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Guideline 18

Guideline 18: Adverse Outcomes Guidelines for Nurse Home Visiting

Definitions
Reference to Adverse Outcomes in this document refers to: parental and infant death, homicide, suicide, child abuse and other traumatic adverse outcomes experienced by the families we serve during or after the time we have provided services to them.
Purpose
The purpose of this guideline is to assure high quality support for the HVer and their teams following an adverse outcome. High quality assistance can help to ensure a healthy grief process and assist in the provision of on-going service excellence to other families served by the HVer in the immediate days following the event, as well as for families served far into the future. We hope that through the delivery of a trauma informed response we can promote healthy team functioning, aid professional growth and resiliency and retain a high-quality, skilled workforce. 
Although evidence-based home visiting programs, such as Nurse-Family Partnership (NFP), can improve outcomes for families, enrolling in a home visiting program cannot prevent all adverse outcomes. While it's common for community members and teams to believe adverse outcomes shouldn't happen to home visiting clients; sadly, they may. 
This document is designed to guide preparation, intervention, and evaluation strategies for Hvers before and after experiencing adverse outcomes aong the families and communities they serve. 
Foundation
This guidance assumes adverse client outcomes that occur during or after families have experienced home visiting are rare; however, they do occur within our programs. This can be especially difficult for program staff as the very purpose of our programs is to promote health and work to prevent these traumatic outcomes. This guidance assumes that nurse home visiting programs are embedded in agencies that value and are actively pursuing trauma informed care principles. Additional tools and resources to assess your agency's alignment with trauma informed care can be found here: https://trauma-informed.ca/wp-content/uploads/2023/04/trauma-informed_toolkit_v07-1.pdf 
It is recommended that the agency conduct a self-assessment, set goals and implement interventions for assuring a trauma informed workplace. Assessment of environmental components of trauma informed care can be found here: https://traumainformedoregon.org/wp-content/uploads/2016/01/Agency-Environmental- Components-for-Trauma-Informed-Care-1.pdf and Trauma Informed Care Tool Kits. 
Background
The support of staff who have experienced a traumatic event with their client is an important part of the process in responding to adverse outcomes. While the death of any client is difficult, nn infant death can be an especially painful loss. The Report on Bereavement and Grief Research by the Center for the Advancement of Health says that “Many health care providers experience grief – sometimes profound grief – when a patient dies." (1, p. 550) Regardless of whether an infant death or other adverse outcome has occurred, grief can also impact other team members, not just the HVer involved with the impacted family. 
Several key concepts about grief care emerge through interview-based research with nurses: (2) 
  • A nurse's grief can have a significant impact on their personal and professional life. 
  • Grief experience can be a medium for growth and transformation. 
  • Encouragement in the form of active and compassionate listening, particularly by understanding colleagues, is essential. 
  • Authentic, compassionate quality care helps relieve some pain of grief. 
  • Education and mentorship are needed to sustain nurses. 
Likewise, several variables impact the level of distress HVers feel after a perinatal adverse outcome, including how their care was perceived at the time of the event, the involved staff's past personal and professional experiences with similar outcomes; the cumulative number of adverse outcomes experienced; the HVer's perception of support outside of work; when parents don't act as HVers expect; and working environment, particularly supervisor collaboration. (3,4) 
A just-in-time brief content review to support bereavement interactions with families is available in Appendix A.

