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Development and Psychometric Validation of the Perinatal Bereavement Care Competence Scale for Midwives

Open AccessPublished:June 15, 2022DOI:https://doi.org/10.1016/j.anr.2022.06.002

      Summary

      Purpose

      The aim of this paper is to develop a scale for measuring the perinatal bereavement care competence of midwives and assess its psychometric properties.

      Methods

      The Perinatal Bereavement Care Competence Scale was developed in four phases. (1) Item generation: 75 items were formulated based on a literature review and interviews with midwives. (2) Delphi expert consultation: 15 experts evaluated whether the items were clear/appropriate/relevant to the questionnaire dimensions, and the items were optimized. (3) Pilot test: The comprehensibility, acceptability, and time required to complete the questionnaire by midwives were assessed. (4) Evaluation of reliability and validity: The scale was validated by initial item analysis, exploratory and confirmatory factor analyses, and internal consistency reliability and test–retest reliability.

      Results

      The final scale consisted of six dimensions and 25 items: maintaining belief (three items), knowing (four items), being with (six items), preserving dignity (four items), enabling (five items), and self-adjustment (three items). Exploratory factor analysis yielded a six-factor structure that was consistent with the theoretical framework and explained 70.8% of the total variance. Confirmatory factor analysis indicated a good fit for the six-factor model. Cronbach's α for the scale was 0.931, and the test–retest reliability coefficient was 0.968.

      Conclusion

      The Perinatal Bereavement Care Competence Scale is a valid and reliable instrument for measuring the competence of midwives in caring for bereaved parents who have experienced perinatal loss.

