITAL MISSION AND VISION
Mission
To provide accessible, responsive, quality healthcare services through innovation, training and
research
Vision
A center of excellence in quality healthcare services, training and research in East and Central
Africa
3.IDENTIFICATION OF A PROBLEM FOR QUALITY IMPROVEMENT IN THE WARD
3.1 Definition
Grief is a reaction to any form of loss that encompass a range of feelings from deep sadness to
anger, and the process of adapting to a significant loss can vary dramatically from one person to
another, depending on his or her background, beliefs, relationship to what was lost and other
factors(mastrangelo and wood,2016).
Grief counseling is intended to help the client grieve in a healthy manner, to understand and cope
with emotions they experienced, and ultimately find a way to move on (Therapy tribe,n.d).
Bereavement counseling-sometimes called grief counseling-refers to counseling offered to
individuals who have suffered a loss, typically the death of a loved one, in order to help the
bereaved through the process of mourning and recovery (Encylopedia.com,2009)
3.2 How Is It Related To Quality Care
Health care providers will encounter bereaved individuals throughout their personal and
professional lives (Casarett, et.al., 2001).
Medicine is usually associated with treatment and cure, but there are instances where patients
die. Grief is an individual, but normal adjustment process after a loss, such as death (Worden
JW, 1991).The grief process affects many aspects of life, including physical, emotional,
cognitive, behavioral and spiritual adjustments(Worden JW.1991). Adjustment is therefore
needed after each death experience.

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Research and professional consensus suggest that the majority of bereaved people will cope with
the pain of a “normal” grief reaction without professional help, and that, over time, they will
begin to feel better (Kersting et al., 2011; Zisook et al., 2014). Still, bereavement is associated
with a variety of negative mental and physical health outcomes (Stroebe et al.,2007; Zisook et
al., 2014). Physical health outcomes include an increased risk of mortality (Buckley et al., 2012),
suicidality (Prigerson et al., 1997; Zisook et al., 2014), and morbidity (Buckley et al., 2012;
Keyes et al., 2014; O'Connor, Schultze‐ Florey, Irwin, Arevalo, & Cole, 2014). Mental health
outcomes include depression, post‐ traumatic stress disorder (PTSD), and difficulties in grieving
that extend in duration and severity beyond the scope of “normal” grief symptoms, also termed
complicated grief (CG) (Zisook et al., 2014).
Pediatric healthcare providers must provide emotional support to their dying patients and their
bereaved families. This task is challenging and is recognized cause of burnout and other forms of
emotional distress (Rich S., 2002;Redinbaugh et al.,2003).Little is known about the impact of a
dying child on Healthcare providers. Evidence suggests that doctors and nurses mainly
experience guilt, sadness and stress when faced with the death of their patient (Rich S.,
2002;Redinbaugh et al.,2003).According to Papadaou et al (2002),the death of a young patient
causes pain and distress in nurses and physicians.
Unattended staff grief can impact healthcare leaders by reducing quality of care, increasing staff
turnover and abseentism, lowering morale in provision of patient care(mary S, 2016).
An article by the New York Times (2019), states that, the grief of fathers, adoptive mothers and
other relatives after a family death is no less real, but postpartum women in mourning endure a
particularly complicated blend of physical and emotional duress.
A study conducted in South Africa on failed resuscitations shared the reactions of doctors after
the death of a patient. The doctors felt emotionally drained and the incident affected their private
lives. Most doctors expressed the desire to have time to reflect on the incident and have time for
recreational activities, which was usually not available because of workload (Isaacs A, Mash
RJ,2004). If another loss will occur before the grief process is completed, bereavement overload
will occur.
Support to health care providers is most effective if it was provided in the workplace. Such
support should provide a listening ear with simple care and encouragement and not necessarily
psychological counselling (Baverstock A, Finlay F,2006) Though the stress and support occur at
work, the healing mostly takes place outside the workplace (Miller B, Sprang G,2017).
It is absolutely normal to experience grief after a miscarriage, whenever it occurs in the
pregnancy; however, recent research shows that around 15% of women who experience
miscarriages suffer from more serious grief related symptoms that may require the assistance of a
mental health professional (Leis-Newman,2012).
Pregnancy loss is a painful and traumatic event that can occur at any time during the pregnancy.
However, late pregnancy losses cause more psychological traumas to the parents and families
and are associated with post-traumatic stress, depression, anxiety and sleeping disorder (Hughes