Interventions for supporting teams PRIOR to experiencing adverse outcomes
  • Have a written policy for adverse outcome response including who is notified and what assistance and debrief resources will be available to staff. The policy should include how communications within the agency will be managed to assure confidentiality. Share the policy as part of your on-boarding process and annually. The policy should include notifying your State Nurse Consultant. The policy should also include cultural responsiveness (see The National Child Traumatic Stress Network or the Health Care Toolbox for more information). 
  • Have a written policy to allow the HVer to attend the funeral during work hours (attendance at funerals and other rituals following a death should align with both the family and HVers' desires). 
  • When conducting routine program outreach and promotion, be careful not to over promise. Consider whether you may want to communicate with Community Advisory Board (CAB) members and other stakeholders to let them know that the program may experience some adverse outcomes, as not all adverse outcomes will be prevented by the program. CAB members may bring resources that could be helpful to a team experiencing an adverse outcome. Knowing what those resources are in advance of an event would be helpful. 
  • Promote staff wellbeing and resilience through reflective supervision and Professional Quality of Life tools. 
  • Build collaboration and sustain trusting relationships across the team in good times so that when things are not going well, staff know they can count on each other. 
  • Consider creating a buddy system between peers for each home visitor so that each team member has an established peer relationship with which to connect. 
  • Provide whole team learning on care for bereaving families, including observational learning (e.g., role play with HVer who feels confident in this area) and to identify staff early who may need more aid in providing bereavement care. (3) 
  • Supervisor and administrators should plan for and secure their own routine reflective supervision. 
  • Provide anticipatory guidance to the team on agency policy for responses to the media. 
  • Review how to express well-intended condolences to fellow staff. 
  • Discuss how to step forward as a self-advocate if triggered by someone else's loss of a client. 
  • Discuss how to appropriately and sensitively 'be with,' even in the instance when there does not seem to be anything else to do. 
  • Encourage each staff person to write down their own ideas on how they would wish to be supported if they experienced one of these events. Consider encouraging team members to share their plans with one another per their comfort level. Hold in mind that what one may find helpful could change based on the individual circumstance. 
  • Establish agency 'traditions' in response to tragic moments. 
  • Reach out to local Employee Assistance Program (EAP) or hospitals for written bereavement materials and discuss the possibility of inviting them or other experts to come speak to the team before incidents occur. 
  • Ensure understanding of county specific policies for confidentiality and privacy and exceptions related to working with law enforcement and Child Protective Services. 
  • Prepare resources that include client education materials on grief, local providers specializing in grief counseling and instruction for how to access local EAP contractors. 
  • Provide resources to help HVers expand their knowledge and expertise in providing high- quality bereavement care. 

Interventions for supporting teams AFTER experiencing adverse outcomes
  •  Acknowledge connection of the HVer to the victim (baby and family). 
  • Listen reflectively; avoid dismissing their worries, but instead listen and support their own reflective inquiry. 
  • Affirm staff in their natural desire to review and question their own care delivery. 
  • Understand that there is no set time period for resolution of grief and that the process waxes and wanes beyond the acute phase of grief. 
  • Remind those impacted of the support resources available. 
  • Provide formal and informal opportunities to debrief. Provide extra reflective supervision time as the HVer and supervisor are able. Promote self-reflection as a form of self-care. 
  • Remind impacted staff of their personal response plan created during on-boarding, and inquire about implementation of the plan. 
  • Acknowledge that during times of significant distress it is important to maintain supportive but professional boundaries. High levels of distress can lead staff to stretch professional boundaries into an unhealthy zone of under or over involvement. For more details, see the continuum noted in the brochure, A Nurses Guide to Professional Boundaries, provided by the National Council of State Boards of Nursing.  
  • Assure the medical record is up to date. 
  • Document the adverse event in the medical record and include as detailed subjective and objective information as possible. 
  • Provide staff information on policies that allow HVer to attend the funeral during work hours (attendance at funerals and other rituals following a death should align with both the family and HVers' desires). 
  • Provide written material for staff following an adverse outcome in the workplace, such as Appendix B: The RBH Road Maps, Acute Signs and Symptoms following a Critical Incident (MyRBH.com). 
  • Provide guidance on how agency leave policies and benefits can allow for time away from the office for bereavement. (3) 
  • Notify appropriate parties per your local agency protocol; notify your program State Nurse Consultant (NFP State Nurse Consultants will inform the National Service Office of the incident). 
  • Invite the Employee Assistance Program to a team meeting to discuss the impact of the adverse outcome and how to work through it. 
  • See section below on fatality review processes. 
  • Consult with your local legal counsel as indicated

Self-assessment following an adverse outcome

The signs and symptoms of a strong response to a critical incident can be physical, cognitive, behavioral, emotional or spiritual. The home visitor should use The RBH Road Maps, Acute Signs and Symptoms following a Critical Incident (Appendix B) to perform a self-assessment of their grief response after experiencing an adverse outcome with a client. ​us.