      Keywords

      Introduction

      Perinatal loss is a highly painful event for parents and families [
      • Heazell A.
      • Siassakos D.
      • Blencowe H.
      • Burden C.
      • Bhutta Z.A.
      • Cacciatore J.
      • et al.
      Stillbirths: economic and psychosocial consequences.
      ]. Most bereaved parents suffer from devastating psychological and emotional symptoms including grief, depression, anxiety, self-blame, and post-traumatic stress, which even cause adverse effects for subsequent pregnancies [
      • Thomas S.
      • Stephens L.
      • Mills T.A.
      • Hughes C.
      • Kerby A.
      • Smith D.M.
      • et al.
      Measures of anxiety, depression and stress in the antenatal and perinatal period following a stillbirth or neonatal death: a multicentre cohort study.
      ,
      • Pollock D.D.
      • Pearson D.E.
      • Cooper D.M.
      • Ziaian A.
      • Foord C.
      • Warland A.
      Breaking the silence: determining prevalence and understanding stillbirth stigma.
      ]. Appropriate bereavement care provided by hospital staffs is essential for helping parents cope with perinatal loss and reducing its negative impact [
      • Smith L.K.
      • Dickens J.
      • Bender A.R.
      • Bevan C.
      • Fisher J.
      • Hinton L.
      Parents' experiences of care following the loss of a baby at the margins between miscarriage, stillbirth and neonatal death: a UK qualitative study.
      ,
      • Shaohua L.
      • Shorey S.
      Psychosocial interventions on psychological outcomes of parents with perinatal loss: a systematic review and meta-analysis.
      ]. Specifically, healthcare professionals should use simple and appropriate language, provide adequate and personalized information, acknowledge grief and parenthood, offer the important choice to parents of seeing and holding their baby, and provide commemorative items such as photographs, footprints, or baby clothes to help parents create meaningful memories and support the grieving process [
      • Shakespeare C.
      • Merriel A.
      • Bakhbakhi D.
      • Blencowe H.
      • Boyle F.M.
      • Flenady V.
      • et al.
      The RESPECT study for consensus on global bereavement care after stillbirth.
      ].
      In China, fetal death that occurs during the second or third trimester of pregnancy is attended by midwives who provide compassionate care and support to the women and are likely to be involved in the bereavement process to help parents make decisions that minimize regret (e.g., over the missed opportunity of seeing their baby) [
      • Shen Q.
      • Liang J.
      • Gao Y.
      Experience of undergraduate midwifery students faced with perinatal death in clinical practice: a qualitative study.
      ]. However, unlike routine nursing tasks, perinatal bereavement care is challenging for many midwives because of the lack of a standardized approach. Midwives often report that supporting bereaved parents is emotionally demanding and stressful, and in some situations, they may experience a sense of personal failure accompanied by guilt and helplessness if they feel that they are unable to provide adequate assistance [
      • Gandino G.
      • Bernaudo A.
      • Di Fini G.
      • Vanni I.
      • Veglia F.
      Healthcare professionals' experiences of perinatal loss: a systematic review.
      ]. This can have serious consequences such as emotional burnout, self-doubt, and even professional resignation [
      • Martinez-Serrano P.
      • Palmar-Santos A.M.
      • Solis-Munoz M.
      • Alvarez-Plaza C.
      • Pedraz-Marcos A.
      Midwives' experience of delivery care in late foetal death: a qualitative study.
      ,
      • Ravaldi C.
      • Carelli E.
      • Frontini A.
      • Mosconi L.
      • Tagliavini S.
      • Cossu E.
      • et al.
      The BLOSSoM study: burnout after perinatal loss in midwifery. Results of a nation-wide investigation in Italy.
      ]. Moreover, the emotional pain of grieving parents can be exacerbated when midwives cannot meet their needs for bereavement services [
      • Helps A.
      • O'Donoghue K.
      • O'Byrne L.
      • Greene R.
      • Leitao S.
      Impact of bereavement care and pregnancy loss services on families: findings and recommendations from Irish inquiry reports.
      ]. Therefore, improving midwives' ability to provide perinatal bereavement care is important not only for the psychological well-being of the parents but also for midwives’ career development.
      Swanson's Caring Theory can serve as a guide for healthcare professionals offering care to parents who have experienced pregnancy loss [
      • Nurse-Clarke N.
      • DiCicco-Bloom B.
      • Limbo R.
      Application of caring theory to nursing care of women experiencing stillbirth.
      ]. The theory encompasses five processes: (1) ‘‘maintaining belief,’’ which refers to conveying confidence and faith that the bereaved parents can get through perinatal loss and face a meaningful future; (2) ‘‘knowing,’’ which is trying to understand the meaning of perinatal death for the women and assessing their partners' perspective and family support; (3) ‘‘being with,’’ which includes simply being there, sharing grief feelings, and conveying ongoing availability without burdening the bereaved parents; (4) “doing for,” which is anticipating and meeting bereaved parents' needs, with a focus on protecting them from harm and protecting their dignity; and (5) “enabling,” which is facilitating the bereaved parents' capacity to grow using professional knowledge and information and helping them focus on important issues and generating alternatives [
      • Swanson K.M.
      Empirical development of a middle range theory of caring.
      ,
      • Swanson K.M.
      Nursing as informed caring for the well-being of others.
      ].
      Up to now, there have been few studies examining Asian midwives' performance when caring for parents suffering pregnancy loss. A qualitative study in China has shown that most midwives experienced negative feelings when supporting bereaved parents, some were able to provide support through empathetic nursing, while others adopted negative coping strategies such as avoiding in-depth communication with the parents [
      • Shen Q.
      • Zhang Z.
      • Liang Y.
      • Zuo Q.
      • Tong P.
      • Zheng Y.
      • et al.
      Midwives' experience of providing bereavement care for women after perinatal death: a qualitative study.
      ]. As we know, a cross-sectional survey can effectively identify midwives' shortcomings in perinatal bereavement care and may be useful for developing strategies to increase their competence, which is not addressed by existing instruments. For example, a self-report questionnaire on nurses' attitudes toward perinatal bereavement care was developed [
      • Chan M.F.
      • Chan S.H.
      • Day M.C.
      A pilot study on nurses' attitudes toward perinatal bereavement support: a cluster analysis.
      ], but there was no confirmatory factor analysis (CFA) in different samples to validate the factor structure. Recently, an instrument that includes four independent subscales, i.e., bereavement support knowledge, skills, self-awareness, and organizational support, was developed [
      • Kalu F.A.
      • Larkin P.
      • Coughlan B.
      Development, validation and reliability testing of 'perinatal bereavement care confidence scale (PBCCS).
      ]; however, the subscales are difficult to be synthesized to measure midwives’ comprehensive competence of perinatal bereavement care due to duplication of some items.
      In the present study, we developed Perinatal Bereavement Care Competence Scale (PBCCS) based on Swanson's Caring Theory and evaluated the validity and reliability of this scale in a cohort of midwives from different hospitals in China.