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p., Riches S., 2003).Research has shown that women experience longer periods and higher levels
of grief after perinatal loss(Capitulo K.,2005).
3.3 Evidence That It Can Work
Given the patterns of difference in reactions to a loss experience, it is critically important that
effective psychological interventions are developed for people experiencing difficulties in coping
with bereavement (Currier et al.,2008). It can be surmised that an effective intervention would be
aimed specifically at help‐ seeking bereaved people at least 6 months after bereavement who
present with, or are seriously at risk of developing, psychopathology (Center for the
Advancement of Health, 2003; Currier et al., 2008; Schut et al., 2001; Wimpenny et al., 2007).
The grief process affects many aspects of life, including physical, emotional, cognitive,
behavioural and spiritual adjustments (Worden JW.1991). Adjustment is therefore needed after
each death experience.
While we all feel grief and loss, and each of us is unique in the ways we cope with our feelings.
Some people have healthy coping skills. They’re able to feel grief without losing sight of their
daily responsibilities. Other people don’t have the coping skills or support they need. That
hinders the grieving process (WebMD,2005-2019).
While grief counseling is not necessary for most people dealing with the loss of a loved one,
people dealing with the loss of a loved one, there are some big potential benefits for those
struggling more than usual (Mehta,2013).
Women may experience psychological problems such as grief, depression, and anxiety(Bennett
et.al., 2012).Some health personnel may not be aware of the extent wo which these problems are
manifested(Sutan R,Miskam HM.,2005).Identifying psychological problems and providing
counselling to such women is much needed to address their fear of problems in future
pregnancies and family life. An intervention cannot bring back their beloved infant, but an
appropriate intervention could promote physical and emotional healing. Midwives are in a
unique position to provide psychological support since they are with women, giving care to them
24 hours, and they know the importance of psychological support. They must take it as a

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challenge to care holistically for women who experience psychological problems, especially after
pregnancy loss(Journal of Asian midwives.,2015).
A journal of Asian midwives, (2015) States Women with pregnancy loss experience various
psychological problems immediately after deliver. They need supportive and protective care
during and after hospitalization. They appreciate the concern of the staff during time of distress.
The study findings showed a reduction in psychological problems of women with bereavement
counseling, after pregnancy loss.
3.4 HOW IT IS IMPLIMENTED IN THE WARD
The focus is mostly on primigravida who has lost a baby and those with prolonged grief who are
probably severely depressed. In the ward counseling of grieving mothers is not slotted in as the
nurses’ task despite the knowledge on grief. In case a mother has lost a baby the ward in charge
or any staff calls counselors from the Gender-based recovery center. Nurses don’t really pay
attention to grieving mothers as they assume that isn’t part of their role being that counsellors are
available from the GBVRC.
The AAP/ACOG Guidelines for Perinatal Medicine, (2012) state that the roles of the health care
team are to help the family start normal grief reaction, actualize the loss, acknowledge their grief,
assure family that their feelings are normal and meet the particular needs of each family.
Hospital counselors are licensed mental health counselors or licensed social workers that help
patients find beneficial things to do after they are released from the hospital (Elizabeth,2012).
3.5 Strengths
Grief counseling on primigravida has helped them in better coping mechanism and hence lower
the risk of postpartum depression
3.6 GAPS IN THE UNIT
1. Concentration on Primigravida forgetting mothers who have had IUFD, miscarriages or
multigravida
2. Nurse negligence
3. Lack of continuity of care focusing on psychological/mental health
4. Lack of guidelines/protocol that detect importance and steps of grief counseling
5. Lack of nursing staff debriefing
6. unavailability of grief assessment tool