Interventions for Supporting Mothers and Families After Adverse Outcomes
​A just-in-time brief content review to guide bereavement interactions with families is available in Appendix A. General guidelines for providing authentic, compassionate quality care with appropriate boundaries are listed below. (5, 6, 7) 
  • Offer interaction with client as soon as possible: clients should receive a call within 24- 48 hours after death or adverse outcome and be offered a home visit within 1-2 weeks. Acknowledge the shock of their bereavement or grief. It is okay to express empathy and show your feelings and concerns. It is okay to cry with the client. 
  • Avoid closing services to a client without providing additional resources and confirmation that the client has connected with those services (per client/caregiver desire). 
  • Understand that all people grieve differently and may need different kinds of supports; provide detailed information about all services and options in your area. 
  • Help provide attachment and bonding memories: use the name of the person who has died; ask to see photos; encourage family members to gather mementos to create memories. 
  • Ask the parent or family members what they might like in the way of supports and make recommendations and/or referrals as agreed upon together. 
  • Offer to help parent or family members receive spiritual aid. This does not mean just religious support, but rather should include consideration of the client's faith, rituals and traditions surrounding death. 
  • Plan and practice mindful self-regulation prior to, during and after discussing the event. 
  • Ensure professional boundaries are maintained (see A Nurse's Guide to Professional Boundaries). 
  • See Appendix C for interventions specific to infant death, stillbirth or miscarriage. ​
    ​

Evaluation Process for Supporting Home Visitors After Adverse Outcomes
​Remember that grief response is highly individualized and HVers may feel real grief over the loss of a client or a client’s baby; however, intense and continued symptoms beyond six months to one year that interfere with one’s ability to function and enjoy life should be evaluated by a mental health professional. Many HVers and supervisors will have worries about the nursing practices provided, wonder what they could have done di​fferently, blame themselves for the outcome, or be afraid of being blamed by others for the outcome. Our goal is to promote a healthy grief response. This includes making meaning from the loss and finding opportunities for professional and personal growth. Consider the best timing for follow up on lessons learned and any desired practice changes. Supervisors can seek assistance from their Nurse Consultant and can encourage reflection from the impacted staff by calling out the benefit of hindsight and talking through worries that crucial warning signs were unaddressed. See Appendix D for reflections and after-action tools. Seek guidance from agency Employee Assistance Program on how to assist staff with these thoughts and feelings.

Legal Considerations for Adverse Outcomes
  • ​Ensure nursing documentation is up to date; document the adverse event in the medical record. 
  • Ensure understanding of county-specific policies for confidentiality and privacy and exceptions related to working with law enforcement and Child Protective Services.  
  • Medical examiners are responsible to investigate deaths that occurred under unknown circumstances or those who die unexpectedly while in good health, while not under the care of a physician immediately before death. (ORS146.090) 
  • All health care providers must cooperate with the medical examiner to provide medical records or other material necessary to conduct a death investigation. (ORS 146.100) 
  • An autopsy is performed when there is a need to establish or confirm cause of death, cases involving suspected criminal wrongdoing or any other case where the medical examiner considers it prudent. 
    • ​The autopsy report with the final cause of death is released only after autopsy and death scene investigation. This may take up to 120 days. 
    • Under ORS 146.045 (5) Notwithstanding ORS 192.345 (Public records conditionally exempt from disclosure)(36): (a) Any parent, spouse, sibling, child or personal representative of the deceased, or any person who may be criminally or civilly liable for the death, or their authorized representatives respectively, may examine and obtain copies of any medical examiner's report, autopsy report or laboratory test report ordered by a medical examiner under ORS 146.117 (Autopsies).

