UNDERSTANDING MOTHERS’ TRUST IN NURSES AMIDST TRAUMATIC CHILDBIRTH EXPERIENCES by CAITLIN FRIESEN Bachelor of Science in Nursing, Trinity Western University, 2018 Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of MASTER OF SCIENCE IN NURSING in the FACULTY OF GRADUATE STUDIES TRINITY WESTERN UNIVERSITY MAY 2024 © CAITLIN FRIESEN, 2024 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH i Abstract Perinatal nurses support mothers in the majority of births in Canada, holding an important role in improving respectful maternity care and reducing adverse outcomes. Trust is a recurring theme in the literature of nurse-mother relationships and a crucial component of relationship-centred and trauma-informed care. However, little is known about how trust develops when mothers have traumatic childbirths. The purpose of this qualitative interpretive descriptive study was to understand mothers’ experiences of trust with perinatal nurses amidst traumatic childbirths. Semi-structured interviews were conducted with eight mothers. Data analysis revealed one overarching theme; Trust in the Nursemother Relationship: A Shelter in the Storm, and three main themes: The Foundations and Fluid Trajectories of Trust, Developing and Maintaining Trust Through Relationship-Centred and Trauma-Responsive Care, and Barriers to Developing and Maintaining Trust. These findings can guide perinatal nurses in partnering with mothers to build a trusted shelter in the storm of traumatic childbirth. Keywords: trust, mothers, nurses, perinatal, traumatic childbirth MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH ii Acknowledgements I would like to thank the following people for their support along this journey: Dr. Kendra Rieger and Dr. Lyndsay MacKay, my thesis supervisors, who encouraged, celebrated, and graciously invested their time and expertise into this thesis. I am so blessed to have shared this journey with you both. Dr. Barb Astle and Dr. Christina West, the second half of my incredible committee who brought remarkable passion and expertise to this project. My family. To each one of you, thank you for your thoughts, prayers, encouraging texts and video calls, and wise and patient guidance. My soon-to-be husband, Stewart. Thank you for walking this journey with me, for supporting me in every way you could, and for your unwavering belief in me. Thank you, God, for your undeniable and generous gifts of strength, peace, and perseverance. Thank you for an identity in You, grounded in love, which surpasses any academic accomplishment. And finally, I would like to thank each mother who participated in this study. Your willingness to share was inspiring. Your bravery, your vulnerability, and your desire to improve future mothers’ experiences of care are the reason this thesis was possible. Thank you. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH iii Table of Contents Abstract ................................................................................................................................ i Acknowledgements ............................................................................................................. ii Chapter One: Introduction and Background ....................................................................... 1 Background ..................................................................................................................... 2 Trust in the Perinatal Nurse-Mother Relationship ..................................................... 2 Traumatic Childbirth .................................................................................................. 4 Trauma-Informed and Trauma-Responsive Care ....................................................... 6 Personal Motivation and Positionality ....................................................................... 7 Problem Statement .......................................................................................................... 9 Theoretical Perspectives ................................................................................................. 9 Purpose and Objectives ................................................................................................. 13 Study Design and Methods ........................................................................................... 13 Definitions of Terms ..................................................................................................... 14 Trust .......................................................................................................................... 14 Perinatal Nurse ......................................................................................................... 14 Mother ....................................................................................................................... 15 Traumatic Childbirth Experience ............................................................................. 15 Nurse-mother Relationship ....................................................................................... 15 Significance and Relevance .......................................................................................... 15 Outline of Thesis ........................................................................................................... 16 Chapter Two: Literature Review ...................................................................................... 18 Search Strategy ............................................................................................................. 18 Review of Selected Literature ....................................................................................... 21 Definitions of Trust ................................................................................................... 23 Personal Characteristics .......................................................................................... 24 Interpersonal and Relational Factors ....................................................................... 26 Structural Factors ..................................................................................................... 32 Summary of Review ..................................................................................................... 33 Traumatic Childbirth Experiences ................................................................................ 33 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH iv Antecedents of TCEs ................................................................................................. 34 Childbirth Events that Contribute to TCE ................................................................ 35 Consequences of TCEs .............................................................................................. 35 Nursing Role and Recommendations ........................................................................ 37 Racial Considerations ............................................................................................... 38 COVID-19 Implications ............................................................................................ 39 Critical Reflection of the Current State of Knowledge ................................................. 40 Chapter Summary ......................................................................................................... 41 Chapter Three: Study Design and Methods ...................................................................... 43 Research Purpose and Objectives ................................................................................. 43 Research Design............................................................................................................ 44 Sampling and Recruitment ........................................................................................ 46 Inclusion Criteria ...................................................................................................... 47 Description of Sample ............................................................................................... 48 Procedures for Informed Consent and Data Collection ........................................... 50 Data Analysis ............................................................................................................ 53 Quality of Data .............................................................................................................. 55 Ethical Considerations .................................................................................................. 57 Respect for Human Dignity ....................................................................................... 57 Justice ....................................................................................................................... 58 Beneficence ............................................................................................................... 59 Trauma-informed Research ...................................................................................... 59 Chapter Summary ......................................................................................................... 60 Chapter Four: Findings ..................................................................................................... 62 Overarching Theme: Trust in the Nurse-mother Relationship as a Shelter in the Storm ....................................................................................................................................... 64 The Foundations and Fluid Trajectories of Trust Amidst Traumatic Childbirth .......... 68 Origins of trust .......................................................................................................... 69 Fluidity of Trust Amidst Trauma............................................................................... 73 The Necessity of Trust in the Nurse .......................................................................... 74 When Trust Occurred ................................................................................................ 75 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH v Developing and Maintaining Trust through Relationship and Trauma-responsive Care ....................................................................................................................................... 79 Relationships as the Groundwork for Trust During TCEs ....................................... 79 Enacting a Caring Presence During Labour, Birth, and Postpartum ...................... 82 I See You: Intuitive Responsiveness to the Mother’s Humanity, Trauma, and Felt Needs ......................................................................................................................... 85 Effectively Communicating Throughout the Perinatal Experience .......................... 89 Supporting the Mother’s Birth Plan ......................................................................... 93 Barriers to Developing and Maintaining Trust Amidst a Traumatic Childbirth ........... 97 Structural Factors Shaping Perinatal Nursing Care ................................................ 98 Feeling Unseen or Insignificant Amidst and Following TCEs ............................... 100 Unsupportive and Harmful Communication Styles ................................................ 104 Lack of Collaboration and Partnership in the Birthing Experience....................... 106 Questioning of the Perinatal Nurse’s Expertise ..................................................... 111 Chapter Summary ....................................................................................................... 113 Chapter Five: Discussion ................................................................................................ 115 Trust Amidst Traumatic Childbirth is Possible: The Fluidity of Trust Explored ....... 116 Heightened Sensitivity in a Traumatic Transition to Motherhood ......................... 117 Hope and Possibility for Rebuilding Trust Amidst Traumatic Childbirth .............. 118 Trust Amidst Traumatic Childbirth is Dependent: Facilitators and Barriers of Trust 119 Facilitators of Trust Amidst Traumatic Childbirth That Resonate with Existing Literature ................................................................................................................ 120 Evolved Needs for Developing Trust Amidst a Traumatic Childbirth: Advancing Understandings of Facilitators ............................................................................... 122 Reflections on Trauma-informed and Trauma-responsive Care ............................ 124 Barriers to Trust Amidst Traumatic Childbirth ...................................................... 126 Trust Amidst a Traumatic Childbirth is Necessary: A Shelter in the Storm .............. 128 When Trust Occurs Amidst Traumatic Childbirth Experiences: Defining Trust .... 128 Impact of Trust and Mistrust in Perinatal Nurses on Traumatic Experiences ....... 129 Application of Theoretical Frameworks on Trust and Traumatic Childbirth ............. 132 Respectful Maternity Care and Traumatic Childbirth Experiences ....................... 132 Relationship-centred Care Within Traumatic Childbirth Experiences .................. 134 Reflections on Interpretive Description, Trust, and Traumatic Childbirth ................. 136 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH vi Chapter Summary ....................................................................................................... 137 Chapter Six: Conclusions and Recommendations .......................................................... 139 Summary of the Study ................................................................................................ 139 Conclusions ................................................................................................................. 140 Knowledge Translation ............................................................................................... 141 Study Limitations ........................................................................................................ 142 Recommendations ....................................................................................................... 145 Education ................................................................................................................ 145 Practice ................................................................................................................... 147 Policy ...................................................................................................................... 149 Research .................................................................................................................. 151 Chapter Summary ....................................................................................................... 152 References ....................................................................................................................... 154 Appendix A: Keyword Search Table .............................................................................. 169 Appendix B: PRISMA Flowchart ................................................................................... 170 Appendix C: Literature Review Matrix .......................................................................... 171 Appendix D: Recruitment Poster .................................................................................... 177 Appendix E: Participant Information Letter ................................................................... 178 Appendix F: Consent Form ............................................................................................. 179 Appendix G: Sociodemographic Questionnaire ............................................................. 183 Appendix H: Semi-structured Interview Guide for Qualitative Interviews .................... 185 Appendix I: Field Notes Template .................................................................................. 187 Appendix J: Debriefing Script ........................................................................................ 189 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 1 Chapter One: Introduction and Background Childbirth is widely assumed to be a joyous time in which there is a welcoming of new life into the world, yet despite these blissful assumptions, up to one third of mothers have described their birth experience as traumatic (Baptie et al., 2021; Koster et al., 2020; Türkmen et al., 2020). Between April 2019 and March 2020, almost 42,000 births in British Columbia (BC) took place in a healthcare facility under the collaborative care of the patients’ registered perinatal nurse and other healthcare providers (Perinatal Services BC, 2020). Considering the significant percentage of mothers who have experienced childbirth as traumatic, the knowledge of nursing care within trauma and childbirth is an important area of research. Traumatic childbirth experiences (TCEs) have been known to decrease levels of trust between mothers and healthcare providers (Beck, 2004a), a critical component of the nurse-mother relationship and a necessary contributor to relationship-centred care (Rider, 2011). Additionally, experiences of traumatic births are correlated with increased postpartum stress, anxiety, and depression (Türkmen et al., 2020) while posing new challenges for mothers interacting with their newborns (Beck & Watson, 2019). The dynamic of trust is central to the nurse-mother relationship and can positively or negatively impact the birthing experience and the overall well-being of mothers (Baptie et al., 2021; Greenfield et al., 2022). Little research has been done to explore the impact that TCEs have on the development of trust within the nurse-mother relationship amidst the birthing process. An understanding of mothers’ experiences of trust during and after a traumatic birth may provide nurses with knowledge and understanding that aids them in caring for mothers from a relationship-centred a trauma- MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 2 informed, and responsive, approach to mitigate the negative impacts of birth trauma. This chapter will provide background information on the role of the perinatal nurse, trust in the nurse-mother relationship, TCEs, and the lens of trauma-informed (TIC) and traumaresponsive care (TRC). Background Perinatal nurses play a unique and vital role in supporting mothers during approximately 98 percent of hospital births in Canada (Statistics Canada, 2021). In British Columbia, perinatal nursing is a specialty that requires registered nurses to complete additional education and training resulting in a “partnership with childbearing women and their families, providing education and support to empower their patients with skills to care for their families” (British Columbia Institute of Technology, 2020, para 1). Broadly speaking, perinatal nursing covers a wide continuum of care, which includes labour support, fetal monitoring, comprehensive assessments, pain management, and postpartum care of mothers and newborns following delivery (British Columbia Institute of Technology, 2020). Perinatal nurses are active participants in the childbirth experience and therefore hold an important role in improving maternity care and reducing the probability of adverse outcomes during and following the childbirth experience (Simpson & Creehan, 2021). For the purpose of this research, my focus is on the perinatal nurse-mother relationship spanning from mothers’ admission to a maternal-child unit for labour to the discharge from the hospital following childbirth. Trust in the Perinatal Nurse-Mother Relationship Trust is a crucial component of the nurse-mother relationship in maternity care. The British Columbia College of Nurses and Midwives (BCCNM) define the nurse- MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 3 patient relationship as being built on “trust, respect and professional intimacy” (2024, para. 2). In the literature, trust is a recurring theme within nurse-mother relationships and is vital to providing RCC to those who have had or will experience childbirth (Massey et al., 2006). While other maternity practitioners may be able to develop this relationship with mothers over the course of the pregnancy, perinatal nurses who work in hospital settings are normally limited to the period of labour, delivery, and postpartum care to establish trust in the nurse-mother relationship. Despite the time restraints on the relationship between perinatal nurses and mothers, an “embodied experience” (Goldberg, 2004, p. 401) of trust can take place. Even the brief moments leading up to delivery can have a long-lasting impact on mothers, whether it be a listening ear, a comforting touch, or an instance of eye contact from the nurse (Goldberg, 2004). Thus, it is crucial that nurses understand how trust is established with mothers to aid in providing relationshipcentred care that promotes wellbeing for mothers and their newborns. Mothers who felt their care was personalized reported increased levels of trust and were less likely to describe their birth experience as traumatic (Baptie et al., 2021). A trusting relationship with the perinatal nurse has been known to foster mothers’ trust in their own abilities in the birthing process (Goldberg, 2008; Kuzma et al., 2020), increase birth satisfaction (Dalton et al., 2021), and is highly related to mothers’ experiences of communication with nurses during the intrapartum period (Dalton et al., 2021). The development of trust is often associated with continuity of care and the opportunity to develop a relationship with mothers over time (O’Brien et al., 2021). Of concern, a lack of trust between mothers and their healthcare providers has been associated with an MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 4 increased risk of additional interventions in the birthing process such as an episiotomy (Greenfield et al., 2022). The development of trust within the perinatal nurse-patient relationship occurs during mothers’ transition to motherhood, which is a complex and momentous phenomenon, comprised of relational, physical, emotional, and societal changes (Hwang et al., 2022). How a woman responds to, or is supported through these significant changes, can positively or negatively impact the well-being of mothers, and ultimately, their newborns. Thus, nurses are in a unique position to provide support to mothers during such transitions (Hwang et al., 2022). Beneficial outcomes of a successful transition to motherhood include secure mother-newborn attachment and bonding, healthy newborn development, optimal maternal parenting behaviors, and healthy maternal mental health (Hwang et al., 2022). In contrast, adverse outcomes from a suboptimal transition to motherhood include, but are not limited to altered maternal role attainment, poor mother-newborn bonding, and increased maternal negative emotions (Hwang et al., 2022). The initial encounter between perinatal nurses and mothers during pregnancy and childbirth is critical in the building of trust that leads to supportive relations, key in aiding mothers’ experience of a positive transition to motherhood (Goldberg, 2005; Hwang et al., 2022). Traumatic Childbirth Trauma can be defined as “the challenging emotional consequences that living through a distressing event can have for an individual. Traumatic events can be difficult to define because the same event may be more traumatic for some people than for others” (The Centre for Addiction and Mental Health, 2024, para. 1). Amidst the childbirth MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 5 experience, distressing events can take place, leading to emotional consequences. Leinweber et al.’s (2022) definition of a TCE provides direct implications for nursing care as it is inclusive of mothers’ subjective experiences, emphasizes the healthcare provider’s potential impact, and allows for an extensive range of events leading to this phenomenon: A traumatic childbirth experience refers to a woman's experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/or long-term negative impacts on a woman’s health and wellbeing. (p. 691) Women are especially vulnerable to the long-lasting impacts of trauma on both mental and physical health during the perinatal period (Kuzma et al., 2020) due to the intimacy of care, assessments, and interventions (Long et al., 2022). As approximately one-third of mothers have described their childbirth experience as traumatic (Baptie et al., 2021; Koster et al., 2020; Türkmen et al., 2020), TCEs are significant in perinatal nursing. Predictors of a TCE include physical, psychological, and interpersonal factors, such as increased medical interventions, negative interactions or power dynamics with healthcare providers, feelings of a lack of control, pain, and fear of harm to oneself or their newborn (Beck, 2004a; Koster et al., 2020; Türkmen et al., 2020). TCEs can also increase mothers’ risks of developing post-traumatic stress disorder (PTSD) while also causing immense distress around the anniversary of their child’s birth, challenges with breastfeeding and attachment to their newborn, and a sense of fear, dread, or complete deterrence to future pregnancies (Beck, 2015; Greenfield et al., 2016). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 6 Newborns born to mothers with PTSD have shown delayed physical and cognitive development (Soet et al., 2003). Not only do traumatic births impact the mother and newborn, but they also have negative effects on other relationships. Relational strain, flashbacks to the childbirth experience during intercourse, and feelings of anger and abandonment have been reported by mothers following a TCE (Beck, 2015). Due to the negative impacts of trauma on mothers’ and newborns’ health, it is beneficial for nurses to gain an understanding of how to develop trust with mothers to aid them in providing relationship-centred, trauma-informed, and trauma-responsive care. Healthcare providers may contribute to mothers’ experience of TCEs by the following: disregard for mothers’ dignity, a mother’s sense of loss of control and lack of care, inefficient and insensitive communication, and an ignorance of mothers’ experiences following delivery (Beck, 2015; Watson et al., 2021). Further, what perinatal nurses may view as a standard or even positive delivery may be experienced by mothers as extremely traumatic (Beck, 2004a; White et al., 2022). These differing perspectives can impact mothers’ abilities to trust their perinatal nurses and enter a supportive relationship with them. A more thorough review on TCEs is provided in Chapter Two with specific consideration of the impact of racial disparities and the COVID-19 pandemic on childbearing mothers and the birthing experience. Trauma-Informed and Trauma-Responsive Care Perinatal nurses are in a unique position to provide trauma-informed care (TIC) for mothers who have a history of trauma and for those who experience traumatic births. TIC is an approach to healthcare that acknowledges the reality of trauma in an individual’s life and the impact on how it may affect their response to health services MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 7 (Knight, 2019). Kuzma et al. (2020) identified a four-part approach to TIC specific to nurses during the perinatal period: understanding of trauma, knowledge of trauma, the ability to recognize signs of historical trauma, and delivery of care with a consideration to avoid retraumatization. This approach reflects the six core principles of trauma-informed care from the Substance Abuse and Mental Health Services Administration (SAMHSA): safety, peer support, collaboration, empowerment, cultural, historical and gender issues, and trustworthiness and transparency (SAMHSA’s Trauma and Justice Strategic Initiative, 2014). To be trauma-responsive is to move beyond the knowledge of trauma-informed principles and enact these principles into one’s discipline (Covington & Bloom, 2018). During the birthing process, reciprocal communication and shared decision-making between the nurse and mother reflect trauma-responsive care (TRC) (Covington & Bloom, 2018; Kuzma et al., 2020). When possible, nurses can support mothers’ autonomy and empowerment by building trusting relationships that allow mothers to make informed decisions about their care (Koster et al., 2020). Within the postpartum setting, nurses can provide TRC through encouraging continuity of care and having honest conversations about the birth process using language that validates mothers’ experiences (White et al., 2022). With a trauma-informed lens, this study illuminates the experience of trauma in the birthing process and provides direction for provision of trauma-responsive and relationship-centred care to mitigate its impact. Personal Motivation and Positionality My motivation to conduct this study stemmed from my professional experience working as a postpartum nurse and through conversations with a colleague who studies MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 8 the concept of trust between nurses and patients within the healthcare system. Personally, I was motivated to facilitate and produce a diverse account of mothers’ experiences of developing trust with nurses amidst traumatic childbirths to empower the voices of mothers who have experienced a TCE. To ensure self-reflexivity, it was important to acknowledge my positionality (Bourke, 2014) and the lens through which I approach the research as a postpartum nurse and an educated, unmarried, White woman with no children. Although I have a basic understanding of the birthing process from my experience caring for mothers and newborns after delivery, I have not experienced it on a personal level. I am aware that my position as a nurse in maternal and newborn care has placed me in a potential position of power in relation to the mothers I have interviewed. During my postpartum nursing practice, I seek to understand each mothers’ individual experience, yet I am often heavily reliant on the labour and delivery nurses’ and/or the physicians’ report of the birth. This report rarely reflects the picture I see when entering the new mother’s room and may have resulted in bias against mothers’ experiences. Already, this misalignment of perception of the birth experience may pose a barrier to earning the trust of postpartum mothers (Beck, 2004a; White et al., 2022). As well, I believe my professional nursing experience can provide an important lens for this research if I practice reflexivity and adhere to strategies for rigour to ensure my perspectives are helpful rather than limiting during data collection and analysis. As a postpartum nurse, I consciously aim to establish trust with maternal patients as a means to develop supportive relationships. I believe that trusting relationships allow for the development of a safe space amid mothers’ vulnerability. An assumption that I bring to this research is that mothers desire to have trusting relationships with their MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 9 perinatal nurses and also see this as a component of good care. A preliminary review of research on trust in the perinatal setting made me aware of the significant incidence of TCEs, along with the causes and the adverse outcomes related to birth trauma. Although not all of the risk factors of TCEs are preventable, a review of the literature highlighted the role of perinatal nurses in mothers’ experiences of childbirth. Problem Statement The problem that this study addresses is the lack of knowledge on the concept of trust between perinatal nurses and mothers amidst and following a TCE. This gap is significant due to the negative impact that TCEs have on mothers, newborns, and the family unit (Beck & Watson, 2019; Türkmen et al., 2020). In attempts to fill this gap in knowledge, in this study I explored how trust is developed and maintained within the perinatal nurse-mother relationships amidst and following a TCE. TCEs have been associated with a lack of or break in trust within the healthcare provider and patient relationship (Beck, 2004a; Kuzma et al., 2020). Trust within the nurse-mother relationship has also been shown to increase mothers’ satisfaction and participation within the birthing experience and feelings of empowerment (Dalton et al., 2021; Kuzma et al., 2020). Theoretical Perspectives To explore the perceptions of trust in the nurse-mother relationship amidst TCEs, the theoretical perspectives of relationship-centred care (RCC) and respectful maternity care (RMC) guided my study. Relationship-centred care (RCC) is described as an enhancement of patient-centred care, which is a common framework used in nursing practice (Rider, 2011). Congruent with patient-centred care, RCC values the healthcare MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 10 professional, the patient, and establishing genuine interpersonal relationships as essential to the provision of good patient care (Hardeman et al., 2020a, Hardeman et al., 2020b; Suchman, 2006). The four main principles of this framework are: (a) the inclusion of personhood, (b) the importance of emotion and affect, (c) reciprocity of relational influence, and (d) the moral benefits of relationships in the healthcare context (Beach et al., 2006). Two anticipated outcomes of RCC are a trusting relationship between the patient and the provider and an enhancement of health (Beach et al., 2006). This approach to care highlights the influence that interactions between patients and care providers has on patient outcomes and supports the need for perinatal nurses to establish trusting relationships with mothers for caring activities to function and occur (Rider, 2011). To engage in RCC, perinatal nurses must adopt a “learner’s stance” (Humbert & Roberts, 2009, p. 594), fostering a shared relationship with mothers to learn from their experiences (Humbert & Roberts, 2009). The principles of RCC guided this study and provided insights into study design, data collection and analysis, and interpretation of findings. RCC includes reflecting on what matters most to the patient (Beach et al., 2006), or in the case of this research, the mother. Thus, interviews were semi-structured to allow mothers to reflect on their experiences and guide the direction of the conversation to capture their unique perspectives, while pursuing genuine, shared relationships with the participants. In their commentary on RCC, Hardeman et al. (2020a) discussed the potential of this framework in the perinatal setting to foster a focus on racial equity in childbirth care from a physician’s perspective. RCC can be useful in revealing how structural and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 11 historical racism impacts mothers’ access to healthcare and how mothers perceive the nurse-mother relationship through the fostering of culturally safe environments. Although the commentary was specific to the doctor-patient relationship, this framework can be applied to perinatal nursing, encouraging nurses to reflect on their personal biases that impact their perception of patient behavior in order to treat all mothers in a caring matter (Hardeman et al., 2020a). The theoretical perspective of RCC can guide nurses in acknowledging and conducting quality pain assessments and management during childbirth and adopt shared decision-making by shifting to see the viewpoint of mothers. Conclusively, approaching care in the perinatal setting with a relationship focus allows nurses to recognize patients’ experiences and how they may be shaped by race, encouraging nurses to create a culturally safe space where patients feel they belong and can receive safe care (Hardeman et al., 2020a). These implications for nurses also reflect the priorities of respectful maternity care (RMC). Providing a theoretical perspective specific to maternal-child nursing, RMC is a global initiative aimed at improving maternity care and reducing maternal morbidity through the promotion of confidentiality, dignity, and privacy while ensuring freedom from “harm and mistreatment, and enables informed choice and continuous support during labour and childbirth” (World Health Organization, 2018, p. 4). Congruent with RCC, this framework aims to improve the patient experience with specific attention to mothers of diverse ethnic and racial backgrounds, who are more likely to receive disrespectful care (Chinkam et al., 2023). Founded on the undeniable value and human rights of mothers and their newborns, RMC calls for changes at the interpersonal and structural levels of maternity care (World Health Organization, 2018). The White Ribbon MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 12 Alliance (WRA) actively advocates for women’s health and has developed a respectful maternity care charter and other resources by asking, listening, and acting upon the voices of mothers (2021). This charter reflects the widely accepted conceptualization of the domains of RMC as listed in Table 1 and is grounded in the universal rights of mothers and newborns (White Ribbon Alliance, 2021). Chinkam et al. (2023) conducted a qualitative study to describe mothers' experiences of unplanned caesarean births to informed best practices that resemble RMC. These mothers desired information, evidence, and space to make informed and shared decisions about their own perinatal care and valued effective communication with their healthcare providers (Chinkam et al., 2023). Acknowledging the persistent disparities in maternity care, adopting a learner’s stance to the lived birthing experience (Humbert & Roberts, 2009), and applying the perspectives of RMC to this research shaped the study design, and data analysis, and interpretation. Table 1 Domains of Respectful Maternity Care • Mothers being free from harm and mistreatment • Maintaining privacy and confidentiality • Preserving women’s dignity • Prospective provision of information and seeking informed consent • Ensuring continuous access to family and community support • Enhancing quality of physical environment and resources • Providing equitable maternity care • Engaging with effective communication • Respecting women’s choices, strengthening their capabilities to give birth • Availability of competent and motivated human resources MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH • 13 Provision of efficient and effective care and continuity of care (Shakibazadeh et al., 2018) Purpose and Objectives The purpose of this study was to explore experiences of trust and mistrust between mothers with TCEs and perinatal nurses on maternal-child hospital units within Canada. The research questions were as follows: 1. How do mothers who have TCEs develop trust with perinatal nurses? 2. How do TCEs impact the development of trust? 3. What are the barriers and facilitators to the development of trust between mothers who experienced TCEs and perinatal nurses? Following a thorough literature review, driven by the research questions and theoretical perspectives, a qualitative approach was taken to explore the development of trust within nurse-mother relationships. Study Design and Methods As the purpose of the study was to inform nursing practice through gaining an understanding of the experiences of mothers, the qualitative methodology of interpretive description (ID) was used (Thorne, 2016). The theoretical perspective of RCC is well aligned with ID because RCC identifies the patient experience and the ability to understand it as a significant aspect of clinical care (Rider, 2011). ID aims to provide healthcare providers with a qualitative approach that equips them to co-create an understanding of the lived experience of patients that can be applied in the unique practice realm in which the experience takes place (Thorne, 2016). Approval was obtained from the Trinity Western University’s Human Research Ethics Board (HREB) prior to conducting interviews or contacting participants (23G06). Utilizing semi- MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 14 structured interviews with mothers who have experienced a TCE, the phenomenon of trust within the nurse-mother relationship was explored. Data was analyzed through ongoing engagement with the data and involved simultaneous and iterative data collection and analysis to develop interpretive themes to answer the research questions (Thorne, 2016). An in-depth description of the study design and methods is provided in Chapter Three. Definitions of Terms Trust Trust is defined as an assurance or reliance on the “character, ability, strength, or truth of someone or something” (Merriam-Webster, 2024). The experience of trust in the perinatal setting is highly connected to the quality of communication with the registered nurse and is commonly associated with nonverbal communication skills and listening (Dalton et al., 2021). Within the nurse-mother relationship, trust can be described as “the optimistic acceptance of a vulnerable situation, following careful assessment, in which the truster believes that the trustee has his best interests as paramount” (Bell & Duffy, 2009, p. 50). This definition identifies the relational aspect of trust and acknowledges the vulnerability mothers face and the power differential between nurses and mothers. Trust requires certainty and a level of reliance in nurses’ abilities to care for mothers well during this vulnerable time (Gonzalez, 2017). Perinatal Nurse A perinatal nurse may be educated in all or some of the stages of maternal and newborn care, within the scope of a registered nurse (Simpson & Creehan, 2021). For the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 15 purpose of this study, the perinatal nurse is defined as a registered nurse who provides intrapartum or postpartum care to mothers. Mother To capture the experience of trust amidst a traumatic birth experience, the definition of a mother is described as a person who has birthed a newborn baby. Further inclusion criteria will be outlined in Chapter Two for the purpose of the study. Traumatic Childbirth Experience Leinweber et al.’s (2022) definition is be used to understand a traumatic birth experience as referring to “a [mother’s] experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/or long-term negative impacts on a woman’s health and wellbeing” (p. 691). This definition allows for inclusivity and subjectivity of mothers’ experiences. For the purpose of this study, a traumatic childbirth will be determined by mothers’ reported experiences. Nurse-mother Relationship Derived from the perspective of relationship-centred care (Beach et al., 2006) and the British Columbia College of Nurses and Midwives’ (2024) definition of the nurseclient relationship, the nurse-mother relationship is be defined as the following: A partnership between the perinatal nurses and mothers, which is based on trust, respect of the person, and a commitment to excellent communication. For this paper, the nursemother relationship will be explored from the hospital admission to the intrapartum setting until the discharge from the postpartum unit following birth. Significance and Relevance MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 16 Perinatal nurses continue to care for a large population of childbearing patients, specifically in Canadian hospitals (Perinatal Services BC, 2020). There is a significant prevalence of TCEs, approximately one-third of mothers (Baptie et al., 2021; Koster et al., 2020; Türkmen et al., 2020), which could result in negative mental and physical health outcomes and pose threats to newborns’ and infants’ well-being (Beck & Watson, 2019; Türkmen et al., 2020). Although some research exists on the midwife-mother relationship following traumatic births, limited research has addressed trust within the perinatal nurse-mother relationship among mothers who have experienced a TCE. Exploring trust between mothers and perinatal nurses could foster the understanding of RCC in perinatal nursing, better equipping nurses in supporting and caring for mothers experiencing traumatic childbirths. Additionally, the vulnerability and subjectivity of this experience require a trauma-informed and trauma-responsive perspective towards care (Covington & Bloom, 2018; Kuzma et al., 2020). This study aimed to give a rich account of mothers’ experiences of developing trust with perinatal nurses amidst TCEs and provide clinical implications for perinatal nurses in providing RCC to mothers with an RMC perspective in the perinatal setting. Outline of Thesis This chapter has provided background information; an overview of the theoretical perspectives and research problem, questions, and design; and definitions of key terms regarding the concepts of trust within the nurse-mother relationship amidst TCEs. A thorough review of the literature on the development of trust in the nurse-mother relationship along with racial and pandemic considerations on this topic were conducted and are presented in Chapter Two. A description of interpretive descriptive methods and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 17 the study participants are provided in Chapter Three. Findings from the data are presented in Chapter Four and a discussion of the results in respect to existing literature is presented in Chapter Five. Finally, Chapter Six provides conclusions and recommendations for various areas of nursing practice, stemming from the findings and discussion of this study. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 18 Chapter Two: Literature Review A review of the literature was done in a systematic way to understand the nature of trust between mothers who experienced TCEs and perinatal nurses to inform this study (Garrard, 2022). This type of review allows the researcher to familiarize themselves with what is known on the topic of interest, including the methodologies used, challenges faced, and inferences made (Thorne, 2016). The literature review was informed by the research questions presented in Chapter One and guided by the review question stated below. Search Strategy The review question is as follows: What is known about the development of trust between mothers and perinatal nurses in healthcare settings? Three main concepts were drawn out of the review question and guided the search for relevant articles: the nursemother relationship, trust, and the perinatal setting. Although central to the research topic, TCEs were not specified as a concept for my search because a preliminary search including TCEs provided insufficient results. Thus, I broadened the scope of the review to explore the literature using the concepts of the nurse-mother relationship, trust, and the perinatal setting to capture what is known about the development of trust between mothers and perinatal nurses. A search strategy was developed in consultation with the health librarian that included both keywords and controlled vocabulary in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE databases. To supplement this search, a separate search was conducted on TCEs in which literature reviews and primary studies were summarized to describe the antecedents, causes, consequences, racial and social considerations, and nurses’ roles in traumatic births. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 19 The keywords for the primary search were determined through a preliminary search of the literature and from a personal and professional understanding of the terms used in this clinical area; the same keywords were searched in both databases (see Appendix A). Nurs* was used in an attempt to exclude midwifery or physicians and to focus on the relationships between mothers and nurses. Due to the specificity of trust in the research question, the only keyword used for this concept was Trust*. This choice of keyword was used to avoid confusion amidst the many possible related terms used in the literature. The perinatal setting is unique as it can include antepartum, intrapartum, triage, and postpartum care, all of which have multiple names, depending on the hospital or facility. To fully capture the birthing and postpartum experience, a broad range of synonyms as keywords were used: Perinatal OR Birth* OR Childbearing OR Childbearing OR Obstetric* OR Pregnancy outcome* OR Childbirth OR Postpartum OR Postpartum OR Intra-partum OR Intrapartum OR Maternal* OR Labour and delivery OR Maternity OR Postnatal. Finally, as the purpose of this study is to further understand mothers’ experience, Mother* OR Patient* OR Women* OR Woman* were the included keywords to specify the type of patient. The final keyword search was done using AND between each set of keywords and database-specific controlled vocabulary of the identified concepts, specific to the titles and abstracts of the existing literature (see Appendix A). Limiters applied to the search included articles in English only, peerreviewed, and with no time limits to capture any changes of the concept of trust between mothers and perinatal nurses over time. The initial search of academic databases resulted in 476 sources, which decreased to 315 after removing duplicates. All titles and abstracts were screened according to the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 20 inclusion and exclusion criteria (see Table 2) to identify articles with a direct focus on the development of trust within the perinatal nurse-mother relationship. Both primary research studies and reviews were included. During screening, 218 articles were excluded (see Appendix B for reasons for exclusion). Ninety-seven full-text articles were collected and further screened according to the inclusion and exclusion criteria, to facilitate a rigorous two-step screening process. To support rigour, the process and results of each step were discussed with my supervisors. Much of the literature (n = 25) was excluded due to the findings of the research not having a specific attention to the concept of trust. Additionally, many results explored the midwife, physician, or public health nurse’s relationship with mothers, and were therefore excluded (n = 62). Ultimately, 11 sources were included in the literature review. Table 2 Inclusion and Exclusion Criteria Inclusion Criteria: Participants: • Mothers who birth a newborn baby in the hospital setting under the care of a perinatal nurse • Or perinatal registered nurses who provided intrapartum or postpartum care to mothers Context: • Perinatal units in the hospital, including labour and delivery and postpartum units Concept: • Trust as a relational and reciprocal piece of the nurse-mother relationship MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 21 Exclusion Criteria: • • Participants: Midwives, public health nurses, or physicians Context: Homebirths, outpatient clinic, neonatal intensive care units, and tertiary pediatric hospitals Garrard’s (2022) guide to reviewing literature in the health sciences was used to create a review matrix for data extraction (see Appendix C). Using the Matrix Method (Garrard, 2022), each source was listed in alphabetical order and organized into column topics. Descriptive category headings included year of publication, purpose, methodology, and participants. Drawing from the research questions, the following data extraction category headings were also used in the matrix: (a) defining trust, (b) facilitators of trust in perinatal nurse-mother relationships, (c) barriers to the development of trust in perinatal nurse-mother relationships, (d) other pertinent findings on trust in the perinatal nurse-mother relationships and (e) findings or discussion specific to TCEs. To compare the finding across studies, the rule of columns was used to identify themes and gaps for each data extraction category heading (Garrard, 2022). An important consideration in this synthesis was identifying whether the responses were from mothers' or perinatal nurses’ perspective and highlighting the underlying factors of trust (Garrard, 2022). Another important consideration during the synthesis was to