      Methods

      This study had four phases: (1) item generation and scale construction; (2) expert panel review; (3) small-scale pilot study; and (4) large-scale reliability and validity testing.

      Phase 1: Item generation

      Using Swanson's Caring Theory as a guide, the basic framework of the PBCCS was established through semi-structured interviews with midwives and a literature review. To explore the feelings and perceived competency status of midwives in China providing bereavement care for parents who have experienced perinatal loss, we interviewed 18 midwives from 11 grade 3A hospitals in Guangdong, China. We found that some midwives had maladaptive negative emotions that caused them to feel overwhelmed, so they distanced themselves from grieving parents [
      • Shen Q.
      • Zhang Z.
      • Liang Y.
      • Zuo Q.
      • Tong P.
      • Zheng Y.
      • et al.
      Midwives' experience of providing bereavement care for women after perinatal death: a qualitative study.
      ]. Accordingly, we included “self-adjustment” as a dimension of the PBCCS. At the same time, we extracted specific items from five evidence-based guidelines for perinatal bereavement care through systematic quality appraisal [
      • Shen Q.
      • Feng X.
      • Liang Y.
      • Zuo Q.
      • Zhang Z.
      • Gao Y.
      • et al.
      Quality evaluation of clinical practice guidelines on perinatal bereavement care: a systematic review.
      ]. We generated an initial pool of 75 items. Based on discussions among the authors, some items were removed because they were unclear, repetitive, or did not align with Chinese culture. The remaining 64 items were grouped into six dimensions including “maintaining belief” (four items), “knowing” (eight items), “being with” (13 items), “doing for” (18 items), “enabling” (15 items), and “self-adjustment” (six items).

      Phase 2: Delphi expert consultation

      A group of experts including nine midwifery experts, five clinical psychologists, and one hospice care expert was convened by email invitation; all had the title of senior deputy and over 10 years of professional experience. The experts were asked to rate the importance of each item on a 5-point scale ranging from 1 (extremely unimportant) to 5 (extremely important) after discussing whether the item was clear or appropriate and listing the specific reasons and suggestions for revision. After two rounds of expert consultation, items that met any of the following criteria were deleted [
      • Schofield R.
      • Chircop A.
      • Baker C.
      • Dietrich L.M.
      • Duncan S.
      • Wotton D.
      Entry-to-practice public health nursing competencies: a Delphi method and knowledge translation strategy.
      ]: (1) average importance score <4; (2) full score ratio <0.2; and (3) variation coefficient >0.2. We also optimized the dimensions and specific items of the scale based on the experts' opinions. For example, the items (“effectively evaluating parents' expectations of pregnancy and parenthood” and “effectively evaluating the level of family support received by bereaved mothers”) were added to the “knowing” dimension; and an item (“making bereavement care plans with the parents”) in the “doing for” dimension was deleted as recommended by the clinical midwifery experts because there are no specific bereavement care plans and no timeline for midwives to accomplish this work in clinical practice. Two items (“if requested, providing additional resources that are in line with the bereaved parents' religious beliefs” and “if requested, providing additional resources that are in line with the bereaved parents' customs and habits”) in the “doing for” dimension were merged into a single item (“if requested, providing additional resources that meet the bereaved parents’ religious and social custom needs”). The experts suggested changing the expression of some items to improve their comprehensibility. Ultimately, two items were added, 16 were deleted, and four were merged, yielding 46 items for the questionnaire.