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4. ANALYSIS OF THE CAUSE OF THE PROBLEM
4.1 Root cause analysis
root cause analysis (RCA) is a method of problem solving used for identifying the root causes of
faults or problems (Wilson,2012). n the domains of health and safety, RCA is routinely used in
medicine (diagnosis), epidemiology (e.g., to identify the source of an infectious disease),
environmental science (e.g., to analyze environmental disasters), accident analysis (aviation and
rail industry), and occupational safety and health (OSHO,2019).
RCA methods
The nature of RCA is to identify all and multiple contributing factors to a problem or event. This
is most effectively accomplished through an analysis method. Some methods used in RCA
include:
The “5-Whys” Analysis” — A simple problem-solving technique that helps users get to the root
of the problem quickly. It was made popular in the 1970’s by the Toyota Production System.
This strategy involves looking at a problem and asking “why” and “what caused this problem”.
Often the answer to the first “why” prompts a second “why” and so on—providing the basis for
the “5-why” analysis.
Barrier Analysis — Investigation or design method that involves the tracing of pathways by
which a target is adversely affected by a hazard, including the identification of any failed or
missing countermeasures that could or should have prevented the undesired effect(s).
Change Analysis — Looks systematically for possible risk impacts and appropriate risk
management strategies in situations where change is occurring. This includes situations in which
system configurations are changed, operating practices or policies are revised, new or different
activities will be performed, etc.
Causal Factor Tree Analysis — An investigation and analysis technique used to record and
display, in a logical, tree-structured hierarchy, all the actions and conditions that were necessary
and sufficient for a given consequence to have occurred.

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Failure Mode and Effects Analysis — A “system engineering” process that examines failures in
products or processes.
Fish-Bone Diagram or Ishikawa Diagram — Derived from the quality management process, it’s
an analysis tool that provides a systematic way of looking at effects and the causes that create or
contribute to those effects. Because of the function of the fishbone diagram, it may be referred to
as a cause-and-effect diagram. The design of the diagram looks much like the skeleton of a
fish—hence the designation “fishbone” diagram.
Pareto Analysis — A statistical technique in decision making that is used for analysis of selected
and a limited number of tasks that produce significant overall effect. The premise is that 80% of
problems are produced by a few critical causes (20%).
Fault Tree Analysis — The event is placed at the root (top event) of a “tree of logic”. Each
situation causing effect is added to the tree as a series of logic expressions.
I decided to use fish-bone diagram as my method of root cause analysis.

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4.2 Counter measures to solve CQI problem area
Root cause of the problem Countermeasures of the root
cause of the problem
Rationale
1. Lack of adequate nurses’ staff
to perform nursing tasks and
counseling services.
Advocate for recruitment of
enough nurses staff to carry
out the patient care at
appropriate time and hence
allowing scheduled time for
provision of counseling
services to clients that need
it.
It is an administrative
responsibility to ensure
that each nurse is assigned
a manageable patient load
so as to render all the
needed care as the support
staff carry out the non-
nursing tasks for optimal
health service promotion
2. Lack of daily action plan
guide
Ensure to have a daily
activity plan, and to be aware
of all the staff and students
present on duty, appointing a
time manager who will
ensure things are done at the
correct time
To ensure all nursing
activities are performed in
time and in the order of
priority and to slot time
for assessment of patients.
3. Lack of perinatal
bereavement tool
Introduction of a standard
perinatal bereavement tool
An assessment tool would
make it easier and faster
in providing a better

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assessment of mothers
and hence make it easier
noticing those at risk.
4. Failure to utilize the
information technology
system to generate and verify
the required patient
information
Introduction of a standard
computerized system for
discharging patients
Helps to reduce a lot of
paperwork and discharge
delay process, this will
enhance the discharge of
stable patients thus
reducing patient nurse
ratio.
4. Ignorance of the highly
skilled and experienced
nurses about their level of
knowledge and expertise of
the student nurses and less
experienced nurses on patient
care
Institute at least one CME in
the ward regarding grief
counseling to perinatal
bereaving mothers.
To ensure that the less
experienced nurses and
student nurses are well
equipped with the right
skills and knowledge on
patient care to fasten
execution of counseling
services to the bereaving
mother
5. Lack of protocols, guidelines
and policies on grief
counseling
Institute guidelines, protocols
and policies about grief
counseling.
Protocol is a guiding
framework outlining then
care that will be provided
to patients in designated
area of practice.
Policy is a formal written
statement detailing the
particular action to be
taken in a particular

