Exploring the Impact of Obstetric Sonographers Dealing With and Supporting Patients Who Receive Negative Outcomes

Abstract

Because of the complex circumstances in pregnancy, obstetric (OB) sonography requires dissemination of results, often during the examination, and the sonographer can be highly involved in that reporting. This creates a complex set of work responsibilities, in which patient support is of utmost importance, especially when the results are unfavorable. While patient experiences of receiving a negative outcome, during an OB sonogram, have been widely reported, there is a lack of literature on the experience of the sonographers involved in delivering this information. Thus, it is important to identify variables that impact providing ethical care for grieving OB patients. Sonographers in a maternal-fetal medicine clinic work very closely with a group of physicians, and other providers, in delivering unfavorable results, making communication, and understanding of roles of the utmost importance. Conversely, sonographers in a general OB/gynecology practice may not have the support of colleagues when communicating with the grieving patient. These demands may cause feelings of guilt, uncertainty, and stress, contributing to the experience of burnout for the OB sonographer. To prevent these feelings, it is important to consider ways to create a positive work environment and provide resources to protect sonographer mental health. Health care systems must ensure employee access to resources for managing stress, because of caring for grieving patients, and prioritize a healthy work environment, even during challenging times. Future studies are needed that investigate possible training materials, beyond basic hospital training, which targets the skill set needed to properly care for the grieving OB patient.

Within each specialty of diagnostic medical sonography, the clinical skills of the sonographer are markedly different. ¹ Obstetric (OB) sonography is unique due to a focus of not evaluating multiple adult organs or systems, but rather the sonographer is assessing pregnancy, and fetal life, within the OB patient. Because of the complex circumstances in pregnancy, OB sonography requires dissemination of results, often during the examination, and the sonographer can be highly involved in that reporting. When the diagnostic information, is unfavorable, the sonographer is also required to provide various levels of support for a potentially grieving patient. This creates an additional, complex set of work responsibilities, in which patient support, as part of the health care team, is of utmost importance. Thus, it is imperative that the health care system provide resources for managing stress involved in caring for grieving patients and prioritize the maintenance of a healthy work environment for OB sonographers.

In recent years, patient-centered care initiatives have been at the forefront of improving the delivery of health care, in the United States. ² As such, the OB health care team is focused on providing the patient with a satisfactory experience, regardless of their pregnancy outcome. Specifically, the sonographic experience, from expectations to processing their diagnostic results, is a very important factor in their perception of care. ³ While patient experiences of receiving a negative outcome, during an OB sonogram, has been widely reported, there is a lack of literature on the experience of the sonographers who are involved in delivering this information. ³ To promote future research which investigates both the methods for managing grieving patients, and the effects that this management has on the well-being of the sonographer, it is important to identify the variables that impact caring for patients in an OB work environment.

Ethical Practice in OB Sonography

Medical ethics is a provider’s obligation to protect and promote a patient’s health interests. Physicians practice with an ethical code, and the sonographer is required to provide patient care according to this code, within their facility. ⁴ In OB care, physicians and sonographers essentially work with two patients, the OB patient, and the fetus. Sonographers image a fetus and maternal structures for the physician to interpret. After a sonogram, physicians provide patient education to the OB patient that promotes the health of the fetus and mother. These suggestions must implement the ethical principles of beneficence, nonmaleficence, justice, and autonomy. ⁴ Autonomy is particularly important for OB providers to respect, due to the unique position of the pregnant patient. Regardless of the sonographic findings that may reveal abnormalities or dangers to the mother or the fetus (or both), the pregnant patient must be given the right to decide on treatment and procedures that are received throughout the pregnancy. ⁵ In many situations, these ethical discussions are driven directly by the sonographic findings, which can make patient care quite challenging for the OB sonographer. In a study of patients receiving fertility treatments, results demonstrated that most patients who reported an overall positive patient experience were those whose treatment ended in a successful pregnancy. ⁶ Thus, the OB sonographer must work hard to make their patients feel properly supported, despite abnormal findings or unfavorable fetal outcomes.

Spectrum of OB Work Environments

The delivery of ethical practice, in an OB work environment, is also dependent upon the specific type of clinic and providers that are present. The size and spectrum of OB care can vary greatly, thus making patient care experiences for sonographers vary as well. Many maternal-fetal medicine (MFM) or high-risk perinatology departments, operating under larger hospital networks, will see patients at any level of the OB patient care spectrum. This can be compounded by the patients with various maternal comorbidities, as well as the complexity of the pregnancy, and congenital abnormalities. Here, it is common for patients to be given results shortly after completion of the sonogram, thus allowing them the immediate benefit of being informed of and referred for additional services. ³ Depending on the procedures and policy present at the individual institution, the sonographer is often included in dissemination of results, required to provide surveillance imaging, and be actively involved in invasive procedures, based on the outcome of the sonogram. Throughout this experience, the sonographer must anticipate the needs of individual patients based on their unique case and be prepared to provide emotional support (within their scope of practice), throughout the examination.