      Phase 3: Pilot study

      We invited 16 midwives from grade 3A hospitals to offer their perspectives regarding the ease of completion, comprehensibility, clarity, and acceptability of the questionnaire, with the items adjusted and revised accordingly. The midwives thought five items should be modified because they lacked clarity. For example, they thought that the item “keeping appropriate silence in due course” was ambiguous because it was unclear what was meant by “due course.” The item was therefore reworded as “keeping appropriate silence when communicating with bereaved parents.” The revised version of the questionnaire was further tested in different midwives until no further problems were identified. In general, the questionnaire was easy to complete and took about 5–10 min.

      Phase 4: Validity and reliability testing

      To assess the validity and reliability of the scale, midwives were recruited from different hospitals by convenience sampling from September to November 2020. Midwives who worked in delivery rooms and consented to participate in the study were included; those who had no experience in perinatal death were excluded. We used Wenjuanxing (www.wjx.cn), a reliable investigation website used in China, to design and publish our electronic questionnaire. Participants could click on relevant links to access and complete the questionnaire anonymously and could only do so once using their own electronic devices. To evaluate test–retest reliability, 15 of the participants were selected to complete the questionnaire again 2 weeks later. Some questionnaires with less than 3 minutes to complete or obvious irregularities were deleted. Based on the random splitting method, all valid questionnaires were divided into two equally sized groups: Sample 1 was used for exploratory factor analysis (EFA), and Sample 2 was used to confirm the factor structure of the scale by CFA. The internal consistency reliability and test–retest reliability were also evaluated. For factor analysis, the sample size should be least 5–10 times the number of all items [
      • Wu M.
      ]; because the PBCCS had 46 items, the minimum sample size for EFA and CFA was 542, considering that 15.0% of questionnaires would be invalid.

      Ethics statement

      This study was reviewed by the Institutional Review Board of Southern Medical University (Ethics Committee of Southern Medical University [2020] No. 17). The participants were also informed that completing the questionnaire was voluntary. The data were kept anonymous and were used only for study purposes.

      Data analysis

      Data were analyzed using SPSS v22.0 and AMOS v24.0 software (IBM, Armonk, NY, USA). Descriptive statistics were applied to the demographic characteristics of the participants, which are presented as mean ± standard deviations and numbers and percentages. Construct validity was assessed by item analysis, EFA, and CFA. In the item analysis phase, items that met any of the following criteria were deleted [
      • Wu M.
      ]: (1) no statistically significant items in a critical ratio; (2) item total correlation (Pearson's correlation coefficient) <0.40; (3) factor loading value <0.40; and (4) items that reduced the overall Cronbach's α level. EFA was performed to extract common factors in the items by principal component analysis and varimax rotation. The Kaiser–Meyer–Olkin (KMO) and Bartlett's tests were used to assess sampling adequacy for EFA. Combined with the scree plot, one factor with an eigenvalue ≥1.00 was extracted [
      • Wu M.
      ]. CFA with maximum likelihood estimation method was performed to verify the fit of the factor structure derived from the EFA based on the following indices: χ2/df, goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI), comparative fit index (CFI), Tacker–Lewis index (TLI), incremental fit index (IFI), root mean square error of approximation (RMSEA), and root mean square residual (RMR). The χ2/df between 1 and 3, GFI, AGFI, CFI, TLI, and IFI values 0.90 or above, and RMSEA values less than 0.08 with RMR less than 0.05 suggested a good model fit [
      • Wu M.
      ]. After CFA, convergent validity was assessed based on the average variance extracted and composite reliability. Reliability analysis was performed by calculating the internal consistency reliability (Cronbach's α coefficient) and the test–retest reliability (intraclass correlation coefficient) for the total scale and its dimensions, respectively.