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situation that is
contractually binding.
Guidelines is
systematically derived
statements that help
practitioners to make
decisions about care in
specific clinical
circumstance.
(NHS,2006)
4.3 Implementation of effective counter measures
1 A daily action plan was drawn and it comprised of time and the scheduled activity, and it was
pinned on the wall where the staff were able to see.
2. CMEs were organized for every Thursday from 2.00pm to 3.00pm where students and
registered nurses were given a condition and common nursing skills and grief counseling
information to present on.
3. The deputy in charge was assigned with the role of ensuring motivation of staff in general.
4. The unit manager was encouraged to advocate for increase of more nurses to provide care to
the bereaved mothers and laisse with the administration to provide policies governing counseling
of mothers.
5.A guideline on provision of grief counseling was made and pinned on the wall where the staff
were able to see.
6.I constructed a perinatal bereavement assessment too to assist in assessment of mothers who
has lost their babies.

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4.4 Effectiveness and standardization of countermeasures
This is an ongoing project that is still for evaluation in four weeks’ time, the counter measures
put in place are formatively evaluated. The effectiveness and standardization of this project will
be determined by the end of the four weeks where monitoring and evaluation will be done
5. AIM STATEMENT
To reduce the risk of mental health disorder by provision of grief counseling to parents that have
lost their babies.
6. RELEVANCE USING EVIDENCE BASED PRACTICE
Pregnancy is usually a joyful experience for a woman. It is one milestone that, even though
sometimes stressful, is rewarding for the reason that the woman takes on a new level of
responsibility. Parents look forward to delivering a healthy baby and dream of a happy and
contented future. Such dreams are shuttered when the death of an unborn or newborn infant
occurs (journal of Asian midwives,2015).
Research has shown that women experience longer periods and high levels of grief after perinatal
loss (Capitulo K.,2005).
Every year, there are over 6.3 million perinatal deaths in the world of which almost all occurring
the developing countries, and 27% of them occur in the least developed countries (WHO,2007).
Research shows that psychiatric morbidity following perinatal deaths varies from 13% to 34%
among mothers suffering from perinatal bereavement (Kirkley et al.,2006). Twenty-five to 40%
of the couples’ experience g perinatal loss report anxiety or depressive symptoms soon after the
loss or in the subsequent two years (lin SX; Lasker JN 1996). Women may experience
psychological problems such as grief, depression and anxiety (Benneth et al.,2005).
A study by Christy et al. (2015), on effect of bereavement counseling on women with
psychological problems associated with late pregnancy loss state that women with pregnancy
loss experience various psychological problems immediately after delivery. They need
supportive and proactive care during and after hospitalization. They appreciate the concern of the
staff during the time of distress. The study findings showed a reduction in psychological
problems of women with bereavement counseling after pregnancy loss.

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Interventions aimed at treating bereaved people with high levels of grief related distress have
been termed tertiary interventions and have been associated with positive outcome (schut et
all.,2001)
7. RELATIONSHIP OF THE PROBLEM TO THE DIMENSIONS OF QUALITY
Safety: People who experience intense grief symptoms that interfere with daily life and can
occur more than 6 months after loss may have complicated grief, which is frequently associated
with anxiety (Kathleen 2019). Grief can impact the level of care provided by nurses if left
unchecked. Through proper selfcare and recognition of loss, nurses can address their emotional
needs without sacrificing the high level of care and compassion they provide for patients (chris,
2016).
Technical competence: The establishment of rehabilitation counseling competencies is an
important development for promoting self-regulation and training with the
profession(Ebener,2007).Ober et al.(2012) suggested that counsellors would benefit from
additional training in the following domains: theories of grief counseling, terms and definitions,
crisis intervention for grief, community-based psychoeducational grief programming.
Continuity: Continuity of care is considered by service user as well as professionals as an
essential feature of high quality health care(Saultz,2003).The significance of continuity of care
was recognized in the National service framework for Mental Health, which states that
“delivering continuity of care for as long as it is needed” should be guiding principle in planning
and delivering mental health service(Department of health,2012).Lack of information on patients
mental status leads to lack of continuity of care after change over shift of nurses hence bereaving
mothers tend to be attended to closely.
Efficiency: This will ensure cost effective use of resources, and value of money. When nurses
complete their tasks on time, they will be able to engage in more patient care e.g. paying
attention to the bereaving mothers and providing bereavement counseling in order to lower the
risk of experiencing mental breakdown and psychosis which may lead to further hospitalizations.
Responsiveness:It relates to a system’s ability to respond to the legitimate expectations of
potential users about nonhealthy enhancing aspects of care (murray and frenk,2000). Willingness