Because of the challenges that come when working with high-risk patients in a MFM clinic, professional teamwork is of utmost importance. Sonographers work very closely with MFM physicians in image analysis, reporting, patient communication, and invasive procedures. In addition, they may have support from a team of fetal therapy or high-risk specialists, including nurses, nurse practitioners, genetic counselors, and social workers, who work in tandem to ensure that the patient receive individualized care throughout their pregnancy. While the additional support is beneficial, it is imperative that each member of the team understand and respect the role of others. Closed-loop communication must be constantly reinforced, thus allowing for efficient management of difficult situations. A 2019 survey of 249 Australian OB sonographers demonstrated that most sonographers felt that communication with patients was less stressful with proper support from sonologists and other professionals. ⁷

The sonography experience in a general OB/gynecology (Gyn) practice is often very different than an MFM office. While the overall case load may contain less complexities, the sonographer is still required to provide thorough investigation of pregnancy and fetal anatomy. However, physician interpretation and results reporting will vary greatly across facilities, and counseling, referral, and ongoing services and testing may not be readily available for the patient, after the examination. At times, remote or off-site reading of sonographic images may even occur. Thus, while an sonographer may not be deeply involved in patient care with daily abnormal findings, they may lack the supporting roles that allow them to successfully manage these cases when they do occur.

On the opposite end of the spectrum from MFM clinics, is the emergency department (ED). In a recent retrospective study, it was found that approximately 39% of pregnancies identified over a 15-year period visited the ED for treatment during their pregnancy. ⁸ In regard to sonographer support, the ED setting can be similar to that of a OB/Gyn practice, in that, levels of physician support and interpretations can vary greatly across institutions, and even attending ED physicians. This is further compounded by the high-stress environment of the ED, as well as the increased likelihood of discovering negative outcomes for mother or fetus. The reasons above highlight even more importance of recognizing the stressors that sonographers are under, performing OB/Gyn examinations in the ED.

OB Sonographer Burnout

As with many health care fields, sonographers routinely experience burnout. Burnout is defined as the condition characterized by the state of chronic stress, which occurs when expectations of an individual exceed their psychological capacity and ability to cope with work demands. ⁹ A 2023 study looked at burnout scores among 70 sonographers in New York City. Of the participants, 81.4% presented with a moderate to high burnout score. ¹⁰ Specifically, OB sonographers may experience adverse personal outcomes, working with OB patients who result in emotionally taxing days. Feelings of guilt, uncertainty, and loneliness cause distress, fatigue, and disengagement. ³ Additional causes of burnout seen throughout the literature include an increased number of examinations per day (i.e., high workload), short appointment slots, long hours, and overtime, training students, and managing patient encounters. ⁹ Although the OB sonographer is often portrayed as the creator of keepsake fetal images, there is an emotional and physical toll that may occur over time when caring for the grieving patient.

OB Sonographer Resources and a Positive Work Environment

To prevent OB sonographer burnout during job demands, it is important to consider ways to create a positive work environment and provide resources to protect mental health. To create a positive work environment, there must be mutual trust and respect for colleagues. In the OB community, validating emotions and sharing experiences about difficult work experiences can create a common ground among sonographers. ¹¹ Team-building activities provide bonding opportunities that allow colleagues to engage with each other in different ways. If working in a larger department with multiple sonographers, teamwork actions such as covering examinations and serving as an active listener can allow for recovery periods. ¹² Equally important is addressing mental health on an individual level, as stress and grief in the workplace will impact each employee differently. The onset of the COVID-19 pandemic brought many health care institutions to quickly commit to resources to improve the well-being of health care workers, but there is a lack of published protocols for interventions or targeted services for specific patient care roles. ¹³ While many facilities advertise staff access to mental health services, they may not always be readily available. It is important for management to take a role in ensuring that their sonographers can receive the mental health services needed to maintain their well-being in the workplace. By working together to promote the health of fellow employees, patient care and satisfaction can improve as well.

Implementing positive work environment tactics could decrease OB sonographer burnout. Although this could also be supplemented by a more root cause approach. Sonographer training specifically focused on delivering negative outcomes focused specific to the OB sonographer can provide a foundation on which the OB sonographer can utilize when negative outcome is discovered. This could be done at both the corporate and employee level. Sonography program curricula could be enhanced to include a specific focus on tactics of delivering negative news, grieving processes, medical ethics, and so on. In addition, and arguably more importantly, some level of negative outcomes training should be included in the onboarding process for all new sonography jobs. Policies and procedures vary greatly across institutions and practices. Implementing a “job-specific” training on this topic allows the incoming sonographer to understand and align with that institution/MFM office/practice’s specific policies, on negative outcome reporting. Not only would this help with patient care and legal considerations, but would also provide clarity to the OB sonographer on exactly what their role is when these negative situations occur.

Conclusion

Now more than ever, it is important to support the mental health of our profession, and the complex environment of OB sonography reinforces this need. Health care systems must ensure employee access to resources for managing stress, because of caring for grieving patients, and prioritize a healthy work environment, even during challenging times. Patient autonomy and professional ethics are an important part of the OB sonographic experience. Therefore, managers should consider better ways to support their sonographers with tools to communicate with patients and support patients during their pregnancy experience. Future studies are needed that investigate possible training materials, beyond basic hospital training, which targets the skill set needed to properly care for the grieving OB patients. To do this, pilot research that explores OB sonographer perceptions of their work experience, role in the OB clinic, and interactions with their patients would be beneficial.

Because of the variation in sonographer roles, interactions with physicians, other health care providers, policies across various clinical sites, and geographic locations, providing a targeted set of professional guidelines for OB patient care, during sonography, continues to be challenging. However, lack of guidelines amid such a complex set of work responsibilities can cause confusion about one’s professional identity. ⁷ Sonographers, especially those in smaller work environments, must receive the support they need to provide their patients with care that upholds values of medical ethics. To foster professional passion and pride that is noted among OB sonographers, it will be important to find specific ways to support the work environment in OB sonography.