State and Local Fatality Reviews
​Child Fatality Review
Oregon's Child Fatality Review process focuses on the subset of child deaths that are "unexpected." This includes deaths to children from birth through age 17 from unintentional injuries, intentional injuries (homicide and suicide), SIDS/SUIDS and unexpected deaths due to natural causes. All local Child Fatality Review (or Child Death Review) teams review cases of deaths occurring to county residents, regardless of county of death (ex: a child may be transported to a hospital out of the county). These teams function at both the state and county levels. This process is federally mandated by the Child Abuse Prevention And Treatment Act with a goal to identify system failings and make recommendations for future prevention. See the Oregon Child Fatality Review website.  

Critical Incident Response Team
If a victim has been in Department of Human Services custody (DHS) or is a sibling of, or another child living in, the household that has been a subject of a Child Welfare assessment or had a report of abuse or neglect in the previous year, the DHS Critical Incident Response Team (CIRT) must be notified within three business days. 

If the victim or a family member has had contact with child protective services, the agency studies these incidents by gathering a group of responsible individuals representing several agencies to form a Critical Incidence Response Team, or CIRT. In the interest of public health, a CIRT seeks to identify systemic issues and generate recommendations for what can be learned, changed or corrected that might reduce future tragic outcomes. 

Each CIRT process creates three separate reports. When criminal and other investigations related to the case close, the final report can be released to the public. In accordance with state law, DHS does not release the personal information about children or families involved in the child welfare system, even if that information has been released through other means. See the CIRT website for more information, the County team contacts can be found here.

Maternal Mortality and Morbidity Review Committee​
Oregon passed House Bill 4133 in the 2018 legislative session, which gave direction to the Oregon Health Authority to form the Maternal Mortality and Morbidity Review Committee. The committee conducts studies and reviews of incidents of maternal mortality and severe maternal morbidity in Oregon. After the review, the committee shares findings and information with health care providers and facilities, social service providers, law enforcement, and many others. See the MMMRC website for more information. This committee is appointed by the Governor and led by state staff.

Oregon Intimate Partner Violence Fatality Review
The Oregon Domestic Violence Fatality Review Team (ODVFRT) reviews domestic-violence related fatalities and makes findings and recommendations with the ultimate goal of preventing death from domestic violence. The purpose of each case review is not to blame individuals or adjudicate the case, but to identify gaps, challenges, and even successes and offer recommendations for system improvements. ODVFRT teams are held at the local and state levels. 

Anticipatory Guidance for Participating in the Review Process
  • Home visiting program staff experiences are of high value to the review process. Staff should be supported in exploring their desires to participate in these processes. 
  • Consider who will be the best representative from your program. If a home visitor will participate, assure support for them by considering joint attendance with the supervisor. 
  • Understand that home visitors often have perspectives on the death that are not shared by any other representatives. These perspectives can lead to recommendations that could have lasting systemic impacts. 
  • It should be recognized that these meetings may not be conducted in a trauma informed manor or strength focused. Staff should be aided in navigating the cultural differences between home visitation and the other systems represented at the meeting. 
  • Reviews may occur many months after the event. 
  • Request an agenda in advance; plan to join the meeting only for the part that applies to your client. 
  • Avoid exposure to other traumatic events during the meeting. Even if you're a standing member on the committee, you may want to take a break from the full meeting this time. 
  • Learn as much as you can about the meeting in advance, such as who facilitates the meeting, location of meeting, what are the intended outcomes of the meeting, etc. 
  • Seek reflective supervision from a trusted reflective resource before and after the meeting. 
  • Plan and practice mindful self-regulation prior to, during and after the meeting. 
Plan time in your schedule to care for yourself and seek needed restorative measures after the meeting.

Appendicies

Appendix A: 
Just-in-Time Brief Content Review to Support Bereavement Interactions with Families
Appendix B:
The RBH Road Maps, Acute Signs and Symptoms Following a Critical Incident
Appendix C:
Interventions for Supporting Mothers and Families After Infant Death, Stillbirth, or Miscarriage
Appendix D:
Reflection and Action Tools
Appendix E: References


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