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of services providers to help customers and to provide prompt services, how attentive they are to
usual and unusual problems. The health care providers will be able to help patients in terms of
health education, customer care.
8. ANALYSIS OF THE PROBLEM AND ITS INFLUENCES ON PROCESS, OUTCOME
The stressful stimuli in combination with the nature of the work environment and the need for
ongoing care of other patients may not allow for adequate support or time to
grieve(Brosche,2003).Burnout and compassion fatigue are concerns for nursing due to its
association with reduced quality of care, poor communication, increased costs related to high
turnover and absenteeism, and decreased job satisfaction in staff. An uncaring attitude or burnout
can lead to labeling the nurse as having a behavior problem, which can contribute to reduced
staff morale and efficient delivery of patient care. Numerous unresolved grief processes can lead
to decreased quality of patient care delivery, high turnover, increased costs, and a potential
nursing shortage (O'Connell,2014).
Verbalizing feelings and expressing emotions can help a patient process loss during grief
counselling. Grief counseling aims to facilitate the bereavement process, that is, to help the
bereaved person adapt to the loss and resolve grief (Worden, 2009). Resolving grief leads to
improved mental health outcomes reducing the incidence of postpartum depression, psychosis or
other mental health related issues.
9. EXECUTION OF QUALITY IMPROVEMENT USING A MODEL
The quality improvement model used is Gemba Kaizen, it has five methods: to sort, to straighten,
to sweep, to sanitize and to standardize so as to enhance waste elimination.
It consists of the following steps:
9.1 CQI problem area
Lack of grief counselling in bereaved mothers who have lost their babies.
9.9 Situation analysis -EPISTEL
Environmental analysis.
- The structural arrangement of postnatal ward.
- The number of patients admitted in the ward during a specific period.

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- The number of patients per bed.
- The position of the nursing station in the unit.
- The number of qualified and experienced nurses assigned per shift.
Findings.
- The unit is subdivided into rooms based on the conditions of mother's e.g. acute room for
Cesarean section mothers, Antenatal room, post SVD.
- Approximately 80 patients are admitted in the Ward during a certain period with at least two
qualified nurses assigned to provide patient care to them.
- Mothers do not share beds except for the post SVD room where mothers share upto two.
- The nursing station in positioned at near the acute and isolation rooms overlooking other rooms
where mothers with other conditions are admitted.
Political analysis.
- Coordination between the county government and the hospital management in the recruitment
of new and more nurses.
Findings.
- Few nurses are employed leading to short staffing in the unit.
Informatics.
- The methods of storing, sharing and retrieval of information among the health care providers.
Findings.
- There is lack of a prioritized action plan guide for the day’s activities.
- There is lack of guidelines in the unit for grief counselling.

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Social analysis.
- Relationship of the mothers and their family, health care providers or their babies.
- Presence of a grief counsellor.
- Availability of adequate staff.
- Forums to improve the level of knowledge and technical skills for all the health care providers.
- The categorization of patients in the unit.
-Presence of nursing staff debriefing.
Findings.
- There is no clear guideline outlined for grief counselling.
- The relationship between the mothers and the nurses is based only on Medical management.
- Lack of adequate staff to carry out grief counselling to mothers who have lost their mothers.
- Patients are categorized on the basis of medical conditions neglecting the mental health aspect.
- Lack of enough CME's and other forums to improve knowledge and technical skills of the
health care providers on grief counselling.
-The ward has a counsellor but emphasis is placed on primigravida.
-Lack of nurses debriefing.
Technological analysis.
- Availability of the perinatal assessment tool.
- Availability of information technology systems for generating required information of the
patients bases on the grief assessment.
Findings.