      Results

      Sample characteristics

      A total of 585 questionnaires were distributed, and 507 valid questionnaires were recovered, for a response rate of 86.6%. The 507 participants were from 142 different hospitals across China and ranged in age from 20 to 54 years. The participants had worked in the obstetrics department for a mean (±SD) of 10.63 (±7.61) years, and 43.4% had experience in providing care for perinatal death in the previous 3 months. The characteristics of the participants are shown in Table 1.
      Table 1Characteristics of Participants Who Completed the Perinatal Bereavement Care Competence Scale Questionnaire (n = 507).
      Variablen (%)
      Age, years
       20–29201 (39.6)
       30–39229 (45.2)
       40–4966 (13.0)
       50–5411 (2.2)
      Gender
       Men1 (0.2)
       Women506 (99.8)
      Educational background
       Secondary specialized school6 (1.2)
       Junior college93 (18.3)
       Undergraduate398 (78.5)
       Master's10 (2.0)
      Professional title
       Nurse86 (17.0)
       Nurse practitioner200 (39.4)
       Nurse-in-charge192 (37.9)
       Associate director nurse27 (5.3)
       Director nurse2 (0.4)
      Certificate of competency in maternal and infant health care
       Yes453 (89.3)
       No54 (10.7)
      Years working in obstetrics department
       <112 (2.4)
       1–5141 (27.8)
       6–10149 (29.4)
       11–1578 (15.4)
       16–2075 (14.8)
       >2052 (10.3)
      Experience of delivery care in perinatal death in the last 3 months
       Yes220 (43.4)
       No287 (56.6)

      Construct validity

      Item analysis

      Data from Sample 1 were used to analyze and select the items. Three items (Items 1, 20, and 21) were deleted according to the exclusion criteria of item analysis, and a trial scale containing 43 items was created (Table 2).
      Table 2Analysis of the 46 Items of the Perinatal Bereavement Care Competence Scale.
      Itemt valueCorrected item total correlation coefficient∗Cronbach's α if item deletedFactor loading
      1−3.902.243.209
      2−5.279.421Unchanged.407
      3−4.422.411Unchanged.405
      4−6.267.465.470
      5−10.086.586.594
      6−9.967.592.603
      7−10.289.577.589
      8−7.927.521.520
      9−11.160.665.686
      10−11.523.666.690
      11−11.874.657.683
      12−8.623.645.686
      13−10.036.666.688
      14−9.617.679.723
      15−10.563.687.723
      16−7.500.618.627
      17−6.366.562.575
      18−9.933.656.686
      19−7.766.558.551
      20−6.666.446Unchanged.379
      21−6.334.448Unchanged.392
      22−7.181.489Unchanged.421
      23−6.866.546.518
      24−8.770.576.557
      25−8.186.485.451
      26−8.483.651.652
      27−10.468.725.727
      28−10.513.697.706
      29−10.681.653.656
      30−10.642.678.693
      31−10.041.643.656
      32−8.364.646.646
      33−11.310.710.721
      34−8.067.605.594
      35−9.704.585.564
      36−7.953.520Unchanged.488
      37−11.847.731.738
      38−12.590.706.708
      39−13.204.766.787
      40−7.507.571.565
      41−9.184.683.701
      42−10.632.696.711
      43−9.959.700.710
      44−10.461.595.585
      45−10.230.594.585
      46−10.672.584.579
      Note: ∗All values were significant at p < 0.001; ↓/↑ decrease/increase in Cronbach's α upon deletion of the item.

