Research Design
This descriptive correlational research was conducted to identify nurses' awareness and stress related to PBC and to examine their relationships.
Research Participants
The participants of this study were nurses working at general hospitals in departments that deal with perinatal death. Participants were recruited through convenience sampling. The inclusion criteria were as follows: nurses working in the obstetrics and pediatric nursing units who had experienced at least one case of perinatal death. Nurses with less than 1 year of experience were excluded because perinatal bereavement was expected to be an infrequent experience. The sample size was calculated using G*Power version 3.10, with a significance level of 0.05, power of 0.90, and a moderate effect size of 0.3. The required number of samples was determined to be 109. The questionnaire was distributed to a total of 150 nurses, considering a possible dropout rate of 20%, and 148 participants participated in the study. Twelve responses were incomplete, so 136 questionnaires were ultimately analyzed.
Research Tools
Nurses’ Awareness of PBC
After translation, the tool developed by Chan et al. [5] (Nurses’ Attitudes towards Perinatal Bereavement Support; NAPBS) was used in this study (supplementary file 1). This self-reporting tool contains a total of 25 questions that respondents answer on a 5-point Likert score, ranging from “I do not agree at all” to “I strongly agree.” This tool consists of three subdomains: attitude (13 items), importance of policies related to PBC (4 items), and importance of training related to PBC (8 items). Higher scores correspond to more positive attitudes toward PBC or a greater recognition of the importance of policies or training related to PBC. Chan et al. [5] reported that Cronbach's α was .92 for the total items, and .86, .83, .90. for the three subdomains of attitude, importance of policies, and importance of training, respectively. In the current study, Cronbach's α was .87 for the total items, and .73, .67, and .90. for the three subdomains, respectively.
Nurses’ Stress Related to PBC
The tool developed by Jang was used in this study after revision (supplementary file 2)[19]. This tool is composed of 29 questions in four domains, consisting of 6 items on difficulties in providing care for patients affected by perinatal death, 5 items on lack of knowledge, 10 items on inadequacies of the environment and systems for handling perinatal death, and 8 items on psychological difficulties. The items in this tool are answered using a 5-point Likert score from “I do not agree at all (1 point)” to “I strongly agree (5 points),” with higher scores indicating high levels of stress. For all items, Jang [19] reported that Cronbach's α was .87, while in the current study, Cronbach's α was .89.
General Characteristics
The questionnaires were developed in this study (supplementary file 3). Information was gathered on participants’ demographic characteristics, including their level of education, whether they were religious, and their marital status. Additionally, information was collected on their personal experiences, such as their workplace, total career experience and experience at their current workplace, personal bereavement experience, and experiences of PBC. They were also asked about whether they had received training on PBC. These factors were hypothesized to be associated with nurses’ perceptions and stress related to PBC.
Research Procedures
Author’s Approval for Use of the Research Tool
The developer of the NAPBS tool, Moon-Fai Chan, approved its use in this study.
Forward Translation
The original tool was first translated into Korean by a translation expert at the Language Education Center of OO University. The translation was then reviewed by three experts (one nurse who is a native speaker of Korean and fluent in both Korean and English, as well as two maternity nursing professors). They determined whether there was any need for corrections due to the accuracy of the initial translation and cultural differences. The translation did not focus on translating individual words and their meanings into Korean; instead, the core concepts were emphasized [20], with the goal that the end product would not feel like a translated tool. As such, it was adjusted to fit the socio-cultural situation and medical institutions in Korea
Reverse Translation
A written translation was again conducted (reverse translation) into English by the nurse. The reverse translator is fluent in both Korean and English, and is a nurse currently working in the United States. The previous three experts who participated in the first translation reviewed the equivalence between the reverse translation and the original version to finalize the translation.
Review of Expert Committee Members (content validity)
The content validity of the translated tool was examined by 10 nursing experts. The survey was conducted once from July 1 to July 15. 2019. The experts included one nursing professor, four head nurses with 10 years or more of experience in the delivery room or neonatal intensive care unit, and five staff nurses with 7 years or more in the relevant departments mentioned above.
They were asked to assess the validity of each item as 1 point for “never valid,” 2 points for “not valid,” 3 points for “valid,” and 4 points for “very valid.” All 25 items had a content validity index of 0.8 or higher, and were selected for inclusion in the final version.
Preliminary Study
Prior to study, the translated Korean version of the NAPBS was preliminarily tested among 10 nurses working at hospitals located in Seoul and Gyeonggi Province. Thereafter, the Korean version of the tool was finalized.
Data Collection
After receiving IRB approval from S University Hospital (IRB No. B-1908/561-305), data were collected from September 1 to September 31, 2019. After obtaining permission from officials at seven general hospitals in Seoul and Gyeonggi-do, where the data were collected, potential participants received an explanation about the study purpose and procedures with a written protocol, and a questionnaire was distributed to nurses who voluntarily chose to participate. The participants provided written informed consent, and the collected data were encrypted and processed in a way that respected the confidentiality of the participants.
Data analysis
Data were analyzed using SPSS for Windows version 25.0 (IBM Corp., Armonk, NY, USA). The specific analytical methods were as follows.
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General characteristics and the main variables of the study were analyzed using descriptive statistics (mean, standard deviation, frequency, and percentage).
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Nurses’ awareness (attitude, importance of policies, and importance of training related to PBC) and PBC-related stress according to their general characteristics were analyzed using the independent t-test and one-way analysis of variance. If necessary, the Scheffé test was conducted as a post hoc test.
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The relationships among the three subdomains of awareness and stress were analyzed by Pearson correlation coefficients. All tests used a significance level of 0.05.