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- There is a lot of paperwork documentation for admissions, discharge and nursing care for
patients.
- Lack of a computerized system for literature in the unit to update oneself on technical skills and
grief assessment knowledge.
-Lack of perinatal assessment tool.
Economic analysis.
- Presence of the insurance package for the NHIF members to enhance billing for faster
discharge process.
- Presence of the Universal health coverage package for all patients.
- Hospital wavering the patients unable to cater for the hospital bills when they are stable and
due for discharge.
Findings.
- The Universal health coverage for all patients has encouraged seeking of health care leading to
high pediatric patient admissions.
- The process for clearing with the NHIF officials for billing during discharge is long causing
delay in the process.
- The hospital wavers some of the needy stable patients but the process is also long.
Legal analysis.
- Laws and policies put in place in the unit for the counseling of mothers who have lost their
babies.
Findings.
- Lack of policies in counselling mothers who have lost their babies.

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9.3. Countermeasures
Refer to 4.2
9.4 Implementation of effective counter measures.
Refer back to 4.3.
9.5 Effectiveness of countermeasures
Refer to 4.4
9.6 Standardization of countermeasures
The counter measures were standardized by integration of the perinatal grief scale as part of the
stationary in the patients file
10.ACTION PLAN
OBJECTIV
E
INTENDED
DEPARTMENT
.
DATE
TO
BEGIN
.
DATE
DUE.
RESOURCE
S
REQUIRED.
OUTCOME/IMPACT
.
. To increase
the number
of nurses in
the unit.
Postanatal
managerial
24th
July,
2019.
Long
term.
A unit
manager who
advocates for
the
recruitment
of adequate
nurses staff
Ensure each nurse is
assigned a
manageable patient
load by concentrating
on the nursing tasks

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To institute
at least one
CME in the
ward
regarding
Grief
counseling
postnatal 24th
July
2019
ongoing
.
Writing
materials for
the CME
schedule, All
health care
providers,
room for
CME
To create awareness
and to increase the
level of knowledge
and skills on
providing grief
counseling to mothers
who have lost their
babies.
To ensure
the
development
and effective
use perinatal
bereavement
scale
Postnatal ward 24th
July
2019
ongoing Nursing staff,
counsellors,
writing
materials
Provides and easier
method of assessing
bereaving mothers
. . .
11. MONITORING AND EVALUATION.
Counsellors may also use client satisfaction or feedback forms as a way of collecting
information which can help them monitor effectiveness (McMahon, 1998).
In this case will asses client’s satisfaction of the counseling sessions and provide feedback forms
that are open ended so ass to allow client to voice their thoughts about the sessions and
possibility of integration of what they have been taught.
12. STEPS TO BE TAKEN TO SUSTAIN IMPROVEMENTS
1.Multiplication or integration of the tool as part of the stationaries in the patient files.
2.Ensuring weekly CMEs for reminders and information boosting are followed.
3.Following up with the nurses to ensure they pay attention.

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13. CONCLUSION
Nurses are generally comfortable but find it difficult to provide perinatal bereavement care.
Strategies for coping include focusing on needed care, talking to nursing peers, and spending
time with their own family members. Nurses take turns providing care depending on "who is best
able to handle it that day" and prefer not to be assigned a laboring patient in addition to the
grieving parents. Developing clinical expertise is necessary to gain the comfort level and the
skills necessary to care for these vulnerable families. Orientation experiences and nursing staff
debriefing would help. Needed education includes grief training, communication techniques, and
guidelines for the extensive paperwork.
14. EVIDENCE OF IMPLEMENTATION IN THE WARD
1.Availability of laminated guideline on the notice board at a strategic location.
2.Availability of perinatal grief scale that will be incorporated as routine.
3.Availability of weekly CME on nurses debriefing

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