      Exploratory factor analysis

      To identify the common factors in the items, we conducted seven rounds of EFA. Items with a lower theoretical correlation and factor loading ≤0.4 were removed from item selection. In the final round of EFA, the KMO value was .903, and the result of Bartlett's test of sphericity was adequate (χ2 = 4021.419, p < 0.001), indicating that the data were appropriate for EFA. Consequently, we removed 18 items (Items 9, 10, 17, 18, 19, 22, 25, 28, 29, 31, 35, 36, 37, 38, 40, 41, 42, and 43), and the principal component analysis identified six factors that accounted for 70.8% of the total variance in the 25 items; these factors were named “maintaining belief,” “knowing,” “being with,” “preserving dignity,” “enabling,” and “self-adjustment.” The factor loading of each item was >0.4 (Table 3).
      Table 3Factor Loading of the Perinatal Bereavement Care Competence Scale with the Maximum Variance Rotation Method (25 Items).
      ItemFactor loading
      Factor 1Factor 2Factor 3Factor 4Factor 5Factor 6
      Item 2: Believing that the grief response of each mother is unique0.7840.1580.0270.2110.1180.062
      Item 3: Believing that the needs of each bereaved mother are different0.841−0.0070.1480.1720.0930.028
      Item 4: Believing that bereaved mothers require support from midwives0.6920.2360.231−0.0250.1220.134
      Item 5: Effectively evaluating parents' expectations of pregnancy and parenthood0.1380.7660.2500.0350.2800.100
      Item 6: Effectively evaluating the mood changes of bereaved parents0.1800.7770.2760.0390.2400.090
      Item 7: Identifying abnormal behavior in bereaved mothers0.1130.7720.2690.1040.1080.119
      Item 8: Effectively evaluating the level of family support received by bereaved mothers0.0380.6800.1460.217−0.0300.311
      Item 11: Easily empathizing with bereaved mothers0.0580.3860.6100.2380.1450.128
      Item 12: Accepting different emotional displays by bereaved mothers (e.g., crying and anger)0.1430.1720.7970.1560.0920.221
      Item 13: Patiently listening to bereaved mothers0.1430.2280.8350.1410.1510.075
      Item 14: Effectively comforting bereaved mothers using appropriate language0.0790.2410.8160.1700.2520.068
      Item 15: Effectively comforting bereaved mothers using appropriate body language (e.g., hugs and back pats)0.0870.2680.8120.1840.1760.105
      Item 16: If necessary, leaving bereaved mothers alone under the precondition of guaranteed safety0.238−0.0440.4960.2680.2450.275
      Item 23: Acknowledging parenthood0.2090.0020.1730.5800.1700.107
      Item 27: Asking bereaved parents whether they wish to see their baby after birth0.1180.0760.2390.7390.3350.143
      Item 24: Referring to the baby with the appropriate terms0.0070.4140.0760.6510.0550.167
      Item 26: Treating dead babies with sufficient love and respect0.1080.0680.2680.7730.2310.041
      Item 32: If necessary, informing parents of the possible cause of the baby's death0.0830.0850.1940.2410.7810.137
      Item 34: If necessary, providing information about the autopsy to the parents0.0500.1290.1020.0880.8160.168
      Item 33: If necessary, providing supportive suggestions about future pregnancies0.1660.2070.2340.2820.7220.140
      Item 30: Providing information about maternal recovery (e.g., wound care and lactation suppression)0.2250.2060.3040.3000.5280.142
      Item 39: Encouraging parents to be involved in communication and decision-making regarding nursing0.2120.2070.3480.3900.4610.212
      Item 44: Acknowledging my own negative emotions in perinatal bereavement care work0.0850.0910.2010.0930.1680.841
      Item 45: Understanding my own negative emotions in perinatal bereavement care work0.0940.1680.1460.1280.1390.784
      Item 46: Effectively coping with my own negative emotions in perinatal bereavement care work0.0510.2700.1070.1500.1990.692

      Confirmatory factor analysis

      After EFA, a CFA of Sample 2 was conducted based on the six-factor model, and the results confirmed a structure with a good model fit (χ2/df = 1.848, RMSEA = 0.058, GFI = 0.868, AGFI = 0.835, TLI = 0.932, RMR = 0.035, IFI = 0.942, and CFI = 0.941). Each item loaded significantly on its corresponding factor, with standardized factor loadings ranging from 0.523 to 0.975; average variance extracted in the six domains ranged from 0.500 to 0.742 and composite reliability ranged from 0.799 to 0.895, indicating good convergent validity. The minimum square root of average variance extracted corresponding to the six factors (0.707) was greater than the maximum correlation coefficient between factors (0.633), indicating good discriminant validity. Figure 1 shows the CFA model of PBCCS.
      Figure 1
      Figure 1Confirmatory Factor Analysis of the Perinatal Bereavement Care Competence Scale.

      Reliability

      The Cronbach's α for the whole scale was 0.931, and the Cronbach's α of the subscales ranged from 0.771 to 0.881 (Table 4). The maximum value for test–retest reliability was 0.968.
      Table 4Reliability of the Perinatal Bereavement Care Competence Scale (25 Items).
      DimensionNumber of itemsCronbach's αTest–retest reliability
      Maintaining belief30.7710.954
      Knowing40.8510.922
      Being with60.9000.895
      Preserving dignity40.7010.909
      Enabling50.8650.953
      Self-adjustment30.8810.906

      Discussion

      The aim of this study was to develop a new scale for assessing the perinatal bereavement care competence of midwives and confirm its validity and reliability. Based on Swanson's Caring Theory, we developed an item pool through semi-structured interviews with midwives [
      • Shen Q.
      • Zhang Z.
      • Liang Y.
      • Zuo Q.
      • Tong P.
      • Zheng Y.
      • et al.
      Midwives' experience of providing bereavement care for women after perinatal death: a qualitative study.
      ] and a review of relevant guidelines [
      • Shen Q.
      • Feng X.
      • Liang Y.
      • Zuo Q.
      • Zhang Z.
      • Gao Y.
      • et al.
      Quality evaluation of clinical practice guidelines on perinatal bereavement care: a systematic review.
      ]. Items from instruments that measure perinatal bereavement care knowledge [
      • Kalu F.A.
      • Larkin P.
      • Coughlan B.
      Development, validation and reliability testing of 'perinatal bereavement care confidence scale (PBCCS).
      ], attitudes [
      • Chan M.F.
      • Chan S.H.
      • Day M.C.
      A pilot study on nurses' attitudes toward perinatal bereavement support: a cluster analysis.
      ], and skills [
      • Kalu F.A.
      • Larkin P.
      • Coughlan B.
      Development, validation and reliability testing of 'perinatal bereavement care confidence scale (PBCCS).
      ] were selected and adjusted according to specific clinical circumstances. Unexpectedly, some items could be categorized in more than one dimension of Swanson's Caring Theory in the initial phase of item generation, which was also the major problem encountered in other studies, given that the five caring processes are interrelated [
      • Kalfoss M.
      • Owe J.
      Empirical verification of Swanson's caring processes found in nursing actions: systematic review.
      ]. For example, the item “accepting different emotional displays by bereaved mothers (e.g., crying and anger)” could be classified under “being with” and “enabling.” Furthermore, some items in “enabling” such as “if necessary, informing parents of the possible cause of the baby's death” were found to be appropriate in the “doing for” dimension when reworded as “help grieving parents understand the cause of their baby's death.” Therefore, the definitions of the five caring processes were refined according to basic principles of perinatal bereavement care as follows: “maintaining belief,” which refers to having confidence and faith that the bereaved parents can get through perinatal loss; ‘‘knowing,’’ which is striving to understand the meaning of the perinatal loss experience for the couple and assessing the level of support provided by their family; ‘‘being with,’’ which includes sharing feelings of grief and conveying ongoing availability without burdening the bereaved parents; “preserving dignity,” which focuses on the recognition of parenthood; and “enabling,” which involves explaining important information and involving bereaved parents in communication and decision-making regarding nursing [
      • Swanson K.M.
      Empirical development of a middle range theory of caring.
      ,
      • Swanson K.M.
      Nursing as informed caring for the well-being of others.
      ]. These changes were approved by experts through two rounds of consultation. The PBCCS required just 5–10 min to complete and can thus be easily adopted in clinical settings.
      Although most items were highly sensitive and differentiated, three items (“believing that the bereaved parents can get through perinatal loss,” “supporting parents in creating memories through the collection of mementoes such as photographs, handprints, and footprints,” and “supporting parenting activities such as holding, bathing, and dressing the baby”) were deleted according to the exclusion criteria [
      • Wu M.
      ] during the item analysis phase. These changes may raise some professionals' worries about the comprehensiveness of the scale; however, they are more in line with the clinical reality under the Chinese cultural background and may improve the broad applicability of PBCCS. In order to identify meaningful variables, EFA was conducted with the principal component analysis method of extraction and varimax rotation [
      • Wu M.
      ]. On the one hand, this yielded a six-factor model were consistent with Swanson's theoretical framework and our previous findings, demonstrating that the PBCCS has good content validity [
      • Polit D.F.
      • Beck C.T.
      The content validity index: are you sure you know what's being reported? Critique and recommendations.
      ]. On the other hand, our findings provide empirical validation of Swanson's five caring processes and further promote the development of caring theory in the field of perinatal loss [
      • Nurse-Clarke N.
      • DiCicco-Bloom B.
      • Limbo R.
      Application of caring theory to nursing care of women experiencing stillbirth.
      ]. The factor structure of the scale was evaluated by CFA using Sample 2 (n = 254). Most of the indices met the statistical requirements except for GFI (0.868) and AGFI (0.835) although these could be considered as acceptable (>0.80) [
      • Jackson D.L.
      • Gillaspy J.A.
      • Purc-Stephenson R.
      Reporting practices in confirmatory factor analysis: an overview and some recommendations.
      ]. The results of the convergent and discriminant validity tests also confirmed that the scale has good construct validity. It is worth noting that two of the dimensions, “maintaining belief” and “self-adjustment,” each had just three items. However, this is a sufficient number to test the characteristics of a specific factor [
      • Gaskin C.J.
      • Happell B.
      On exploratory factor analysis: a review of recent evidence, an assessment of current practice, and recommendations for future use.
      ]. The Cronbach's α and test–retest reliability of the whole scale were both >0.9, indicating that the scale has excellent reliability [
      • DeVon H.A.
      • Block M.E.
      • Moyle-Wright P.
      • Ernst D.M.
      • Hayden S.J.
      • Lazzara D.J.
      • et al.
      A psychometric toolbox for testing validity and reliability.
      ].
      The results of our analyses demonstrate that the 25-item PBCCS is reliable and valid for assessing perinatal bereavement care competence among midwives. The PBCCS can provide guidance for midwives in their care of bereaved parents and a means for midwives to assess their own level of competence in this aspect of their work. The scale can also be used as a tool to evaluate the effectiveness of perinatal bereavement care education and training. The PBCCS should be validated for other medical professionals who engage in perinatal bereavement care such as obstetricians, neonatologists, perinatal psychiatrists, nurses, and community medical workers; it would be interesting to compare the level of competence among these groups and explore the possible reasons for any differences.
      There are several limitations of our study. First, although we recruited participants from 142 hospitals in China, our study sample is not sufficiently representative via convenience sampling. Second, the sample size of 15 participants for testretest reliability is relatively small. Therefore, a larger sample is recommended to further validate the stability reliability of the PBCCS. Third, the scale is a self-reported instrument, and social desirability bias may have influenced reporting of self-capability. In order to reduce the reporting bias, the midwives were asked to fill out questionnaires anonymously. Finally, the PBCCS was developed based on the Chinese culture, and its validity and reliability study was conducted in China. Accordingly, further testing of this scale is still needed with more diverse samples from other cultures and countries.

      Conclusions

      The 25-item PBCCS is a valid and reliable tool for measuring midwives’ competence in providing bereavement care to parents who have experienced perinatal death. The scale can also serve as a practical framework for midwives to assess their own feelings when providing support to bereaved parents. Additional studies are needed to determine whether the PBCCS can be applied to other healthcare professionals who participate in bereavement care.

      Declaration of interest

      None.

      Funding

      This work was supported by the 2020 Medical Education Research Project of the Medical Education Branch of the Chinese Medical Association and Medical Education Professional Committee of the Chinese Society of Higher Education [grant number 20B0327 ]. This funding source had no role in the design of this study or its execution and analysis nor the interpretation of the data or the decision to submit results.

      Acknowledgments

      The authors thank all of the midwives who participated in the study.

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