examine the type of delivery mothers experienced and other relevant considerations such as mothers who used substances, or mothers of racial minorities. A synthesis of the included literature will be provided in the following sections. Review of Selected Literature MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 22 Of the 11 included sources, ten were primary studies and one was a systematic review. Two studies were done in Canada, four in the United States, one in Nepal, one in Thailand, and one in China (see Appendix C for study details). Four studies were published between 2002 and 2008 (Chunuan, 2002; Cricco-Lizza, 2006; Goldberg, 2004; Goldberg, 2008), two between 2011 and 2014 (Fleming et al., 2011; Sapkota et al., 2014), and five between 2020 and 2022 (Dalton et al., 2021; Kantrowitz-Gordon et al., 2022; Murphy et al., 2022; Othman et al., 2020; Renbarger et al., 2020). It is evident that there was an increase in research exploring mothers’ and perinatal nurses’ experience of trust over the past ten years. With the exception of the systematic review (Murphy et al., 2022) and two cross-sectional studies (Chunuan, 2002; Othman et al., 2020), the remaining eight sources were of qualitative design. Both Goldberg’s dissertation (2004) and publication of the study (2008) were included in this literature review due to the unique definitions of trust and interpretations of the findings. Five primary studies solely interviewed or surveyed postpartum women (Chunuan 2002; Cricco-Lizza, 2008; Fleming et al., 2011, Sapkota et al., 2014, Othman et al., 2020), two included both mothers and perinatal nurses (Goldberg, 2004; Renbarger et al., 2020), and two had only nurse participants who had experience caring for pregnant and labouring women and their newborns (Dalton et al., 2021; Kantrowitz-Gordon et al., 2022). Although the purpose of my thesis research was to further understand mothers’ experiences of trust, the nurses’ perceptions were included in this review to provide insights for my research and explore whether nurses and mothers have a similar understanding of the experience. To introduce the synthesis, several definitions of the construct of trust are described and analyzed. Following definitions, the synthesized MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 23 findings on the experiences of trust in maternity care are presented, providing insight into personal, interpersonal, and structural factors influencing the development of trust (McLeroy et al., 1988). Definitions of Trust To develop a deeper understanding of and describe the concept of trust between mothers and perinatal nurses, the various definitions of the term “trust” were identified in the articles. Out of the 11 sources, five definitions of trust were provided and are presented in Table 3. A common theme found from the definitions was the idea that trust is relational, occurring between nurses and mothers and requiring a level of mutuality (Chunuan, 2002; Dalton et al., 2021; Goldberg, 2008). Trust was described as a patient’s confidence in another’s actions (Goldberg, 2004). A level of vulnerability on the part of the patient was associated with trust (Dalton et al., 2021) and trust encompassed an expectation that the nurse has the mother’s best interest in mind (Dalton et al., 2021; Renbarger et al., 2020), yet could be built through characteristics such as effective communication (Chunuan, 2002) and compassion (Renbarger et al., 2020). Goldberg (2008) provided a distinctive definition of trust, relating to the embodiment of the birthing experience, empowering mothers to trust in their own birthing abilities through a trusting relationship with their nurse. Table 3 Definitions of Trust MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH Chunuan (2002) 24 “Trusting relationship with the nurse refers to nurses’ characteristics that support patient-nurse interaction and communication such as interest in patients, sensitivity to patients and their feelings, and listening to patients' problems” (p. 109). Goldberg (2004) “To support, help or elicit confidence” (Oxford Concise Dictionary of English Etymology, 1996 as cited in Goldberg, 2004; James, 1997 as cited in Goldberg, 2004). “Dependent on another’s goodwill and one is necessarily vulnerable to the limits of that goodwill” (Baier, 1994 as cited in Goldberg, 2004, p. 77). Goldberg (2008) “The trusting relationship that is established between a perinatal nurse and the birthing woman is embodied”. “By building a trusting relationship with her nurse, a birthing woman potentiates the possibility of discovering the birthing powers embedded within her own body” (p. 74-75). Renbarger et al. (2020) “Trust occurs when women feel their health-care providers care about them, work in their best interest, and are compassionate and culturally sensitive” (Birkhauer et al., 2017, as cited in Renbarger et al. (2020); Briscoe et al., 2016 as cited in Renbarger et al., 2020, p. 181). Dalton et al. (2021) “Trust is relational, it is a voluntary response based upon expectations about the trustee’s future behavior, it involves vulnerability and risk, and it assumes the trustee will have concern for the trustor’s interests” (Gilson, 2006, as cited in Dalton et al., 2021, p. 617). Personal Characteristics In addition to definitions of trust, the literature review revealed how personal characteristics of mothers and nurses influenced the development of trust in the nursemother relationship. Maternal sociodemographic factors such as employment, number of children, and intention of pregnancies were associated with varying levels of trust in the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 25 nurse-mother relationship in a study of postpartum women’s satisfaction with intrapartum care in Thailand (Chunuan, 2002). This study reported that labourers and farmers were more satisfied within the trusting perinatal nurse-mother relationships than the housewife and skilled worker participants. The same study noted that multiparous women and those with unplanned pregnancies experienced higher levels of trust than primiparous women and those who had planned their pregnancies (Chunuan, 2002). Chunuan (2002) also noted that primiparous women were more likely to have emergency caesarean sections and complicated deliveries, attended by obstetricians, compared to multiparous women who were more likely to be cared for by registered nurses. Therefore, readers of this study may associate the mode of deliveries with the level of trust during the birthing process. In addition to various lifestyle circumstances, the mothers’ level of preparation, such as prenatal classes and understanding of the birth process, helped mothers understand the nurses’ actions, fostering trust in the relationship (Sapkota et al., 2014). Goldberg (2004), through her seminal findings on the birthing experience, developed the concept of embodied trust. A level of self-trust and embodiment led mothers to trust their bodies and uteruses in the birthing process. Goldberg (2004) defined embodiment as a “unified view of the body” (p. 96), understanding that a mother does not live nor give birth separated from their body, but as a whole. In some cases, this embodiment was empowering and healthy, while for others it was a result of misplaced trust, a disappointment in the care they received, and a need to trust one’s body (Goldberg, 2004). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 26 Terms used to describe personal characteristics of the nurse that facilitated trusting relationships included mutual respect, honesty, integrity, relationship strength (Goldberg, 2004), kindness (Cricco-Lizza, 2006), caring, consoling (Goldberg, 2008), and warm-heartedness (Sapkota et al., 2014). Murphy et al. (2022) summarized personal nursing characteristics that fostered trust as that of humanity and empathy, guiding the development of trust in the nurse-mother relationship. Beyond the personal characteristics of the nurse was the identified desire for confidence in the clinical expertise of the nurse, which is discussed in a following section. Interpersonal and Relational Factors Interpersonal factors between perinatal nurses and mothers were identified as contributing to the establishment of trust. Common themes pertaining to interpersonal factors found in the literature included: quality of communication, listening, clinical expertise, and the general relational demeanor. Communication. The most commonly identified facilitator in the development of trust in the perinatal nurse-mother relationship were nurses’ effective and informative communication skills (Chunuan, 2002; Cricco-Lizza, 2006; Dalton et al., 2021; Goldberg, 2004; Goldberg, 2008; Murphy et al., 2022; Sapkota et al., 2014). Communication not only referred to the act of conversation, but relied on the process, direction, and content of the interaction (Fleming et al., 2011). Findings from a systematic review of Black women’s experience of perinatal care indicated that good communication between mothers and nurses was positively associated with trust and care satisfaction (Murphy et al., 2022). Perinatal nurses’ communication strategies that build trust included introducing oneself to patients (Goldberg 2004), asking mothers what name MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 27 they prefer to be called (Othman et al., 2020), and regularly using mothers’ first names throughout their care (Goldberg, 2004). Keeping mothers informed of the progress of their labour and the decisions that were being made positively impacted the development of trust and made mothers feel comfortable participating in shared decision-making (Goldberg, 2008; Renbarger et al., 2020; Sapkota et al., 2014). Evidently, it was not solely the informational updates that mothers appreciated, but nurses’ explanations of why interventions were necessary (Goldberg, 2008). In addition to involvement in the decision-making process, participants experienced trust with perinatal nurses when they were guided through the various stages of labour. During the second stage, nursing instructions on how to breathe were associated with the establishment of trusting perinatal nurse-mother relationships (Cricco-Lizza, 2006). Mothers trusted their nurses who had integrity and communicated in an honest, kind, encouraging, and delicate manner during their interactions (Goldberg, 2004; Goldberg, 2008; Renbarger et al., 2020). Specific to mothers who used substances throughout their pregnancy, one study found that nurses identified mothers’ gratitude for care and openness as indicating a trusting relationship was established (Renbarger et al., 2020). Perinatal nurses reported that mothers who openly disclosed personal information that was relevant to their care, such as substance use, physical or mental health concerns, and history of abuse, affirmed nurses’ personal identity of being trustworthy healthcare providers (Dalton et al., 2021). The mothers in this study also reported an experience of trust when the nurses shared personal or relatable information with them (Renbarger et al., 2020). Informative and effective communication from both nurses and mothers facilitated trusting relationships. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 28 Echoing this finding of informative and effective communication facilitating the development of trust, ineffective or a lack of communication was found to prevent the development and maintenance of trust between perinatal nurses and mothers. In one study, mothers with substance use disorders reported numerous accounts of nurses’ communication behaviours that hindered the establishment of mothers’ trust in the nurse and their care, including nurses’ cruel gestures, rolling of the eyes, and general difficulties with communication (Renbarger et al., 2020). The same participants described being blamed by nurses for the absence of accessible intravenous sites and the poor health status of their newborns (Renbarger et al., 2020). In addition to negative communicatory interactions, a lack of engagement and sharing of information was identified as barriers to the development of trust (Goldberg, 2008). From mothers’ perspectives in one study, it was the silence of nurses or an absence of a relationship with their nurse that hindered the development of trust (Goldberg, 2004). In another study, nurses’ lack of attention and communication regarding newborn care or updates on their newborn’s status was viewed as a negative communication style that prevent the development of trust (Renbarger et al., 2020). From the nurses’ perspective, perinatal nurses reported that mothers’ contradicting and dishonest communication behaviours, including inconsistent disclosure of information, were a factor that broke nurses’ initial trust with mothers (Dalton et al., 2021). It is evident that communication is key to the development of bi-directional trust between perinatal nurses and mothers. Listening and Feeling Heard. Similar to the trusted voice of nurses, when nurses offered mothers a listening ear, trust was established within nurse-mother relationships. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 29 Mothers reported that when nurses listened to them and tended to mothers’ requests (Cricco-Lizza, 2006), this attentiveness helped establish trust with their nurse. Mothers with substance use disorders perceived that feeling heard allowed the nurse to see the patient as both a woman and a mother (Renbarger et al., 2020). Perinatal nurses mirrored this perspective and acknowledged that mothers benefit from feeling heard and involved in their care (Dalton et al., 2021). Trust was thwarted when nurses did not listen to or pay attention to mothers. In one study, a participant described mistrust in the nurse after not receiving an epidural when requested (Goldberg, 2004). Although there were other contributing factors to this decision, the mother viewed this as neglect from the nurse and feeling pressured by the physician to not receive the epidural (Goldberg, 2004). In another study, nurses’ lack of attention to the individual needs of mothers and newborns hindered the development of trust (Sapkota et al., 2014). Nurses experienced difficulty establishing trust with mothers who did not listen to their advice and recommendations. For example, perinatal nurses who cared for mothers with substance use disorders saw non-compliance, or active substance use, as a cause for mistrust as they felt their guidance and expertise were not listened to (Renbarger et al., 2020). In one qualitative study, one nurse reported that mothers who were able to “relax and listen to my instructions” demonstrated that they trusted their nurse (Dalton et al., 2021, p. 620). Again, both mothers and nurses reported that feeling heard and seen fostered the development of trust. Relational Characteristics of the Nurse. Relational characteristics of perinatal nurses, including nurses’ personal characteristics, also impacted the development of trust MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 30 between perinatal nurses and mothers (Goldberg, 2004). Interpersonal connections were identified in two studies as enablers of the development of trust, which included nurses spending time with and helping mothers throughout their care (Cricco-Lizza, 2006; Renbarger et al., 2020). Perinatal nurses’ non-judgemental and authentic, personalized demeanor towards mothers enabled the development of trust (Goldberg, 2008; Renbarger et al., 2020). Contrastingly, for both nurse and mother participants, relational characteristics such as personal distance, hostility, or bias were identified as barriers to building trust (Murphy et al., 2022; Renbarger et al., 2020). Interpersonal Racism. Some studies identified racism and disparities within healthcare systems as influential of the development of trust within perinatal nursemother relationships. Findings from Murphy et al.’s (2022) systematic review on the perinatal experiences of Black women provided rich insights on the racial mistreatment that Black mothers have faced within perinatal care. Experiences of mistrust in the perinatal setting were amplified due to the historical disparities that Black mothers have faced in healthcare systems and with their providers. Specific to perinatal care, mothers reported biases or inequities in care such as “pregnancy stigma, stereotypes and stigmatization, being judged, and experiencing negative assumptions” (Murphy et al., 2022, p. 467) leading to a decrease of trust in healthcare providers. Reciprocity in trust was important to Black mothers in the perinatal period, with a reported desire not only for mothers to be able to trust their healthcare providers, but for the providers to trust mothers, both of which were described by the women as lacking in perinatal care. A favourable finding in this review was that Black mothers who described their perinatal MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 31 experience as positive also reported that they trusted and received less discrimination from their providers (Murphy et al., 2022). Confidence in Clinical Expertise. Mothers’ confidence in the nurses’ clinical expertise was recognized as facilitating of trust (Cricco-Lizza, 2006). For some mothers, this confidence arose due to the guidance of the nurse in the labouring process having a direct impact or positive change on their progression (Fleming et al., 2011; Sapkota et al., 2014). One study reported that nurses’ assistance to mothers in positioning and pushing was associated with the development trust in the nurse-mother relationship (Sapkota et al., 2014), particularly when mothers’ change in position allowed mothers to feel their baby move (Fleming et al., 2011). After childbirth, mothers who felt their nurse provided quality newborn and postpartum care were better able to establish trust (Renbarger et al., 2020). Mothers who were satisfied with the general nursing care received during childbirth also reported higher satisfaction with the trusting relationship with the nurse (Chunuan, 2002). Pain management during the intrapartum and postpartum period was identified as indicative of trust in the nurse, for mothers with and without substance disorders (Chunuan, 2002; Renbarger et al., 2020). Mothers with substance disorders viewed the nurses’ expertise in addiction and childbirth as a positive influencing factor in development of trust within their relationship (Renbarger et al., 2020). Similarly, when nurses lacked knowledge about addiction or withheld pain medication, trust was lost (Renbarger et al., 2020). Perinatal nurses in Dalton et al.’s (2021) qualitative study reported that mothers must feel they are in competent hands to establish trust and that they expected mothers to trust them based on their scope of practice. In this same study, trust was summarized as MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 32 the willingness of mothers to follow and accept the nurses’ guidance and to concede to the nurses’ expertise (Dalton et al., 2021). In other words, trust allowed mothers to rely on the nurses’ expertise and personal care (Fleming et al., 2011). Structural Factors Beyond the relational factors in the establishment of trust between perinatal nurses and mothers, structural factors were also identified in this literature review as important. The following section briefly outlines the impact of continuity of care and hospital processes of care on trust in the nurse-mother relationship. Hospital Processes of Care. Processes outside of perinatal nurses’ immediate control contributed to both the development and prevention of trust with mothers. Two studies identified continuity of care, through recurrent and familiar nursing personnel, as important in establishing trust in the nurse-mother relationship. In some cases, this approach to care can mean continuity of nursing staff throughout the labouring process (Cricco-Lizza et al., 2006), but was also referred to the consistency of care provided in the prenatal period (Murphy et al., 2022). Within the perinatal context, it was reported that the hospital processes, and on occasion the nurses, prioritized the physician’s orders over the patient preferences (Goldberg, 2008). One study described a mother who was led to believe the perinatal nurse did not trust that the mother’s labour was progressing because the nurse strictly followed their triage protocol, which did not lead to an immediate admission without the physician’s assessment (Fleming et al., 2011). From the nurses’ perspective, mothers who were resistant to the nurses’ actions as they followed hospital policies and protocols portrayed a sense of distrust (Dalton et al., 2021). Although resistance could be related to MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 33 characteristics of mothers, nurses, or the relationship between them, nurses recalled this resistance when mothers’ birth plans were not followed, when doulas were present, or when families referred to external resources to justify their personal plan of care or preferences (Dalton et al., 2021). Perinatal nurses in this study received these preferences as an attempt for control, thus indicative of distrust in the nurse (Dalton et al., 2021). Further, time constraints and mothers feeling rushed with their providers also left few opportunities to develop trusting relationships (Murphy et al., 2022). Summary of Review This literature review provided a detailed description of various definitions of trust in relation to perinatal nursing. Specifically, trust was described as reciprocal (Goldberg, 2004), a foundation for mothers to feel cared for (Sapkota et al., 2014). This literature review also highlighted various facilitators, barriers, and contributing factors to the development of trust between the perinatal nurses and mothers including personal characteristics, interpersonal factors, and structural factors. Most evident was the emphasis on interpersonal factors of trust, such as communication, feeling heard, relational aspects of the nurse, and mothers’ confidence in nurses’ expertise. These review findings informed my research study, specifically in the development of the interview questions, thematic analysis, and interpretation of findings. Traumatic Childbirth Experiences A separate search of the literature was done to understand and describe what is known about TCEs because there were minimal findings specific to TCEs and perinatal nurse-mother trust. This supplementary review of the literature regarding TCEs resulted in an overview of TCEs, related racial considerations, and the implications of the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 34 COVID-19 pandemic on TCEs. Adding to Leinweber et al.’s (2022) definition of traumatic childbirth: “woman’s experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions” (p. 691), Simpson and Catling (2016) describe traumatic birth as a multidimensional event with up to one-third of mothers reporting they have experienced a TCE. A literature review (Simpson & Catling, 2016), qualitative meta-synthesis (Fenech & Gill, 2014), metaethnography (Elmir et al., 2010), and a prospective, observational study (Soet et al., 2003) were synthesized to provide insights about the antecedents, causes, consequences, and recommendations for addressing TCEs. An additional search was conducted to explore racial considerations (Hardeman, 2020a; Markin & Coleman 2021) and the impact of the COVID-19 pandemic (Diamond & Colaianni, 2022; Mayopoulos et al., 2021) related to TCEs. Antecedents of TCEs Although the subjectivity of the definition of TCE indicates that any mother may experience their birth in this way, there are populations known to be at a higher risk of a TCE. Structurally disadvantaged populations such as unmarried, young, minority women, or those with financial instabilities were considered to be more susceptible to negative birth experiences (Soet et al., 2003). Additionally, those at risk include mothers who have a general perception of the world as unsafe, pre-existing mental illnesses, or history of trauma (Simpson & Catlin, 2016; Soet et al., 2003). Pre-conceived expectations of the birthing experience have also been associated with traumatic births if the expectations are not met (Soet et al., 2003). Further, primiparous women are more likely to perceive their birth as traumatic than multiparous women (Soet et al., 2003). Finally, support persons MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 35 during labour can facilitate or help prevent traumatic childbirth. Female support persons during childbirth were associated with a positive birth experience while a lack of a partner was correlated with a higher incidence of post-traumatic stress symptoms following delivery (Soet et al., 2003). Childbirth Events that Contribute to TCE Further contributing to the incidence of TCE are events occurring during the labour and delivery process. Similar to the findings on the development of trust between mothers and nurses, communication and interactions from the healthcare provider impact mothers’ experience of traumatic childbirth. Mothers who described their delivery as traumatic reported feeling ill-informed, and either not involved in the decision-making or having interventions that they did not consent to (Elmir et al., 2010; Simpson & Catling, 2016; Soet et al., 2003). This sense of powerlessness is intensified through the hostility, ignorance, and mistreatment of mothers by healthcare providers to the extent that mothers reported feeling raped (Elmir et al., 2010; Soet et al., 2003). In one study, some mothers attributed these contributors to trauma to a lack of continuity in providers (Elmir et al., 2010). Unexpected levels of pain during the second stage of labour and increased interventions, such as caesarean sections, can also contribute to TCEs (Simpson & Catling, 2016; Soet et al., 2003), as well as poor delivery outcomes: for example, mothers who birthed a stillborn, or a newborn who required a NICU admission (Simpson & Catling, 2016; Soet et al., 2003). Consequences of TCEs The complications associated with TCEs can have significant impacts on mothers, newborns, and families. Mothers have reported flashbacks, nightmares, difficulty MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 36 sleeping, and feelings of anger, anxiety, grief, and panic from TCEs (Elmir et al., 2010; Fenech & Thomson, 2014; Simpson & Catling, 2016; Soet et al., 2003). In some cases, these feelings led to depression and a sense of loss of self, motherhood, or family, and even suicidal ideation (Elmir et al., 2010). Coping with a TCE can be difficult for mothers. Some mothers avoid events that potentially remind them of their birth experience while some noted that they kept distracted by returning to work early (Elmir et al., 2010; Fenech & Thomson, 2014). The traumatic experience can prevent some mothers from desiring to have more children, and to the point that they feared sexual intimacy or requested permanent forms of birth control (Elmir et al., 2010; Fenech & Thomson, 2014; Simpson & Catling, 2016). A survey done in the U.S. reported that nine percent of new mothers met the criteria for birth-induced PTSD (American Psychiatric Association, 2000), noting that mothers can develop PTSD from a TCE. In attempts to diagnose and provide appropriate assessment and diagnostic tools, TCEs have been categorized under post-traumatic stress disorder or post-traumatic stress symptoms (PTSS) in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013). These mothers showed symptoms of post-traumatic stress including emotional detachment, frightening flashbacks, insomnia, anger, anxiety, depression, and social and familial withdrawal (Beck, 2004b; Beck, 2015). Although mothers may develop PTSD or PTSS following a TCE, not all will (Greenfield et al., 2016), therefore it is important for perinatal nurses to be aware of the causes, signs, and impact of TCEs on mothers, newborns, and the family unit. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 37 Newborns and partners of mothers who experienced a TCE can also face negative impacts. Newborns born to mothers with poor mental health, such as PTSD, have suboptimal cognitive, psychological, and physical development (Soet et al., 2003). Mothers with TCEs reported difficulty bonding and feelings of disconnectedness with their newborn, and often stopping breastfeeding prematurely (Elmir et al., 2010; Fenech & Thomson, 2014; Simpson & Catling, 2016). In other cases, mothers felt overprotective of their newborn, expressing the need to compensate for the traumatic experience and feeling as though they had failed their newborn (Elmir et al., 2010; Fenech & Thomson, 2014). Mothers who experience TCE can also experience relational problems with their partners. Many women have reported a fear of sexual intimacy as previously mentioned, due to either the reminder of the birth experience or a portrayal of blame on to the partner (Fenech & Thomson, 2014; Soet et al., 2003). Elmir et al. (2010) highlighted mothers’ need for partners to acknowledge their trauma and provide emotional support in addition to the practical support they may already be providing. Nursing Role and Recommendations The body of literature on TCEs provides guidance and recommendations for healthcare providers in preventing and recognizing TCEs, as well as insights for my study. Due to the focus on communication in the literature, authors encourage further training for nurses in effective communication and adequate support during labour (Soet et al., 2003). Nurses can ensure excellent pain management and promote mothers’ active participation in their care to reduce TCEs (Elmir et al., 2010; Soet et al., 2003). Postnatal screening for complications of a TCE, such as postpartum anxiety, depression, and PTSD, may equip providers to identify mothers at risk of negative outcomes due to TCEs MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 38 and follow-up more thoroughly following hospital discharge (Soet et al., 2003). During prenatal care, providers can flag mothers with a history of trauma or pre-existing mental illnesses to allow for a continuity of information, and extended time to create an individualized care plan (Soet et al., 2003). Soet et al. (2003) also suggest further training on perinatal psychology for those providing care during labour. Breastfeeding was seen as a way to compensate for the birth experience and mothers described this feeding choice as a way to start the newborn’s life well (Elmir et al., 2010). Nurses can promote breastfeeding to encourage bonding and healing experiences following a traumatic birth or refer them to lactation consultants. All of these recommendations are further supported by encouraging continuity of providers when possible (Elmir et al., 2010). For example, continuity can be promoted through recurring nursing assignments, having mothers’ labour nurses also providing postpartum care when the structure of the unit allows. When personnel continuity is not possible, continuity of care can still exist through consistent messaging and ways of care. More recently, research on traumatic births has expanded to explore the perinatal experiences of racially oppressed mothers (Hardeman, 2020a; Markin & Coleman 2021) and also the impact of the recent COVID-19 pandemic (Diamond & Colaianni, 2022; Mayopoulos et al., 2021). Racial Considerations Supplementary literature was synthesized to provide insight on the racial considerations in perinatal care and TCEs. Racially oppressed mothers (e.g., Indigenous, Hispanic, and Black women) are at a significantly higher risk of complications related to childbirth (Hardeman, 2020a; Markin & Coleman, 2021) and are vital to consider when discussing traumatic births and trust in the nurse-mother relationship. Despite the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 39 increased risks, there is little research specific to racialization and perinatal care, prompting further studies in this area. Black mothers have experienced a mistrust in healthcare providers due to a persistent dismissal of pain, preferences, and unsupportive communication in prenatal and perinatal care (Markin & Coleman, 2021; Wang et al., 2020). This experience also extends to mothers of Hispanic, Indigenous, and Asian descent (Markin & Coleman, 2021). According to Markin and Coleman (2021), there is an association between racism during childbirth and an increase of post-traumatic symptoms and reported TCEs by such mothers, supporting the history and presence of gendered and racial biases and stereotypes from healthcare providers during the birthing process. Mohamoud et al. (2023) reported an exploration of maternity care experiences, published by the Centers for Disease Control and Prevention. In this article, it was noted that approximately twenty-nine percent of mothers experienced mistreatment or discrimination during perinatal care (Mohamoud et al., 2023). Of that number, Black, multiracial, and Hispanic women reported the highest levels of mistreatment, at 40%, 39%, and 37%, respectively. The most common types of mistreatment reported were a lack of response when asking for help, harmful communication, an absence of physical privacy, and pressure to receive or withhold certain treatments (Mohamoud et al., 2023). Therefore, a trusting relationship between mothers and the nurse is imperative to providing RCC to mothers who have experienced racialization and childbirth trauma (Hardeman, 2020a). RCC and RMC help create a caring environment that is personcentred and culturally safe, helping to decrease mothers’ experiences of racism. COVID-19 Implications MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 40 Further complicating mothers’ birthing experiences in recent years has been the isolating and restricting impacts of the COVID-19 pandemic. Reported incidences of birth trauma increased during the pandemic due to policy-related factors such as mask mandates during labour, support person limitations, and unexpected changes to birth location (Diamond & Colaianni, 2022). In addition to the institutional changes to the birthing process, mothers with a positive diagnosis of COVID-19 have had an increase in emergency caesarean sections, low-birth weight or preterm babies, neonatal intensive care unit (NICU) admissions, and reported greater pain during childbirth than those with a negative COVID-19 test (Diamond & Colaianni, 2022). Restrictions for COVIDpositive mothers were strictly enforced and resulted in higher rates of separation from their newborn and limited to no support persons (Diamond & Colaianni, 2022). All of these factors have contributed to a rise in reports of TCE among mothers who have tested positive for COVID-19 during labour and delivery (Mayopoulos et al., 2021). As the mothers in this study may have had their TCE within the pandemic, or shortly following, these findings were important to consider. Critical Reflection of the Current State of Knowledge The review of the literature and supplementary searches provided a description of what is known about the development of trust in the perinatal nurse-mother relationship, TCEs, and racialization and COVID-19 considerations on the topic. The current state of knowledge lacks mothers’ voices about their experiences of trust amidst traumatic birth. Considering the negative impacts of TCEs, more research is required to uncover ways that nurses can support mothers during and post a TCE in attempts to improve maternal, newborn, and family outcomes, and increase birth satisfaction. Of note, a critical MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 41 unpacking of the conceptualization of resistance within the trust literature is needed. Within RMC, little attention has been paid to the impact of trauma on the birth experience (Cantor et al., 2024) and only two of the extracted sources for the literature review mentioned trauma in their discussions of trust (Dalton et al., 2021; Murphy et al., 2022). This review identified more about the interpersonal interactions between nurses and mothers, rather than the process of delivery such as medical interventions, possibly due to the chosen search terms. As discussed above, nurses often view deliveries as normal or uncomplicated, while mothers experience it them as traumatic (Beck, 2004a). This review highlighted the current emphasis on communication and characteristics of the nurses in developing trust presented in the literature. Although medical interventions in labour may be outside of mothers’ and nurses’ control, there is an opportunity to develop trusting relationships amidst the unpredictability of the birthing process. TIC literature provides helpful insight in caring for those who have experienced past trauma (Kuzma et al., 2020), but is missing consideration for the moments in which the trauma is actually occurring, during and following the birthing experience. In order to understand trust amidst trauma, we first must understand how mothers respond to traumatic events as they are occurring, and further explore ways in which nurses can caringly intervene and build trust in the nurse-mother relationship. Chapter Summary A review of the literature conducted in a systematic way demonstrated the incidence and implications of TCE as concerning. Within the birthing experience, trust is an important piece of the nurse-mother relationship, and can be facilitated or hindered through personal, interpersonal, or structural factors. A review of the literature on TCEs MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 42 provided a summary of the causes and consequences of TCEs, followed by current racial and societal considerations. Mothers’ TCEs are prevalent within perinatal nursing care and there are serious negative outcomes associated with them for mothers, newborns, and their families. Ethnic minorities are at risk of TCEs due to their experiences of racism and mistreatment. The COVID-19 pandemic also perpetuated the problem for recent mothers due to isolation guidelines. As nurses provide close and constant care for birthing mothers, they are in a prime position to support mothers and be a protective factor to buffer mothers from the negative outcomes of TCEs. One way to do this is to develop trusting relationships with mothers where such support can be provided. The sparsity of evidence on trust and TCEs support the relevance of this qualitative study to address the gap in what is known of mothers’ experiences of trust and TCEs. Knowledge developed from this study offers insight and understanding on how nurses can develop and maintain mothers’ trust within perinatal nurse-mother relationships. Findings on the prevalence of TCEs during the COVID-19 pandemic are particularly applicable to the population of mothers included in the study because only mothers who had given birth in the last two years were included. Chapter Three outlines the methods used in this research study to explore maternal experiences of developing trust with perinatal nurses amidst a TCE. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 43 Chapter Three: Study Design and Methods The purpose of this chapter is to present the research methodology that was used to answer the research questions, and the methods for sampling and recruitment, data collection, and data analysis. The following sections will also include specific details regarding how quality of data was achieved, ethical considerations, and mitigating strategies to address study limitations. Research Purpose and Objectives The purpose of this study was to explore experiences of trust and mistrust between mothers with traumatic childbirth experiences (TCEs) and perinatal nurses on maternal-child hospital units within Canada. A thorough literature review was conducted to discover what is known about the development of trust between nurses and mothers within perinatal care. The objectives of this study were informed by the literature review and theoretical perspectives of RCC and RMC, to answer the following research questions: 1. How do mothers who have experienced traumatic births develop trust with perinatal nurses? 2. How do traumatic childbirth experiences impact the development of trust? 3. What are the barriers and facilitators to the development of trust between mothers who experienced a TCE and perinatal nurses? Thorne’s (2016) approach to qualitative research interpretive description (ID) guided the research design as it aligned with the research purpose and questions. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 44 Research Design From the rigorous review of the literature, it was evident that little was known about the construct of trust within the nurse-patient relationship as it relates to perinatal nursing and TCEs. Therefore, a broad qualitative approach was warranted to explore mothers’ subjective realities and experiences of TCEs (Polit & Beck, 2021). Two primary concepts of the research question, trust and TCEs, are subjective in nature and thus required insights into the dynamic experiences of mothers in order to guide those who care for them. Interpretive description (ID) is described as a methodological direction of qualitative research (Thorne, 2016). It expands on current knowledge by focusing on a phenomenon within its embedded context to produce understandings of a disciplinaryspecific phenomenon that accounts for the variation of participants’ experiences (Thorne, 2016). ID depends on the foundation of a real-world question, an investigation on what is known and not known about the topic, and an appreciative commitment to providing practical applications and recommendations for the nursing discipline (Thorne, 2016). ID is also built upon constructivist assumptions, acknowledging the multiple interpretations of an experience, constructed by the participant’s unique context (Polit & Beck, 2021). This perspective encourages subjective interactions between the researcher and participants when collecting and interpreting these multiple and dynamic realities, supporting the choice of semi-structured, qualitative interviews in this study (Polit & Beck, 2021). Knowledge derived from these assumptions not only builds an understanding of the experience, but also how the experience or reality, such as trust or traumatic childbirth, was constructed (Polit & Beck, 2021). Through inductive analysis, I identified interrelated themes among multiple subjective perspectives to produce an MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 45 interpretive description about the development of trust and mistrust between mothers with TCEs and perinatal nurses. The clinical applicability of findings related to trust, TCEs, and the nurse-mother relationship supported the use of ID in an effort to equip nurses in providing quality, relationship-centred care. The purpose-driven design of ID was developed to allow researchers in disciplines such as nursing the flexibility to generate knowledge that is clinically relevant and relatively unexplored (Thorne, 2016). ID encourages researchers to select, modify, and defend methods and techniques of qualitative design to support the research question and disciplinary intent of the study (Thorne et al., 1997). Further considerations when selecting a research design were the congruence of the theoretical frameworks guiding the research questions with ID, and the applicability of the method to the nursing phenomenon under study. ID has been used to explore how to improve RMC among mothers from diverse ethnic and racial backgrounds who experienced unplanned caesarean sections (Chinkam et al., 2023). Additional ID studies have been done to explore mothers’ experiences of early labour perinatal care (Morson et al., 2013) and the postpartum period (Glavin et al., 2017). The methodological direction of ID was a good fit for this study, supported by the necessity of further research on trust amidst TCEs identified through the literature review, the emphasis on mothers’ subjective experiences, and an evident application of ID studies within the context of RMC and perinatal nursing. Details on how qualities of ID were applied to the study are described in the remainder of the chapter. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 46 Sampling and Recruitment Convenience sampling, the selection of those readily available (Polit & Beck, 2021), was the primary strategy to recruit participants, conducted using a virtual recruitment poster. This approach allowed participants to self-identify their eligibility by reflecting on their birth experience and honoured the subjectivity of trauma within childbirth. Social media platforms including Facebook, Instagram, and LinkedIn were utilized for recruitment purposes due to the accessibility and convenience for potential postpartum participants and feasibility for the researcher (Maloni et al., 2013). In 2016, it was reported approximately 68% of mothers access their Instagram social media platform daily (Instagram Business Team, 2016). Therefore, a virtually shareable poster (see Appendix D) was displayed on my personal social media platforms (e.g., Instagram, Facebook, LinkedIn) with a link for potential participants to access further information about the study. The recruitment poster described the purpose of the study, inclusion criteria, and a QR code to link to the participant information form (Appendix E). The linked form further described the entirety of the inclusion criteria, what was required of the participants, my email and phone number, and information on confidentiality, data storage, and compensation. The format of the poster was designed to be shared on the social media platforms in order to reach as many mothers as possible. Thorne (2016) supports flexibility in sample size dependent on the study intent and scope in ID studies. Thus, the intended number of participants was between six and ten mothers, or until I, and the thesis committee, believed the quality of data was sufficient for developing a rich understanding that addressed the purpose of the study. Thorne (2016) challenges the commonly used criterion of data saturation and instead MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 47 simply encourages researchers to assess whether their study has produced meaningful contributions to their discipline with evidence of logic and credibility along the way (Thorne, 2020). The final number of participants needed to address the purpose of the study was eight mothers: seven from the initial recruitment process and one recruited following initial thematic analysis. Further information regarding adequacy of data is discussed among data collection strategies. Inclusion Criteria Due to the spectrum of approaches to maternity care across the globe and considering the purpose and feasibility of this study, mothers who wished to participate were screened to ensure they met the following inclusion criteria: 1) English-speaking mothers who had given birth to a live baby within the last two years, 2) newborn was born at, equal to, or greater than 37-weeks gestation, 3) they had received care from a perinatal nurse in hospital during labour and delivery, 4) were at least six weeks postpartum, 5) were at least 19 years old, 6) delivered in Canada and 7) self-identified as having had a traumatic childbirth. Altuntuğ et al. (2023) reported that TCEs are associated with an increase in maternal birth recall, yet the recall of specific details, such as newborn birth weight, decreases within three years following delivery (Casas-Guzik et al., 2020). Therefore, the participants were limited to those who had given birth within the last two years to ensure recall, yet no sooner than six weeks postpartum, following the standard initial healing duration for postpartum patients (HealthLink BC, 2023). The timing for inclusion criteria was to allow mothers time to process the birth experience and the initial transition home. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 48 Mothers were excluded from participating if they experienced a premature delivery earlier than 37-weeks gestation, a newborn loss, a stillbirth, or a newborn with medical complications causing the mother to be discharged from the hospital without their newborn while the baby remained admitted to a Neonatal Intensive Care Unit (NICU). The experience of premature labour, newborn loss, or stillbirth may include varying levels of fear and/or grief that would most likely not occur in a term, live delivery (Avelin et al., 2013). Similarly, admission of a newborn to a NICU may be traumatic for mothers and may even lead to a diagnosis of PTSD yet be unrelated to the birthing experience (Kim et al., 2015; McKeown et al., 2023), thus it could be difficult for mothers to distinguish between experiences of care provided by NICU nurses or labour and delivery nurses. For the purpose of this study, mothers who have experienced these events were not included, although future research involving these populations is warranted. Finally, due to the subjectivity of traumatic childbirth as defined by Leinweber et al. (2022), self-identification of a TCE was an important inclusion criterion to honour the experience of each mother. Description of Sample The eight participating mothers resided in Alberta (4), British Columbia (3), and Ontario (1), all of whom identified as female and were married, with varying levels of education and employment. Table 4 provides the full sociodemographic characteristics of the participants. Three participants were between the ages of 27 and 29, two between 30 and 33, and three were 34 years old. Six mothers selected White/European as their primary ancestry, while one shared both White and Southeast Asian ancestry and one selected South Asian. During their pregnancies, half of the mothers experienced MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 49 complications including preeclampsia (2), high blood pressure (1), anxiety and depression (1), and small fetal head circumference (1). Six of the mothers were primiparous, while two mothers had a previous delivery prior to birth they shared in their interview. Three mothers had a vaginal birth, one of which was an assisted delivery. The remainder of participants underwent a caesarean birth, four of which were unexpected and one spontaneous labour of breech presentation, resulting in a caesarean birth. Table 4 Sociodemographic Characteristics of Participants (N=8) Demographic characteristics Identified gender Female Age in years 27-29 30-33 34 Marital status Married/partnered Highest level of education Bachelor’s Master’s Other (Associate’s Degree/Postsecondary Diploma Program) Employment status Full-time On leave (maternity leave, sick leave) Other (stay at home parent) Ancestry (select all that apply) White/European Southeast Asian South Asian n (%) 8 (100) 3 (37.5) 2 (25) 3 (37.5) 8 (100) 4 (50) 2 (25) 2 (25) 2 (25) 5 (62.5) 1 (12.5) 7 (87.5) 1 (12.5) 1 (12.5) MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH Type of delivery Vaginal birth Vaginal birth requiring forceps or vacuum Unexpected caesarean section Spontaneous labour with breech presentation requiring caesarean Number of deliveries 1st 2nd Sex of newborn Male Female Complications during pregnancy Yes No 50 2 (25) 1 (12.5) 4 (50) 1 (12.5) 6 (75) 2 (25) 3 (37.5) 5 (62.5) 4 (50) 4 (50) Procedures for Informed Consent and Data Collection Participants self-identified via social media posts through the attached link or QR code on the poster and were directed to the Qualtrics contact form (later described). Once eligibility was confirmed as per the inclusion and exclusion criteria, information about the study was provided, questions answered, the consent form provided, and a mutually convenient time to conduct the virtual or in-person interview was scheduled. The consent form (see Appendix F) was provided to participants in advance using Qualtrics for their review, which is further discussed with the ethical considerations of the study. Informed consent is an important ethical consideration of qualitative inquiry and included discussion regarding the benefits and risks to the participants, compensation, confidentiality, the information specific to withdrawing from the study, and the explicit reminder that participation was voluntary. Qualtrics was also used to collect participants’ sociodemographic information, sent by a separate link, available in Appendix G. Those who chose to participate in this study were given the option of completing the interview virtually on Microsoft Teams, on-campus at TWU in a comfortable and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 51 private location, or at their home. Although both in-person and virtual modes of interviewing allow the researcher to observe non-verbal cues, which are highly valued in qualitative analysis, virtual interviews pose unique potential ethical considerations in comparison to in-person meetings. Concerns regarding access to technology, retrieval of signed consent, and data storage and privacy are greater when conducting interviews remotely; therefore, in-person interviews were encouraged when geographically feasible (Lobe et al., 2022). Due to mothers’ geographic locations and schedules, all the participants chose to join the interview virtually. Eligible mothers were invited to participate in a 30-to-60-minute semi-structured interview conducted by myself. Interviewing can be used to ensure that the participant’s perspective will be collected to inform the generated knowledge (Thorne, 2016) while a semi-structured format utilizes a flexible approach that focuses on the phenomenon or topics for the conversation, rather than a list of explicit questions that must be followed (Polit & Beck, 2021). I prepared for the semi-structured interviews by completing a practice interview, and after the first interview, reflecting on already collected data to adapt interview questions as needed. To record the content of the interviews, the Microsoft Teams record feature was used for all interviews. An audio recorder was also utilized to ensure recording had taken place if technological malfunctions occurred. Microsoft Teams provides a transcription service in which recorded text was transcribed throughout the interview and was available for download upon completion (Chhabra, 2021). Further information about data storage and privacy for virtual interviews is presented in the discussion of ethical considerations. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 52 Questions developed for the semi-structured interview guide were guided by the findings of the literature review, the theoretical perspectives of RCC and RMC, and by my personal clinical experience in maternity nursing care (see Appendix H). The semistructured interview guide included prompts that were used depending on the trajectory of the interview and the participant’s responses. Mothers were asked a variety of questions including those about their birth experience and if able, asked to identify moments of trust or mistrust with the perinatal nurse. As suggested by Callister (2004), I made every effort to validate the importance of mothers’ experiences and approached the discussion with flexibility, understanding that some participants would be more willing to share than others. During and following the interview, I recorded field notes (see Appendix I for template) to note observed non-verbal cues and communication and improve reliability of the findings. The field notes were written, detailed, reflective, and descriptive observations that were drafted to capture the context and my initial reflections on the interviews (Polit & Beck, 2021). These observations were included in data analysis as they included my personal responses to the interview and analytical considerations immediately following data collection. Additionally, an unrecorded time of debriefing occurred with mothers upon completion of data collection, guided by the script found in Appendix J. Ultimately, data collection concluded based on the information power of the sample (Malterud et al., 2016). Information power refers to the richness of the data, related to the study’s aim, specificity of the sample, the application of theoretical perspectives, the analytic strategies, and the “quality of dialogue” (Malterud et al., 2016, p. 1756). Considering these factors, the level of information power a study has can MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 53 determine the necessary sample size to answer the research question. Due to the exploratory nature of this study, the primary aim was to present selected and shared patterns about the phenomenon. Only mothers who fit the inclusion criteria were included in the study, yet there were variations in the collected sociodemographic data, such as age, complications in pregnancies, and numbers of pregnancies. Each mothers’ story provided rich insight into experiences of trust in the perinatal-nurse mother relationship amidst TCEs and were analyzed through the lenses of relationship-centred, respectful maternity and trauma-informed and responsive care. (Malterud et al., 2016). Through thematic analysis and frequent consultation with the thesis committee, data adequacy was determined following the inclusion of a final participant recruited after the initial phase of data analysis. This interview was used to evaluate whether substantive findings were still being extracted from the data, or if the existing findings were sufficient to progress, while maintaining feasibility of the study. Sociodemographic and pregnancy characteristics were collected and compiled and included basic demographic information as well as specific details to the childbirth experience such as parity and mode of delivery. These were used to complement the study findings and provide a rich description of the sample to support transferability of findings. Data Analysis Amidst data collection, inductive thematic analysis was conducted simultaneously with data collection to assist in finding “pattern among the pieces” (Thorne, 2016, p. 155). Analysis of this kind stretches the findings “beyond the obvious” (p. 156) and consists of two distinct processes: sorting and organizing data and the conceptualization MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 54 of the findings (Thorne, 2016). After each interview, transcription was done by the Microsoft Teams’ recording and transcription feature and confirmed by a manual check, conducted by myself, which allowed for deep immersion in the data (Thorne, 2016). During data analysis, analytic notes and reflective journaling were used to make meaning of and help sort the data. Audio recordings, analytic notes, reflective journaling, and transcripts were frequently reviewed throughout data analysis to increase familiarity with the data. Transcriptions were individually uploaded to NVivo and broadly coded into “meaning units” (Thorne, 2016, p. 160). Caution was taken when utilizing coding as an analytic tool as it could hinder the inductive process, thus I repeatedly revisited the purpose of the study and engaged in reflexivity (Thorne, 2016). The next step of data analysis was the conceptualization of the identified patterns, in which the researcher, an “interpretive instrument” (Thorne, 2016, p. 176), made sense of the findings. I used constant comparison throughout data analysis to compare and contrast data from different participants and new data with emerging themes, identify unique experiences that were insightful, and take note of the complexities within the data. As recurrent immersion and a deeper understanding of the data occur, relationships between the patterns began to form to produce an interpretive understanding. These relationships require reflective interpretation as the “pieces of the puzzle” (Thorne, 2016, p. 177), and the puzzle as a whole, becomes visible to the researcher. Taking a step back from the intricacies of analysis allowed for refinement of the relationships by evaluating relevance and alternatives of the thematic findings. Consultation with the thesis committee occurred frequently (e.g., every one to two weeks) during the data analysis phase of research to ensure identified patterns were clear and to adapt interview questions MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 55 for future interviews dependent on analytic directions. Before presenting the data, ID supports member checking, going back to the data source to gather participants’ reflections on the synthesized findings (Thorne, 2016). This process of member checking was done with the inclusion of a final participant interview, following initial analysis and adaptations to the interview guide. This interview both affirmed and elucidated the findings of the study. The following section will describe the steps taken to ensure credibility and trustworthiness of the findings. Quality of Data Thorne (2016) has adapted common evaluation criteria of qualitative research and acknowledges that ensuring credibility of research is essential to ID studies. First, epistemological integrity refers to the commitment to a logical process from the research question to the research strategies, that is consistent with the existing knowledge of the topic (Thorne, 2016). A discussion of RCC and RMC and a thorough literature review on trust and mistrust in the perinatal setting were used to guide the methods and research strategies based on what is already known and gaps in the literature. The findings of this study addressed the research question and purpose and were presented as a thematic analysis. Epistemological integrity was pursued throughout the study by frequent consultation with members of the thesis committee, Dr. Kendra Rieger and Dr. Lyndsay MacKay, both of whom have expertise in maternal-child nursing or trust-related research, respectively. Representative credibility refers to the consistency of the interpretation of the findings to the sample that was studied, which can be achieved through triangulation of data sources (Thorne, 2016). Eight mothers’ unique stories were analyzed over a period MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 56 of five months to approach the data with varying angles of interpretation, guided by the literature review and theoretical perspectives of RCC and RMC. Further, the relevant clinical and research experience of the thesis committee and myself contributed to the researcher triangulation and credibility of the data. Analytic logic supports credibility of the research by providing evidence of logic (Thorne, 2016) and detailed description of the inductive process that has taken place. This evidence of logic was maintained throughout the study in consultation with the thesis committee and with explicit description of reasoning behind all steps of the research study. Field notes, including analytical and reflective observations, were recorded during and following interviews as an audit trail for reference during data interpretation. Further evidence of logic was also demonstrated in the thematic findings and interpretive discussion sections of this study. Within data analysis, awareness of one’s position and influence as a researcher is incredibly important as one’s personal experiences and assumptions are required for primary mental sorting of the data as repeating or contrasting words or phrases are identified. Recognition and consideration of interpretive truth, and the “truth external to [the researcher’s] own bias or experience” (Thorne, 2016, p. 235) was achieved with the addition of reflective journaling, used to identify my own biased perspectives during the data collection, analysis and discussion. Interpretive discussion with the thesis committee and member checking with an additional participant following initial data analysis and interpretation, supported “check[ing] interpretations against those of our research subjects” (Thorne, 2016, p. 235). Further strategies were also applied to ensure minimal risk and maximized benefits to the study participants. Together, these techniques support the quality of data in this study. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 57 Ethical Considerations Ethical considerations are imperative to any research involving human subjects and can be categorized as the pursuit of respect of human dignity, justice, and beneficence (Polit & Beck, 2021). Various steps, described below, were taken to maximize confidentiality and minimize risk to participants including approval from Trinity Western University’s Human Research Ethics Board (HREB), which was acquired prior to recruitment and data collection. Respect for Human Dignity Informed consent included full disclosure and was obtained from all study participants prior to the interview and before any data was collected to support selfdetermination and human dignity. As outlined in the informed consent, participants were able to withdraw at any point of the interview and could request to have their information removed up until one week following the interview. Due to the concurrent process of data collection and analysis (Thorne, 2016), after a week, the analysis had commenced and included transcripts were ultimately part of the study because data collection and analysis occurred simultaneously. To support the fair treatment of participants, anonymity was maintained by removing any identifying data from the transcripts or sociodemographic information and by assigning unique study identifications. All data was stored on a password-protected computer to ensure confidentiality and will be stored for ten years, pending secondary research. Data from interviews or transcriptions conducted on Microsoft Teams are stored in Canada, protected by encryption and permissions (Spataro, 2020), and will be permanently deleted following the ten-year period. Those who participated in virtual interviews were presented with this information at the forefront of MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 58 the discussion. In addition to myself, only the thesis committee members, Dr. Kendra Rieger and Dr. Lyndsay MacKay, had access to the data once anonymity was ensured. Compensation for qualitative study participants is neither encouraged or discouraged, yet similar to other decisions in the research process requires a rationale to avoid coercion while still encouraging participation (Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council of Canada, & Social Sciences and Humanities Research Council of Canada, 2018). To compensate study participants, an electronic bank transfer of $50 was given to mothers upon completion of the interview. This amount of compensation was decided on based on an estimation of daycare fees for mothers requiring childcare to participate in the study and was not considered coercive. Justice To ensure the participant’s rights to fair treatment and privacy (Polit & Beck, 2021), if the participant chose to end the interview prematurely or requested for their information to be removed from the study, they would still receive compensation for their time. No participants withdrew prior to or following data collection. All mothers have access to their transcripts upon request and will be provided with a study summary via their preferred contact information upon completion of the study. For mothers who participated remotely on Microsoft Teams, the company’s privacy notice was made directly available when recording began. As mentioned, identities of participants were fully protected by assigning unique study IDs. Explicitly for contact purposes, a master list of participant names and contact information was stored on a password-protected computer, available only to myself. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 59 Beneficence Another important consideration to human research is the pursuit of welfare or beneficence of the study participants (Polit & Beck, 2021). Recounting traumatic events may bring up distressing feelings or memories for participants. Thus, mothers were offered contact information for local counselling services following the interview and when required, I provided a pause if discomfort or distress from the participants was evident (Callister, 2004; Thorne, 2016). I also conducted a period of debriefing following completion of the interview to assess the participant’s response and wellbeing. Callister (2004) identifies listening to birth stories as an important nursing intervention that benefits mothers through the sharing of significant life experiences, fears, “missing pieces” (p. 510) and feelings of disappointment from the birth experience. Further, sharing their story may have allowed mothers to identify personal strengths and make meaning of the experience (Callister, 2004). Trauma-informed Research Due to the intimate nature of recounting traumatic experiences, a traumainformed approach was required when interacting with the participants who had a TCE. I have experience in postpartum nursing care and have completed education modules on the provision of trauma-informed care, which supported my data collection in a traumainformed interview approach. Alessi and Kahn (2022) identified guidelines qualitative researchers can take to ensure safety and promote resilience for participants who have experienced trauma. Through the relevant clinical experience, additional education, and a thorough literature review, I learned about the impacts of traumatic events on individuals (Alessi & Kahn, 2022). These contributions, and a specific attention to the construct of MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 60 trust, were helpful in creating and extending trust and safety in the research interview. Next was knowing when to pause or change direction during the interview to avoid retraumatization. I ensured that mothers were aware of their right to withdraw, as well as observing verbal and non-verbal cues to guide the need for breaks during the interview. A time of debriefing also occurred in which participants were offered contact information to counselling and mental health services. The final guideline of this framework is the researcher’s commitment to self-reflection during the conduction of the research (Alessi & Kahn, 2022). Continuing reflection occurred throughout the research process, presented through reflective and analytical journaling and discussion with the thesis committee. Chapter Summary This chapter has provided an outline of the research methodology and strategies in participant recruitment, sampling, and data analysis, guided by ID (Thorne, 2016). ID’s inductive approach to qualitative research was supported for this study based on the research question’s applicability to the perinatal nursing context and emphasis on the participants’ lived experiences. Upon receiving HREB approval, recruitment commenced, and strategies were utilized to ensure quality of data and credibility of the findings. Acknowledgement and mitigating strategies of ethical considerations of inperson and virtual data collection such as informed consent, confidentiality, and risks posed to the participants were presented. Data analysis was conducted concurrently with data collection, first by identifying themes through the sorting and organizing of the findings, and further through conceptualization and interpretation (Thorne, 2016). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH Directed by ID, this study contributes applicable knowledge about trust in the nursemother relationship amidst TCEs in pursuit of RCC and the global initiative of RMC. 61 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 62 Chapter Four: Findings Interpretation of mothers’ experiences revealed one overarching theme, three main themes, and associated sub-themes (see Table 5). The overarching theme embedded throughout the data was perinatal nurses’ opportunity to build trust and co-construct a Shelter in the Storm, protecting and supporting mothers amid traumatic experiences of childbirth. The first main theme was the Foundations and Fluid Trajectories of Trust Amidst TCEs, which presented the course of trust-building as an active and fluid process, with many moments along the birthing experience where trust was built, maintained, or broken. The second main theme provides insights into supportive and trauma-responsive factors that influenced this trajectory of trust and speaks to how the perinatal nurse’s positive words and actions contributed to the Developing and Maintaining Trust through Relationship and Trauma-responsive Care. Finally, the third theme, Barriers to Developing and Maintaining Trust Amidst TCEs, describes how trust was prevented, restrained, or broken. This chapter will elucidate these themes and uncover the significant implications the findings hold for perinatal nurses in developing trust amidst TCEs. Table 5 Themes and Sub-themes Themes • Sub-Themes Trust in the Nurse“I don't feel like I could have emotionally done it without mother Relationship as a her. No way.” Shelter in the Storm • • The Foundations and Fluid Trajectories of Trust Amidst TCEs “I'm going to have to trust them with what they know more than what I know” Foundation of trust: the nursing expertise MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH Themes 63 Sub-Themes “I had like a really high trusting relationship already”: Past experiences and expectations “It really tapered out throughout that shift”: Fluidity of trust amidst trauma “I didn't realize that I had to trust my nurses so completely”: The necessity of trust in the nurse “A space where you can be heard and understood”: Trust as a comfort to be myself and ask for what I need “You feel confident in their abilities and intentions” Confidence that the mother’s and baby’s best interest are at heart • Developing and “She felt like a friend”: Relationship as the groundwork for maintaining trust trust through relationship and “I’m going to sit here with you”: Enacting a caring presence trauma-responsive care in labour and postpartum “She recognized the value of what I went through”: I See You: Intuitive responsiveness to the mother’s humanity, trauma, and felt needs “There's something about being informed about what's happening to your body”: Effectively communicating throughout the perinatal experience “She was so thrilled for us”: Supporting the mother’s birth plan Barriers to developing and maintaining trust amidst TCEs “When are you going to let me leave? I'm a prisoner of this place”: Structural factors impacting perinatal nursing care “I don't have anyone in my corner”: Feeling unseen or insignificant amidst and following a TCE “I needed them to stop yelling at me”: Unsupportive communication styles MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH Themes 64 Sub-Themes “She didn't keep me in the loop even though she was four feet away”: Lack of collaboration and partnership in the birthing experience “If she didn't know about this, then what else does she not know about?”: Questioning of the perinatal nurse’s expertise Overarching Theme: Trust in the Nurse-mother Relationship as a Shelter in the Storm Within mothers’ TCEs, trust in the nurse-mother relationship provided a shelter within the storm, a safe haven that could protect them from the negative impacts the traumatic experience may have left behind. As one mother shared, “The nurses, being a consistent source of support and you know encouragement …that definitely impacted our experience with them. If not for them, I think I don't know what would have happened” (P2). Mothers entered the birth experience with their own understandings of trust. Past healthcare experiences and expectations of perinatal care comprised the foundation for developing trust with their nurse. If the perinatal nurses came alongside mothers and supported them, trust was established, and their relationships became strengthened. Together, they built upon mothers’ foundations of trust to establish trusting relationships that were a shelter in the storm. Walls and a roof of trust were built around the mothers to shield them from the storm of a TCE. Otherwise, the storm of a TCE could pour out traumatic experiences that included panic, fear, pain, and a loss of control for mothers transitioning to motherhood. One mother shared how critical this relational shelter was: “Afterwards I was like, this [nurse] has given birth to my baby. I really was MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 65 like this woman is the reason that this could happen. I don't feel like I could have emotionally done it without her. No way” (P5). Participants identified several supportive factors that built and maintained trust in the nurse-mother relationship and enabled their co-constructed shelter to stand firmly, withstanding the pressure and invasiveness of the traumatic experience. When trust was weak or broken with the nurse due to various factors, the integrity of the shelter faltered. The storm of traumatic childbirth looked different for each mother, and both influenced and was influenced by the development of trust. Mothers described TCEs as comprising fear for one’s life, poor or uncertain newborn status, feeling robbed of the birthing experience, unexpected interventions or complications, and structural shortcomings (see Table 6). These contributors to trauma impacted the development of trust, as can be seen in the quotes in Table 6. Giving voice to mothers’ honest experiences of trauma also revealed areas where trust, when established in the nurse-mother relationship, could act as a shelter and a protection from certain harmful aspects of traumatic childbirth. These traumatic experiences provided complex contexts for the development of trust or mistrust with perinatal nurses. It was clear that a trusted perinatal nurse had a significant impact on the mothers’ birthing experiences within this tumultuous context. Amidst a TCE, perinatal nurses held the building blocks of trust in the nurse-mother relationship and had an opportunity to partner with mothers to develop a steady shelter to weather the often unexpected storm of traumatic childbirth. Perinatal nurses were described as the “first line of defense to what being a mother is” (P8), a vital and influential partner in the transition to motherhood MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 66 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 67 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 68 during TCEs. When asked what she would want perinatal nurses to know when caring for mothers amidst traumatic childbirth, one mother shared: “Your job is very important…it's just a day in your life, but it's very impactful. So, I guess keep sight of the fact that you're part of long lasting and very important memories. And I suppose that that can be quite scary, but see it on the positive side that the help you offer is really important” (P5). Clearly, perinatal nurses played a pivotal role in how mothers experienced birth and postpartum, as one participant articulated: “Who can I jump on as lifeboat? And that nurse was my lifeboat” (P3). Although the storm of a TCE may be inescapable, mothers’ stories give hope for perinatal nurses, ensuring that the care they provide and the steps they take to establish trust with mothers can build a shelter that safely brings them through their birthing trauma. The Foundations and Fluid Trajectories of Trust Amidst Traumatic Childbirth The participants’ experiences of trust amidst a TCE were unique for each mother and did not always start out in a positive way or follow a linear, upward, trajectory. The trajectory of trust initially depended on factors preceding the perinatal experience, including past healthcare experiences and mothers’ expectations of nursing care. Within the perinatal nurse-mother relationship, the trajectory of trust built on this initial foundation and was fluid, with potential to be maintained, strengthened, or broken throughout mothers’ birthing and postpartum experiences. When trust occurred, mothers described it as a comfort to be who they truly were, and a safety in knowing the nurse was competent in prioritizing the mothers’ and newborns’ wellbeing. These ideas (sub-themes) about the trajectories of trust building will be further explicated below. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 69 Origins of trust Foundation of Trust: The Nurses’ Expertise. The majority of mothers spoke to the foundation of their trust originating from their understanding and respect of the nurses’ scope of practice and expertise before they were admitted. Most mothers acknowledged their limited knowledge of the birthing experience, leading them to place a baseline level of trust in the competence and expertise of the perinatal nurses as they entered the hospital setting. Beyond the nurses’ knowledge, this competence included trust in the training and education of nurses and an expected adherence to the ethical principles of the nursing profession. One mother shared how she entered her delivery already trusting the nurses and the healthcare team: “because of my own limited knowledge with healthcare and you know policies, procedures of the technical stuff and whatnot. So, at some point I'm going to have to trust them with what they know more than what I know” (P2). Another mother shared about this pre-existing trust in her nurses, saying, “I went into labour a little bit cautious but optimistic, hoping for the best, generally trusting them because I think that there's a lot of research that goes into healthcare” (P4). This confidence in the nurses’ clinical expertise was described as a “baseline of trust” (P7), which laid the foundation for a potentially deeper level of trust and the formation of a relationship between the perinatal nurses and mothers. This baseline level of trust in the nurses’ clinical expertise could exist amidst a TCE, “trusting that they're gonna do their job to the best of their ability when they show up for their work” (P3), even if a deeper relationship and level of trust was not formed between the nurse and the mother during their hospital stay. Further, this foundation could also be built upon, broken, or maintained throughout the birthing experience; thus, it was dependent on the nurses’ words and actions MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 70 amidst a TCE as described in the second theme. The level of foundational trust mothers arrived at the hospital with was influenced by past healthcare experiences and hopes and plans they held for their birthing experience. Past Healthcare Experiences and Expectations. For some mothers, past healthcare experiences either tainted or supported their trust in nurses in general. Interactions with nurses occurred both within and outside of mothers’ most recent pregnancy experiences, such as during past deliveries, in the obstetrician’s office, or emergency room visits. Multiparous women reflected on their past deliveries as creating the foundation of trust they had in perinatal nurses coming into subsequent deliveries. For example, a mother who delivered her first child in Dubai was given no choice in the mode of delivery as her care providers directed her towards a caesarean birth for monetary reasons. This led to a mistrust in healthcare providers’ intentions, yet she was pleasantly surprised in her ability to trust her nurses in her second delivery in Canada as they listened to her wishes and supported her towards a vaginal birth. Contrastingly, another multiparous mother entered her second delivery already trusting the nurses and midwife based on her past delivery: “I had a super high respect for the nurses and my midwife. Cause in the pandemic, they were the only source of care and attention I had… I actually had like a really high trusting relationship already” (P8). This mother’s first delivery was also traumatic due to the isolation and lack of resources associated with giving birth during the COVID-19 pandemic. Despite this trauma, she held onto the trust in her nurses she experienced during her first delivery, which was the foundation to her ability to place trust in the perinatal nurses during her second TCE. Throughout their pregnancies, some mothers recalled both positive and negative experiences which impacted their foundational trust and complicated trust-building. For one MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 71 mother, prenatal appointments or phone calls with nurses positively impacted their foundational trust in the perinatal nurses during a high-risk pregnancy. She shared how she established foundational trust in nurses during these interactions: “I feel like that actually built up my trust a lot with nurses in that sense because they were like super good at monitoring me, making sure baby was okay, making sure I was okay, looking at all the signs. I had to call them also and talk to an RN every single day on the phone. So, I felt I was with nurses in general, trusting that program and trusting how everything was working” (P3). However, this mother also had a history of negative experiences with emergency nurses outside of the perinatal unit who dismissed her intense and persistent nerve pain at an emergency department. These instances impacted her foundation of trust entering her delivery as she reflected back on her conflicting experiences with nurses: “and so I had a bit of trust going into like when I was induced and but then it did shift me back to those other nurses that I had those [negative] experiences with” (P3). Similarly, another mother had a range of influential positive and negative experiences. She shared past experiences of difficult and painful intravenous line starts that caused her to worry going into the perinatal experience. However, she also described her appointments during pregnancy as having a positive impact on her perception of nurses: “During my obstetrician appointments I always felt really cared for by the nurses. I feel like I saw the obstetrician for five seconds, and so it was nurses that we're checking in on me and so that that really built confidence for me that nurses are incredible… I brought that into my hospital experience” (P5). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 72 This inconsistency of experiences with nurses built a wavering foundation of trust, as mothers held both positive and negative expectations entering the perinatal setting. When negative experiences had previously occurred, trust could still be developed within the short and vulnerable period of childbirth. Yet, these mothers’ experiences of trust were quicker to revert, or break, amidst the trauma and unsupportive actions of the perinatal nurses. Moments of mistrust and unsupportive care in past deliveries were transferred to subsequent deliveries, with one mother sharing that “it carried itself into my second birth…I felt a little bit more like, okay, I'm in this myself” (P5). Clearly, mothers had varying experiences with nurses outside of the perinatal unit, setting either a tone of trust and/or worry for their interactions with perinatal nurses. Primiparous mothers also held expectations of nursing care influenced by prenatal classes, mutual friends, or their own personal research that impacted their ability to develop and maintain trust with nurses. Sharing her friend’s experience, one mother said: “I have heard some bad stories from friends and stuff about like their nurses like not being great or like one of my friends, her nurses literally wouldn't even check her like when she was like, “I feel like this pain is getting really bad”. And then by the time they finally got a doctor in, like, she was crowning” (P7). One mother shared her concern about perinatal nurses’ support of breastfeeding: “there's a lot of literature that basically says you shouldn't trust your nurse, or you should be on your guard…we were going to fight for breastfeeding. We knew that and then that did happen” (P4). Unfortunately, in this case, the mother’s expectations of the nurses’ lack of support of breastfeeding were affirmed by her personal experience. At the same time, this mother expressed a personal connection and trust in healthcare workers which balanced her negative MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 73 experience: “I'm generally someone who trusts medical professionals. I mean, my husband is one and so we kind of have a unique view into that world” (P4). This connection to the profession was also shared by one of the mothers who worked as a pediatric nurse. Her employment inevitably equipped her with expectations of the care she would receive. One mother sought information from an online group of mothers who had delivered at the same hospital she planned to deliver at, which provided her with positive feedback from the other mothers: “The number one thing on there and on other things that I had looked up just on Reddit and stuff were like the hospital is old, but all the nurses were amazing, and so that really like, set my mind at ease” (P7). Seeking out external information and opinions prior to delivery was both helpful and limiting to the experience of trust amidst a TCE. Mothers’ confidence in the nurses’ expertise, past experiences with nurses, and expectations of care were the origins of trust that set the foundation for their ability to develop and maintain trust with nurses amidst a TCE. Fluidity of Trust Amidst Trauma In the hospital setting, trust could be built and maintained between mothers and perinatal nurses amidst a TCE; however, it could also be broken, attesting to the fluidity and the wide spectrum of mothers’ experiences of trust. There were notable trajectories found in the data, as for some mothers, trust was present to begin with, but decreased over time: “it started out strong, but it's really tapered out throughout that shift because she constantly needed second opinions” (P6). For others there was a complete break in trust, leaving the mother to feel “shut off a little bit and being like, okay, well, I got it then. I'll just deal with it myself” (P1). A lack of trust in nurses left this mother feeling alone, unsupported, and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 74 withdrawn during a TCE, a time when she needed the nurse to come alongside and support her. Importantly, two mothers expressed that trust between mothers and nurses could be repaired and rebuilt after it was broken, even amidst the trauma of the childbirth experience (P5): “if there is a break in relationship, repair is available” (P8). At times, trust was built between mothers and nurses during a singular monumental act of care from the nurse such as providing pain relief or making the choice to sit close to a mother after her TCE. However, most often trust was developed over time, through the consistent relational and trauma-responsive approaches from the perinatal nurse. After reflecting on her experience of trust a mother shared: “It's apparent now talking it through that I felt that like those little micro building of trust was really integral to how my experience was and how I felt as a person, but also how I feel about the whole experience” (P3). Within each micro moment of trust building (e.g., introductions, providing pain medications, or being a hand to hold), what may seem to be insignificant words or actions to the nurse had a long-lasting influence on the ability to develop trusting and supportive relationships with nurses and the mothers’ experiences of the TCE. Theme two further explores how nurses developed and maintained trust during the birthing and postpartum period. The Necessity of Trust in the Nurse During moments of extreme vulnerability and unpredictability amidst a TCE, mothers shared how they felt they needed an unyielding trust in their nurses to endure the trauma of childbirth, and to find a protective shelter in the storm. For example, following an epidural insertion, a mother was directed to start pushing yet could not sense her body was ready to. She said, “the thing that freaked me out about the epidural is that I didn't realize that I had to MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 75 trust my nurses so completely because I couldn't feel when to push” (P5). In this moment, she could not trust her body to tell her when she was ready to push, she had to trust her nurse to communicate this to her. During a postpartum hemorrhage, another mother recalled feeling strapped down as two nurses pressed firmly on her uterus, expelling the blood in an attempt to stabilize her. Despite feeling uninformed of why the interventions were necessary, she understood that “there's a level of you just have to trust that they know what they're doing and trust that them not telling you is the right thing” (P3). Despite having prepared for delivery, attending prenatal classes, and doing their own research about newborn feeding, mothers depended on the practice wisdom of the nurse to fill in the gaps which emerged during the unpredictability of childbirth and postpartum. One participant experienced confidence that she was “in good hands. This is all fine. This is how it is” (P6), as she released her experience into the hands of the perinatal nurses. Yet, for others, although trust in the nurse was necessary, it did not always develop under positive circumstances. One mother shared how in conversations about breastfeeding preferences, she was met with disregard, and unhelpful and somewhat forceful alternatives. She said: “I didn't have my textbooks with me. I didn't, you know, I didn't have time to research what we really needed to do in this moment, and this is just what they were telling us that we needed to do so. Okay. We'll do it because I want him to be okay” (P4). Amidst a TCE, trust felt necessary for mothers, but was not always established or maintained in the nurse-mother relationship, contributing further to the trauma. When Trust Occurred Despite the challenges of TCEs, most participants reported developing trust with their perinatal nurses. At the beginning of the interviews, mothers were asked to describe what MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 76 trust encompassed for them when it occurred. The two main themes that emerged from mothers’ definitions of trust were a comfort to ask for what they needed and a confidence in the nurse’s intent and abilities in caring for her and her newborn. Trust as a Comfort to be Myself and Ask for What I Need. Trust thrived between mothers and nurses when mothers felt that they were in a safe place where they could truly be their authentic selves. This included an environment where nurses did not judge mothers, rather they ensured mothers felt heard and understood. For mothers, trust was “a space where you can be heard and understood… there's an element of just understanding of who each other is, but then we can share whatever we want and not to be judged for it” (P8). For another, trust was when “you let down your guard, when you can let down your barriers, when you can just be yourself and you don't feel like you're gonna get taken advantage of… you just feel safe in that space” (P4). When that safety was present, and mothers felt they could truly be themselves, there was a comfort in which mothers felt permission to share who they were and ask for what they needed (P7). “Trust is when I can be myself with somebody and be taken at face value with no judgments… it makes us want to trust the nurses and to share more of ourselves and you know, not withhold information” (P2). For another mother, trust meant that her values and expectations were considered and understood, and therefore she received the personalized care she anticipated. This acceptance and commitment from the nurse created a bond of trust, where the mother was confident that “when I share something with them, they accept it for what it is… you can't break it. Like you can't break what we agreed on. That would be a breach of my trust” (P2). When this comfort was present, the nurses were able to understand mothers’ true selves and desires and the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 77 mothers felt safe, leading to the development of supportive relationships built on trust and provision of trauma-responsive care amidst a TCE. Confidence that the Nurse has the Mothers' and Newborns’ Best Interests at Heart. For others, trust was a confidence that the nurses had the mothers/babies’ best interest and well-being at heart, which drove all care decisions. A trustworthy nurse was described by a mother as: “Someone that's reliable, being able to rely on somebody. Feeling confident, like when you have trust with somebody, you feel confident in them and their abilities. That you trust that they have your best intention and that their intentions for you are good” (P3). Mothers’ confident reliance on nurses was founded on an understanding of and respect for the nurses’ expertise, trusting that nurses would use their clinical knowledge to the best of their ability to provide high-quality care. However, beyond a confidence in the nurses’ expertise was a deeper understanding and belief that the nurses genuinely cared for the mothers and wanted the best for them and their newborns. This type of trust in nurses was described as: “believing someone. It's believing they have your best interest in mind. Yeah. Understanding that they have knowledge that I do not have and that they will use their knowledge for my benefit” (P5). At times this trust was necessary for mothers to trust the nurses’ actions when they could not control how birth was unfolding, particularly during obstetrical emergencies. In moments in which mothers felt helpless due to the chaos and unpredictability of childbirth, trust was “feeling confident in someone else's decisions that they make regarding myself. Well, it's so many things. Like it's, sort of I guess releasing. Releasing the fact that I don't MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 78 know everything, and I need help” (P5). To admit the need for help and confidently rely on nurses involved mothers believing the nurses caring for them “do the best by you and do the best by the process” (P6), using the knowledge and expertise they hold for their benefit, and their wellbeing. In addition to the nurses' good intentions, trust was a mutual understanding that mothers would be included as active and valued participants in their deliveries in pursuit of the dyad’s best interest. It was an underlying awareness of the intimacy and significance of childbirth, and the bond that would be inevitably shared during the nurses’ and mothers’ times together. One mother shared the wonder of the perinatal nurse-mother relationship this way: “You're in a space with someone that is a is a stranger, but then you're trusting them with like, if we're talking about childbirth, it is the most important thing in that moment and probably top in your life. I don't know what you know or what you've been through, you don't know what I know, and I've been through. I'm trusting that you'll make all the best judgments and calls. And you basically walk into the space and you're like, okay, I'm gonna give birth and then I just need you to do what you do” (P8). To mothers who had experienced a TCE, trust was a safe space to be their true selves, in which their needs were respected and met, and confidence that their and their newborns’ well-being were priorities to the perinatal nurses. Trust took an upward trajectory when nurses’ words and actions reflected relational and trauma-responsive ways of caring. The following theme speaks to the moments throughout mothers’ TCEs in which trust in their nurse was maintained or developed. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 79 Developing and Maintaining Trust through Relationship and Trauma-responsive Care The second main theme elucidates facilitators to the development of trust in the nurse-mother relationship, which influenced the trajectory of trust-building described in the first theme. Trust was complex, ever-changing, and dependent on the nurses’ relational commitment to mothers and the ability to provide trauma-responsive care. The foundational and expected level of trust described in the previous theme was often deepened and expanded through the nurses’ words and actions with mothers during labour, birth, and the postpartum period. These trust-building ways of being and doing included the development of relationship, a caring presence, an intuitive responsiveness to mothers and their needs and experiences, effective communication throughout the perinatal process, and support of mothers’ birth plans. Relationships as the Groundwork for Trust During TCEs Trust was developed when nurses went beyond the technicalities of care and sought to develop relationships with mothers. Relationships were formed between nurses and mothers through the intensity and intimacy of TCEs through familiarity, vulnerability, a commitment to the relationship, and reciprocal trust, all of which created opportunities for trust to be developed and maintained. One mother shared the powerful impact of relationship with her nurse, and the care she received as such: “that's what made the whole thing positive, even though it was so traumatic. If we were able to walk away from that place with smiles on our faces, it was because of what the nurses did and nothing else” (P2). A level of commonality was a comfort to mothers, even within the short period of time spent with the nurse. Similarities in personalities, ages, values, and energies were all noted to strengthen relationships with the nurses on initial introductions and during care. The MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 80 nurses’ willingness to be vulnerable with mothers uncovered some of these similarities and helped them to find common ground, strengthening the connection. For example, when a participant’s mother could not be there for her delivery, she found comfort and trust in a nurse who had the same name as her mother, forming an instant bond between the nurse and the participant. Another mother acknowledged past judgements in healthcare experiences due to her weight that contributed to her hesitations to trust her nurses. When her nurse shared her own weight loss journey, the mother expressed that “I felt like she understood me more and she understood the system and how it treats people of size” (P3). Nurses’ willingness to be vulnerable and appropriately share personal experiences of their birth created a space for relationships to be built. For three of the mothers, relationships were built when perinatal nurses shared their own experiences or birth stories, including the feeling of her contractions, her trial of labour following a caesarean section, or her experience with surrogacy. Each shared experience formed a thread of connection in the nurse-mother relationship as mothers could see a pieces of themselves in the people caring for them. Mothers also sensed when their nurses saw the nurse-mother relationship as beyond the duties and tasks of the nurse’s job description. Two mothers described their nurse as a friend or a family member, with one mother sharing: “I felt like I was a relative to her, like somebody that she deeply cared for, that she wanted to be okay” (P3). Mothers also observed the relationship with the nurse as a partnership, working together to create plans of care or checking in on mothers even when they were not assigned to them. The attentiveness shown by the nurses conveyed investment in well-being of the mothers and their newborns which deepened the nurse-mother relationship. Development of nurse-mother relationships allowed MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 81 mothers to be vulnerable with the nurses, strengthening trust within the relationship. One mother shared her surprise and response to this type of care: “I didn't even know that they were going to be invested in this, like at all. Like I didn't know that they cared as much.” (P2). For the majority of mothers, the formation of a nurse-mother relationship was reliant on reciprocal trust. In other words, not only did mothers have to trust nurses, but nurses also had to trust mothers in order to develop relationship with them and direct their care accordingly. To be trusted by the perinatal nurses meant that the nurses’ care was communicated to mothers, mothers’ opinions and desires were valued, and their experiences of labour were regarded as true and significant. When deciding when to come to the hospital, one mother reached out to the triage nurses and voiced her symptoms. Although she was not in active labour, she felt that the nurses listened to and trusted her experiences of labor: “They took my symptoms serious enough to ask me to come to the hospital right away, even though I had not progressed much with delivery…that showed me that they trusted in what I said, and they valued in the information that I gave” (P2). During one mother’s labour, the effectiveness of the epidural was dependent on the nurse trusting the mother’s report of pain and sensation in order to alter the dosing or change the mother’s position. This mother shared: “I started feeling my contractions again a little bit. And I think there are definitely some nurses that might have been like, okay, that's normal. Like, sometimes it doesn't work super well or whatever, but for her to be like okay, “where are you feeling it? Is it here? Is it here? Okay, let's change your position. See if that helps”. She didn't just brush it off. She was like, “okay, let's figure this out, okay”? So, I think I really MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 82 appreciated that she took the time to listen and be like, okay, like it was working before and now it's not” (P7). Reciprocal trust within the nurse-mother relationship was important to mothers amidst a TCE as it implied a mutual respect of each other’s knowledge and experience. To mothers, this meant being trusted as a person experiencing a birth, a person entering motherhood, and a person capable of making safe and responsible decisions for herself and her newborn. The relational bond that developed and withstood the strains of the traumatic birth between nurses and mothers, who were both witnesses to the reality of TCEs, built trust. Following a severe postpartum hemorrhage, a nurse came to say goodbye to the mother at the end of her shift, saying “it was so wonderful that I got to be part of this experience with you” (P7). The investment that was evident from nurses’ actions and words, within the groundwork of a relationship, created a sense of partnership and teamwork, where trust could thrive. The trust that developed from the nurse-mother relationship, through familiarity, vulnerability, a commitment to the relationship, and reciprocal trust, could provide mothers with comfort and protection amidst the trauma of the birthing experience. Enacting a Caring Presence During Labour, Birth, and Postpartum Participants described a caring presence from their nurse as an essential component to the development of trust amidst TCEs. Mothers experienced a caring presence from nurses when they made themselves physically and emotionally available to the mothers throughout the perinatal process (e.g., careful monitoring of the mother’s and newborn’s wellbeing and consistency in care and personnel). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 83 The physical closeness of the perinatal nurse, especially during moments of trauma, provided emotional support to mothers and fostered trust. A mother who experienced excess bleeding following delivery described the value of this caring presence: “Through the hemorrhage, the fact that she just like, made a very distinct choice to, like, stay with me and, like, try to like, seek help from other nurses for her other patients and stuff was really, really amazing. Deciding like, hey, I'm gonna sit here with my patient after this traumatic experience because she needs support, even if I'm just sitting here quietly” (P7). Another mother said, “she didn't leave my side when things were going a little bit, like, you know, awry” (P1). The physical closeness was also delivered in the form of therapeutic touch: holding the mother still during an epidural insertion or stroking her hand and looking her in the eye. When receiving an epidural, one mother shared that despite the fear and pain that came with a stranger inserting a needle into her spine, she had her nurse holding her still: “I felt safe with her” (P4). A trusted nurse created a safe space amidst the traumatic moments, vulnerabilities, and uncertainties of childbirth, and a space for mothers to be their authentic and real selves. For another mother, a caring presence was crucial in the development of trust: “I actually didn't trust anyone else, but I trusted her because she... sat really close to me the whole time” (P5). Mothers who felt they were checked on carefully and frequently recounted developing trust with their nurses, knowing that their own and their newborn’s well-being were monitored when the nurse was present. One participant shared, “I had a nurse with me round the clock. There was somebody with me in the room all the time and that is MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 84 spectacular care” (P2). For some mothers, the importance of monitoring extended beyond maternal well-being to also include newborns’ health statuses: “I feel that actually built up my trust a lot with like nurses in that sense because they were like super good at monitoring me, making sure baby was okay, making sure I was okay, looking at all the signs” (P3). The direct and constant care from the nurse and the thorough assessments of mothers and their newborns developed trust amidst TCEs, from the caring and competent reassurance of the dyad’s wellbeing. Trust also developed when a caring presence was consistently provided by the same nurse throughout the perinatal experience. Many of the participants recalled multiple interactions with the same nurse in various stages of labour and delivery, noting that time spent together fostered trust. When mothers remembered the nurse, and even more so, when the nurse remembered the mother, a familiarity was ensued and created comfort for the labouring mother. As one participant recalled: “Trust also was built through relationships in time…one of the nurses I had known from a couple of my visits there and so right away, I felt like really comfortable with her and she was amazing” (P3). In recurrent deliveries, following a traumatic birth, reconnecting with past nurses was especially meaningful. One mother had a nurse from her first traumatic delivery visit her during her stay of her second birth: “[that] story built trust, like a returning... nurse, to come visit me was really important” (P8). Amidst the trauma, a caring presence from the perinatal nurse provided mothers with competent company and care, never leaving mothers to feel alone in their experience. A seemingly simple act of being consistent and nurses being physically and emotionally close MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 85 to the mothers when completing thorough assessments and monitoring aided in mothers’ abilities to trust in their nurses. I See You: Intuitive Responsiveness to the Mother’s Humanity, Trauma, and Felt Needs Grounded in relationship, and strengthened by a caring presence, another significant element in developing trust was the nurses’ acknowledgement of mothers’ humanity and trauma, and response to their felt needs. Trust was built when mothers felt that nurses recognized their humanity amidst their suffering during their TCE, as one mother shared, “as a human, anything that makes you feel like...they understand me, they get me. They know my reality. They know me more than just what my numbers say, made me feel more human” (P3). Further, following and during TCEs, meaningful moments were created when the nurses did not ignore mothers’ suffering within traumatic experiences. One mother sensed this support from her nurse and shared the following: “I just felt really, really supported in that I was a human being who had just been through something insane and not just another patient that she kind of just had to go do her rounds on” (P7). Nurses’ validation of mothers’ humanity and recognition of their suffering came from their holistic approach to nursing care that made mothers feel seen in their entirety, not just as a labouring patient with a difficult birth on a maternity unit. In one participant’s words: “So, I trusted her that way too, because I felt like it was really holistic...she was looking at me as like a patient, but then also like a person, and a mother, and a pregnant person, and a wife, and an anxious person, a scared person … and like, a happy, hopeful person” (P5). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 86 To be seen as a mother who had experienced a traumatic birth instead of a patient alone not only developed trust in the nurse, but also affirmed mothers in their experiences and helped them regain an element of humanity. Mothers highly valued the nurses’ ability to intuitively anticipate and respond to their needs, both physically and emotionally, as a result of nurses viewing mothers in their full humanity and not just a patient. Nurses demonstrated an understanding of mothers’ emotional needs, concerns, or insecurities, and tailored their care accordingly. Mothers described many aspects of care in which this holistic care was enacted. For one mother, this responsiveness occurred in a small action, when the nurse provided competent care by closing the curtain when performing a catheterization, implying that “you are your own person and I know how invasive this is all gonna be” (P8). For another mother, who experienced a postpartum hemorrhage, her nurse made a conscious choice to stay with her during this difficult time, proving her awareness of the mother’s humanity and needs during times of uncertainty: “Her saying “I'm gonna stay here”. That was just like a lot as well because like I said, if she had asked me “do you want me to stay?” I would have said “no” for sure, so I’m glad that she was just like I am going to stay here until your husband comes back and someone like me, I need somebody to say that and just do that for me (P7). For some postpartum mothers, the nurse who offered to clean up her blood following delivery provided the care in a way which made mothers feel that these actions were beyond the job description. In this way, the nurses recognized the mothers’ vulnerabilities and suffering and responded. One mother described her nurse as “an angel” who willingly and consensually washed her, highlighting the safety of that nurse in such an intimate moment: MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 87 “all she did was wipe me. So, I was like, I really trust her. Like I really trusted that” (P5). In these ways, trust was developed when mothers’ needs were anticipated by the nurses based on their holistic understandings, emphasizing an intuitive responsiveness of the nurse. Nurses’ intuitive care in response to seeing their patients’ humanity, echoed principles in trauma-responsive care. For example, offering options in care demonstrated responsiveness to the mothers’ felt needs amid trauma and was effective in building trust and empowerment, aligning with trauma-responsive principles (Covington & Bloom 2018). With the onset of labour pains, mothers appreciated being given options for pain management from the perinatal nurses: “I was surprised that they were like, “Hey, if you want, you can you have the epidural, but you can also take the gas, you can try it”… so they didn't restrict my access to any pain medication that I could get” (P2). After an exhausting labour of over 20 hours followed by an emergency caesarean section, one mother was approached by her nurse who said, “Let us take your baby. We'll feed her. Do you want formula? Do you want breast milk? What do you want? She just gave us options to allow us to have a few hours of sleep…she was my favorite” (P6). The nurses who provided mothers with options, gave mothers an element of control over their care, and also gave opportunity for pain relief and rest. One mother acknowledged the unique role that nurses have in developing trust in this way: “But I think maybe as a nurse…you're creating [a space], to be like what you can control, let's bring that to the top for you, you know, let's give you those options. And it just sets you up” (P8). Entering motherhood empowered, knowing they were capable and worthy of control over their experience, was noted as important by mothers. This empowerment was supported by a responsiveness to mothers’ MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 88 needs in offering care options, and thus, honouring mothers’ desires to be involved in their own care. The trusted nurse, at times, advocated for mothers when they could not do so themselves, responding to their unspoken needs. When an epidural caused a participant to lose consciousness, the mother praised her nurse for ability to read her: “I wasn’t even really using my voice because I didn't feel like I could, but she was. She was reading it from me” (P5). As mothers’ needs evolved throughout the birthing journey, the perinatal nurses were intuitive to the changes, making intentional care choices for the otherwise unapparent needs of the mother. This instinct fostered trust as mothers confidently felt as though their needs would be met, and advocated for, by someone who understood what they needed. For the majority of participants, the inclusion of partners in the TCE was also vital in developing trust in the nurse as it demonstrated their responsiveness to the mothers’ need for support. One participant voiced multiple times throughout the interview that the nurse’s care for her husband was incredibly memorable. She said: “she was there to give him the moral support that he needed to see me through. See us through this” (P2). In addition to moral support, perinatal nurses also guided the partner to physically support mothers, whether having the partner hold her leg during pushing or demonstrating how to swaddle the newborn following delivery. This support was integral to navigating their TCE. For some of the participants, the partner also experienced the birth as traumatic. In these cases, trust extended beyond the nurse-mother relationship for the partners who were updated on the mother’s and newborn’s status, felt confident in the nurse’s competence, and were equipped to support the mother. This inclusion allowed mothers to be more present in the birthing experience, knowing that their support person was also being supported. Trust appeared to be interwoven MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 89 and strengthened within the triangle of relationships of the mother, the partner, and the perinatal nurse. The importance of this connection lay in mothers’ need for their partners, and the nurse’s ability to include and empower the mother’s support person. For one mother, her need for her husband was powerful, expressing: “I think he just played a part in it being less traumatic for me” (P8). Amidst a TCE, there were many moments in which mothers felt a lack of control and a stripping of their humanity. Within the vulnerability of childbirth and a TCE, feeling seen for who they were and the suffering they were experiencing made the nurses safe and trusted people to turn to. The perinatal nurses’ intuitive responses to the needs and experiences of mothers, enacted in various care encounters, further fostered the development of trust. Effectively Communicating Throughout the Perinatal Experience The ways in which the nurses communicated with mothers before, amidst, and following a TCE were impactful in building trust in the nurse-mother relationship. The perinatal nurse, at times, took on the trusted communicative roles of an encouraging coach, a messenger or informant, and mothers’ advocates within the wider interdisciplinary healthcare team. One effective communication technique identified many of the participants involved verbally guiding and coaching mothers during labor and the postpartum period, creating an environment where trust could be maintained or developed. Some mothers valued coaching and affirmative support of their efforts in the pushing stage of labour. One mother, who had incredible support from a nurse when pushing for the first time, commented on the importance of clear and supportive guidance while pushing: MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 90 “They were like, let's go. We were gonna go. And they timed me and then they said, OK, we're gonna push this way. And then we tried. We tried really hard and we were ready. The baby's head was like, almost crowning” (P2). Later, she said: “That really built my trust and in the way she supported the pushing exercise. That really, really helped me a lot and I didn't see myself trusting a nurse and then I started pushing” (P2). Nurses also empowered mothers by providing verbal guidance and coaching during the postpartum stage when offering feeding support and performing maternal and newborn assessments. This empowered mothers and built their trust that the nurse wanted her to succeed in the transition to motherhood. For example, in moments where mothers felt they had lost control over their own body and their motherhood during labour, the postpartum nurse had an opportunity to help mothers regain control by communicating about feeding positions and educating on strategies to improve milk supply. When facing challenges with breastfeeding, one mother recalled this interaction with her nurse: “I was stressed out about it, and she was like, “Oh my God, no, you can start this right now. It's not a big deal. The baby can still latch. Let's start getting her to latch just to get her used to it”, and really made me feel empowered” (P3). The perinatal nurses’ communication strategies of offering verbal encouragement and guidance gave mothers an element of control which had been lost due to the TCE. This empowerment fostered trust as mothers were guided gently and confidently through the birthing process. Effective communication strategies of providing guidance and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 91 encouragement enabled mothers to be an active participant in their delivery, trusting they would be informed and included in the decision-making. Trust was also developed when the nurses ensured that mothers were clearly informed about interventions and care activities throughout the perinatal experience. Participants provided examples of perinatal nurses who explained the reasoning for emergency interventions or intimate postpartum assessments and asked for consent before performing this care. Mothers noted how this preparation increased their trust in nurses. One mother described the importance of feeling informed by her nurse in the context of a manual removal of the placenta: “And when they're talking through something, even if they're not explicitly, like getting you to sign a piece of paper, but there's something about being informed about what's happening to your body, you do feel like that gives you more sense of control” (P8). Several of the mothers were separated from their newborn at birth, adding to the trauma of the birthing experience. When this separation occurred, perinatal nurses often communicated effectively through providing frequent updates to mothers regarding their newborns’ care and status when the mother could not be present with the newborn. A participant described this experience as: “The nurse was very actively checking over and sort of updating me on what was happening because [my husband] was over with [my baby], with those nurses. And so, yeah, so that was super helpful that she like just proactively gave me updates and was like, okay, they're like doing this, they're doing this, she's doing well” (P7). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 92 In these moments, the nurses were trusted sources of assurance and information about the newborns’ wellbeing, allowing mothers to rest and recover knowing their babies were in trusted hands. Effective communication was not only important between the perinatal nurse and mothers, but within the entire healthcare team. Mothers who sensed trusting collaboration and consistency between members of the healthcare team, seen through effective communication between the nurse and obstetrician, midwife, or other nurses, experienced increased trust in their nursing team. One participant described her experience with nurses and the obstetrician during her time in triage as follows: “There was really good communication, which made me feel more trust in the nurses, that they knew they could go to the doctor… [the obstetrician’s] teamwork with the nurses made me feel better, because I know that they like her, they respect her, that she respects them” (P3). Similarly, another mother observed this communication within the nurse-midwife relationship, saying, “if we're talking about trust and relationships, it was nice to see that the nurse and the midwife were always on the same team in front of me” (P8). Three of the participants also recalled their nurse requesting second opinions, either from another nurse or a physician. This communicative display of humility and a desire to ensure safe care enabled the development of mothers’ trust in their perinatal nurses. Overall, the nurses’ ability to communicate effectively with mothers and healthcare team members increased mothers’ trust in perinatal nurses’ competence and commitment to the inclusion of mothers in their care and the dyad’s well-being. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 93 Supporting the Mother’s Birth Plan In addition to the nurses’ abilities to communicate effectively in the perinatal process, trust was built within in the nurse-mother relationship when mothers felt supported in their birth plans and preferences. This commitment was shown through compassionate listening and response to mothers’ preferences, advocacy within the healthcare team of mothers’ preferences, the perinatal nurses’ competence which supported mothers’ birth plans, and a pursuit and celebration of progress in the perinatal experience. All participants shared moments when the nurse listened and acknowledged their birth plans and worries about the implications of their choices, which made them feel that their birth plan was considered and supported, even if not all went as planned. Mothers expressed trust was established when nurses listened to and encouraged them in their desires and requests regarding pain management and newborn feeding preferences. Nurses who provided effective pain management during labour and postpartum were deemed as trustworthy as mothers sensed the nurses’ desire for comfort and relief within their birth plans. Pain management was a key part of mothers’ birth plans, and significant pain, and ineffective pain management were identified as contributors to mothers’ experiences of trauma during childbirth. Thus, the pharmaceutical analgesics given in labour not only provided pain relief, but acted as a catalyst of trust in the nurse-mother relationship: “She gave me the shot of morphine. And so, immediately I was like oh, you're the lady with the drugs. You're the one who I want taking care of me. So, in that moment, that was my first meeting of her. She definitely had my trust because she brought me morphine” (P6). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 94 Following a break in trust with her nurse, due to the perinatal nurse’s harsh communication style, another mother described the rebuilding of trust as conditional to her receiving the relief from her epidural: “I honestly think that if I still felt shitty, I think if I wouldn't have gotten the epidural and I wasn't having pain medication, I actually feel like it would be harder to rebuild the trust” (P5). For this mother, the pain medication she had requested and received allowed her to be present and feel well enough to begin to regain trust in her nurse. The meaning of this pain relief was that the nurses were compassionately listening and responding to the mothers’ desire for pharmaceutical intervention. Trust was further strengthened when nurses advocated for the mothers’ birth plans within the healthcare team. Nurses found tangible ways to make mothers’ preferences for care known, which facilitated trust-building. One nurse made sure to write the mother’s goals of care on the white board in the room so the entire care team would have a clear understanding of the birth plan. Shift handover at the bedside proved to build trust in that mothers were able to see and hear their preferences being communicated to the oncoming nurse. To know that the primary nurse was aware and receptive to mothers’ birthing preferences was one thing, but to have those needs be handed over to the oncoming nurse built mothers’ confidence that the entire team would support them and their plans. This advocacy between nurses included end-of-shift report and collaboration with the interdisciplinary members. Having received report from the outgoing nurse, a primary nurse approached the anesthesiologist in front of the labouring mother and said “the night nurse has told me this lady has been in a lot of pain… what we’ve done is not enough. You have to up the [epidural] dosage” (P2). The mother did not have to use her voice amidst a painful experience; she could trust that the nurses were advocating on behalf of her birth plan MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 95 regarding pain management. Nurses who provided this commitment to mothers’ birth plans within transfers of care were described as “a medium in between me and other people and everybody else in the room” (P5), which built mothers’ trust in nurses as they were confident that their birth plans were valued, communicated, and considered. A celebration of mothers’ birth plans, experiences, and progress developed trust through the affirmation of mothers’ choices for their birth and their newborn, knowing the nurse trusted and supported them. A mother who had delivered her first child by caesarean section voiced her desire to have a vaginal birth for her second. She shared, "the nurses were very supportive, and they said “Yeah, let’s go ahead and let’s try it and let’s see what happens”… they were allowing me to progress, and they were excited and encouraging me too” (P2). Other mothers recalled moments of celebration from their nurse that stood out amidst their TCE, such as, “she told me I was going to be the best mom” (P5). This affirmation of her progression and motherhood, amidst the support of her birth plan, was incredibly memorable, and the mother became quite emotional at this time in the interview. Following newborn feeding difficulties and a lack of support from some postpartum nurses, another mother was overwhelmed with the support and excitement she received from her nurse when they made progress with the feeding plan: “she was clapping, she was so excited that this was working, and she was just so thrilled for us that this is how we wanted to feed, that this was happening for us” (P4). To celebrate mothers’ progress instilled a sense of empowerment, a belief in their bodies and motherhood, and encouraged them to keep going. This confidence built trust, not only in the nurse, but in mothers and their abilities to birth and care for their newborns. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 96 Similarly, nurses who took steps to help labour progress and assisted in the establishment of newborn feeding fostered trust in the nurse-mother relationship. An important contributor to developing trust was that progress was subjective to mothers’ expectations of their birth, not the perinatal nurses’ expectations, hospital policies, or protocols. One mother who endured labour for many hours with minimal progress expressed trust in the nurse who entered the room and immediately changed her labour position in an attempt to shift the fetus’ position and encourage active labor. In comparison to the prior nurse, the mother sensed the desire and the expertise to pursue a vaginal birth, which the mother had hoped for, and said, “I had more trust in her in that moment that she was looking to actually move this along” (P6). Another crucial aspect of maintaining trust was how the nurse responded to and supported mothers during deviations from the birth plan, reflecting the nurses’ competence. When complications or challenging moments arose in the perinatal experience, mothers looked to their nurse for support and confident reassurance. From the hospital bed, mothers witnessed nurses’ quiet, yet assertive, competence as they prepared the room for delivery, assisted in decision-making with the healthcare team on behalf of mothers, and took initiative in mothers’ care. “Calm” and “collected” were words used to describe the competent nurses that mothers experienced trust with when mothers birth plans deviated unexpectedly. Surprised by her ability to trust her nurse during unforeseen interventions, without the presence of a physician, one mother said: “I didn't think I'd be able to trust a nurse and start, you know, delivering, start pushing, to give birth to a baby. But the way that the nurse looked so prepared, she had everything ready. If the baby came out right there in that room, she had a, you MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 97 know, a thing prepared for to receive the baby. She had all the instruments laid out, you know, to support the baby. She knew what she was doing, and she had full confidence. That really built my trust” (P2). The exude of confidence from the perinatal nurses was contagious, leading to an increase in mothers’ self-confidence, and feeling supported despite birth plans not unfolding as planned. At times, the confidence was transferred through words: “she told me that I could do it, and so I believed that I could do it” (P5). For another mother, the confidence did not need to be said, it was solely known: “she created this environment that was calm, that made you believe you could do it…she made me feel like I had a little bit more to give, to keep going” (P7). In the presence of a calm and confident nurse, mothers felt supported during unanticipated events, and trust in nurses’ competence was developed. Mothers had a baseline level of trust in nurses due to their respect and confidence in the nurses’ established profession and expertise. Importantly, a deeper level of trust was built through the establishment of nurse-mother relationships. Within nurse-mother relationships, the nurses’ words and actions fostered or maintained trust, including enacting a caring presence, communicating effectively, acknowledging and recognizing the humanity of mothers and the trauma they have experienced, and supporting mothers’ birth plans. Barriers to Developing and Maintaining Trust Amidst a Traumatic Childbirth Mothers shared experiences in which trust with nurses was difficult to develop or maintain amidst a TCE, which revealed barriers and undermining factors to the establishment and maintenance of trust. At times, structural factors such as workload and transfer of care processes limited the quality of nursing care that was possible, preventing trust from being established or fracturing established trust between mothers and nurses. Nurses’ words and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 98 actions could break or inhibit the development of trust and leave mothers feeling unseen, unsupported, alone, and unsafe. These words and actions enacted by nurses included mothers feeling abandoned following delivery, unsupportive communication styles, a lack of collaboration with mothers, and lack of expertise. Structural Factors Shaping Perinatal Nursing Care Mothers identified several structural factors that impacted and shaped how perinatal nursing care unfolded and created barriers in the development of trust. Structural factors included inadequate and inconsistent nurse-mother assignments and rushed or ineffective care processes. When structures (e.g., heavy workload, models of care, short-staffed units) shaped nursing assignments to be too large or inconsistent, mothers were not given the time needed to develop trusting relationships with their nurse. The constant turnover of nurses and the limited staffing was noticed by the mothers. In one hospital, a mothers shared: “I think the difficulty is there were so many nurses coming and going but then we probably saw 5-6 other nurses just in that 48-hour time period… So, if you don't have someone consistent, then that makes it pretty tough” (P4). In another scenario, it seemed as though there were not enough nurses to safely care for the patients in a rural hospital. The mother who delivered at this hospital noticed “there was like one nurse on. I'm just like, that's not right. I know that [the hospital] is less beds and stuff like that, but that shouldn't be the case really that like there was like one nurse?” (P5). In both scenarios described above, mothers did not have the time or sufficient number of interactions needed to build trust due to frequent nurse turnover and unmanageable workload assignments. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 99 During or following a TCE, trust was broken when mothers sensed care processes, such as discharge or transfers of care, were rushed or inefficient. The lack of clear and efficient care processes (e.g., guidelines, roles) impacted nurses’ abilities to keep mothers comfortable and informed, resulting in a lack of trust. In one instance, a mother waited without pain management in triage for two hours, then the nurses rushed to prepare to admit her to the unit, hastily placing an intravenous line in. The mother questioned the sudden rush and attributed it to ineffective staffing: “I had been there for two hours, and I was just like, why is this now all of a sudden scrambling to do this?” (P1), ensuing an unnecessary sense of panic that prevented this mother from placing her trust in the nurses. Mothers were not always informed of their care transfer between nurses: “Where is the other lady?”, one mother asked. “Like she's just gone. Right. And so, I didn't know if there was a transfer of care” (P3). Such situations could result in nurses not being informed of mothers’ TCE, and therefore, unaware of mothers’ traumatic experiences. This lack of handover prevented nurses from acknowledging the mothers’ humanity and providing the needed supports, which ultimately thwarted mothers from placing trust in nurses. For one mother, this acknowledgement was lost in the transfer of care, as the one nurse who knew what she really went through was gone: “I don't know how well versed they were, and like everything else that had happened.” (P7). Insensitive standardized care was noted by a mother who experienced the nurses’ care processes as a “cookie cutter approach to everyone” (P4), created by the uncritical application of guidelines. This type of approach was a barrier to the development of trust because nurses neglected the personal and subjective piece of nursing care and did not recognize mothers’ humanity amidst a TCE. For another mother, after she was informed that MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 100 she would be staying one more night, a nurse came to alert the mother that she needed to be discharged as soon as possible as per the unit’s administration. The mother recalled “she was kind of rushing us and she was like, ‘No, you are actually supposed to go’” (P2). The mother felt betrayed, confused, and hurried out when she was not prepared. These processes, structures, and guidelines in place for nursing care and hospital discharges limited the opportunity for mothers to develop trusting relationships with nurses amidst a TCE. Feeling Unseen or Insignificant Amidst and Following TCEs When the perinatal nurses’ words and actions made mothers feel alone or dehumanized, treated her as an annoyance, or mistrusted or invalidated her experience, the development of trust was hindered or broken. Mothers’ trust in nurses could be broken or inhibited when mothers sensed that the nurse stepped back or abandoned them in times of intensity and trauma during the birthing experience. After an emergency caesarean birth and postpartum hemorrhage, unable to mobilize independently, one mother recalled a lack of nursing support during the initial hours of motherhood, sharing: “in the first night when I was just like, really needing a lot of help. And they just like, weren't there” (P1). Her preconceived expectations of support from nurses during that time did not match with the care that she received, resulting in hindered trust in the nurse-mother relationship. During labour, a perinatal nurse was noticed to be falling asleep at the mother’s bedside, leaving the mother to feel disregarded: “there's not very many times like a mother feels very cared for. So, for you to be nodding off beside me, it felt just kind of like what?” (P8). When receiving an epidural, another mother spoke to a break in trust related to an absence of a supportive perinatal nurse: MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 101 “Part of the reason why the epidural was so traumatic for me was because I felt my nurses step back…this was the only moment that I really didn't appreciate for my nurse, and I really wasn't trusting her. The mood had shifted, and I was like, oh, this is really serious” (P5). For this mother, pre-existing trust in her nurse was broken when she sensed the nurse’s commitment to her was conditional, dependent on the environment and personnel, such as the anesthesiologist, in the room. The same mother shared that following her TCE, she experienced abandonment when her nurse’s shift ended: “My awesome nurse was just gone, and she didn't say bye to me … I felt abandoned… considering everything and how scary it was, and then I felt like I really have someone in my corner. And then I was like, shit, I don't have anyone in my corner” (P5). To mothers, perinatal nurses were expected to be a safety net and a source of support in the transition to motherhood. When these expectations were not fulfilled and mothers were left alone to experience and process the trauma of their births, they were unable to develop or maintain trust with the nurses because they felt as though they were abandoned. At times, the nurses’ attitudes and behaviors suggested to mothers that they were a bother or an unnecessary addition to the nurses’ workload. Nurses’ negatively perceived attitudes and behaviours impeded mothers’ development of trust in them because mothers questioned the authenticity of the nurses’ caring nature and commitment. On recurrent visits to the maternity triage due to intolerable and untreated pain, one mother sensed she was an inconvenience to the nurses: “I felt like they were like, wow, this girl again. Like, I can't believe she came back, and I was embarrassed to be honest” (P1). In this moment, the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 102 mother was unable to develop trust due to a sense of insecurity from the nurses’ demeanor. For other mothers, the dismissal occurred during the postpartum stage, feeling rushed out of the hospital by the perinatal nurses. One mother expressed, “it felt like she was trying to get us to leave” (P2) when an oncoming nurse informed her and her husband that they needed to be discharged immediately, after being told they would be staying another evening. Similarly, another mother recalled difficulty building trust with her nurses because “every other one of them said it seemed really grumpy and really like we wanna get you out of here” (P3). Mothers were in tune to their nurses’ negative attitudes, or lack of compassion, leading to them to sense that they were a bother, creating a barrier to the development of trust within the nurse-mother relationship. Further, when mothers’ physical and emotional experiences were dismissed by the perinatal nurse, reciprocal trust was missing from the nurse-mother relationship because mothers did not feel as though nurses trusted them. Mothers recalled this mistrust from their nurses in moments of intense pain, during and following epidural insertions, and the transition to motherhood. Despite yelling out in intolerable pain, a mother described how her triage nurses “were fairly dismissive of my pain” (P1), leaving her to manage her contractions without any comfort measures or analgesics. Later, the nurses acknowledged her pain only after confirming the frequency and intensity of contractions with the objective data from the monitor. “Finally, she and another nurse took me super seriously, was noticing she's hooked me up. She's like, wow, you're actually having contractions…you're not having a break. She's like ‘you are having only about 5 second breaks between your contractions’” (P1). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 103 When nurses trusted the seemingly objective data over mothers’ experiences, trust in the nurse could not be developed. Epidural complications were notable contributors to mothers’ trauma during childbirth experiences and were also moments in which trust was broken. When assessing the effectiveness of the epidural, a mother was firmly asked to describe her contractions as pain or pressure, sharing: “I don't know how to explain this to you, but I was like it hurt like to me, it was pain to me. It was pain and the nurse was kind of yelling at me… And then and then you know what? I wanted her to stop. So, I said it's pressure. It's pressure. It's pressure. I actually just lied, which really scares me…don't even wanna look into what could happen if that goes wrong” (P5) The nurses’ mistrust in this mother’s expression of pain led to a sense of fear and a lack of safety, resulting in an inaccurate expression of her experience and an increased potential for interventional consequences. During an emergency caesarean birth of another mother, the numbness of the spinal anesthetics reached the mother’s chest, leaving her to feel panicked and breathless. Mustering all the breath she could, she whispered “I can’t breathe” again and again, only for someone to look at her and say “you’re fine. Just take a breath” (P6). At times, mothers’ voiced experiences and concerns were dismissed, hindering the development of trust with the nurses. In summary, mothers who felt perinatal nurses did not listen to their voiced concerns, but rather dismissed or mistrusted their experiences, had difficulty developing trust: “I did not trust that nurse at all because that nurse did not trust me” (P5). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 104 Unsupportive and Harmful Communication Styles Another way in which nurses’ actions and words broke or hindered the development of trust with mothers was through harmful, unprofessional, or impersonal communication. Blunt or aggressive communication from the nurses was damaging to mothers’ experiences of trust, especially during times of vulnerability. When an epidural insertion was complicated by a sudden decrease in blood pressure, the mother vividly remembered her nurse yelling at her “Is it pain or pressure?” before she lost consciousness. The aggression in this interaction scared the mother and created an unsafe environment in which she felt alone, “I needed them to stop like yelling at me… it was just yelling that at one point that that I felt like, oh, I can't trust anyone” (P5). After previously developing trust with this nurse, the yelling was enough to break trust with that nurse as she no longer felt that her nurse was on her side. It seemed as though the safe and trusting nurse was now against her. The majority of unsupportive communication occurred following a TCE, when mothers were already experiencing emotional and physical fragility. During the recovery and postpartum period, one mother described her nurses’ communication as “blunt, a little bit less supportive… these were the nurses I actually despised. They were really rude” (P3). Nurses gossiping was also observed by the mothers, “they were like they were also like trash talking like, not patients. But just like gossiping at the desk” (P3). Mothers found it difficult to develop trust with these nurses due to an uninviting environment built by yelling, rudeness, and gossip. In addition to the curt communication from the nurses, judgemental and shaming comments by nurses to mothers following a TCE inhibited the development of trust because such comments made mothers feel insecure and inadequate to care for their newborns. A MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 105 first-time mother recalled her nurse responding to her questions in a demeaning manner: “she was really sarcastic. She was really harsh. I kind of wanted to be like lady, this is my first time. I don't know. She just kind of would give really smart answers …like I should know” (P6). A multiparous mother reflected on how her nurse’s communication surrounding feeding would have impacted her as a first-time mother when the nurse instilled a sense of judgement and panic, offering formula following ten hours of no breastfeeding: “I often think in my story if I was a first-time mom that would have been really horrible to hear, not questions or information about feeding. Just like, ‘Have you been giving formula? It's been ten hours’” (P8). This nurse’s seemingly judgemental and insensitive approach, as demonstrated through shaming and disregard for the mother’s feeding preferences, thwarted the development of trust. Another mother experienced her nurse’s communication as indicative of her inability to care for her newborn: “She saw [my baby] crying and she was like, “Well, you know, we can take him for the night if you want and we can take care of him”. So, to us, we interpreted that as we are failures. We can't even parent two nights in, so we don't know what to do with our child” (P5). Although it was unclear whether the nurse meant to shame the mother or imply that she was incapable of caring for her newborn, this way of communication, which was insensitive to the needs and emotions of the mother, presented a barrier the development of trust. Some mothers noted that trust was thwarted when nurses communicated poorly or prioritized their tasks over the mothers’ emotional needs. Characteristics such as “quick” and “efficient” (P2) were used to describe postpartum nurses who mothers did not experience trust with: “they came in and they did what they had to do and left. And I guess that's what MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 106 they did that I think broke trust… they didn't seem like they cared at all” (P3). These nurses approached perinatal care with a task-oriented mindset and neglected to communicate with mothers and their families on a personal level and offer emotional support, acknowledging their humanity. A mother reflected on this approach as such: “I guess when you're feeling really stressed out about things, you kind of hope that you feel a little bit more, I don't know, not supported, they were supportive in their job, but I guess emotionally supportive” (P3). When nurses communicated with mothers in an unsupportive and judgemental manner, lacking emotional support, the development and maintenance of trust was hindered. Following a TCE, when mothers were in a fragile and vulnerable state, difficulty developing trust was attributed to a lack of compassionate communication as one mother shared, “I just felt like I needed more kindness in that moment and didn't feel like I got it” (P5). Lack of Collaboration and Partnership in the Birthing Experience Mothers found it difficult to develop trust when they did not feel they were included as active participants in their traumatic birth experience. Mothers and nurses’ experiences became separated, and relationships were not established when nurses did not collaborate with mothers to provide safe care. This was a barrier to the development and maintenance of trust. One way in which mothers felt a lack of collaboration was through inconsistent and inadequate information about perinatal procedures and care from nurses. Following delivery, one mother was left to clean up her own blood after her nurse did not inform her of what to expect regarding postpartum bleeding. “The nurse that was watching me when I was in recovery, didn’t realize that the labor and delivery nurse didn’t talk me through things, … what you can expect and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 107 all that kind of stuff, and so that was just absolutely terrifying because it was like, I mean, I just think of the movie, There Will be Blood” (P6). Ineffective transfers of care between perinatal nurses resulted in lack of collaboration and partnership with mothers, resulting in mothers not receiving required information, and left to maneuver through the recovery phase on their own. When there were inconsistencies between the nurses’ teaching, the confusion led to a mistrust in information: “Again, it was a very mixed information that was given to us. There was one nurse that said the baby does not need to bathe at all for like the first week and then there was another nurse which said the previous nurse should have done it on her shift. Why is the baby not washed yet? And we're like, we don't know. I don't know” (P2). Inconsistencies not only occurred between nurses, but within minutes of each other from the same nurse. Eager to leave the hospital, one mother recalled her nurse providing and then retracting permission for the dyad to be discharged home. She shared, “I was already so stressed out …and she came in. She was like, “Yeah, you can go”. I got dressed and she came back, and she was like, “I'm sorry, I'm wrong. You can't go. I rethought about it”. I bawled” (P8). This inconsistent messaging from the nurses caused a sense of uncertainty in the mother, which broke the mother’s trust in the nurse’s words and her assessment of the dyad. Similarly, when mothers were not informed about complications or interventions, trust was broken or inhibited. After reflecting on her TCE, one mother expressed a wish that her healthcare team would have guided her more directly towards a caesarean birth initially: “I said, look, if natural is not a plan for me, you need to tell me. But nobody told me that I should not choose that because it's not safe for me or whatnot until the end” (P2). During MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 108 labour, another mother observed conversations between the nurse and the physician regarding her plan of care without including the mother, yet the plan of care was being implemented directly in front of her. Despite the close proximity of the nurse, the mother felt an incredible distance, “she was with us for her full 12-hour shift and just didn't keep me in the loop even though she was four feet away” (P6). She elaborated: “She was starting to question my charts but wasn't really telling me what was going on and she kind of thought like, “Huh, this is weird. I don't really know what this means”, and that's when I started to question like okay, so now what? And so, she was bringing in the doctor and they talk. I'm just sitting there and they're not really explaining anything to me. And I just want to be kept in the know, that's really it” (P6). Nurses’ lack of collaboration with mothers extended to the postpartum period, immediately after delivery for one mother whose newborn was taken away for additional support: “there are little parts of that that I didn't feel great about, like the nurse was like, “Hey, I'm just taking the baby and she's gonna go see a pediatrician”. And I was like, without me? Like what?” (P3). Being uninformed regarding her and her newborn’s well-being, and why her newborn was being taken from her, inhibited trust due to a lack of information and inclusion in the perinatal care. Some mothers recalled that their nurses did not acknowledge the inherent expertise they held of their own bodies and of what it needed during the birthing and postpartum periods. This undermined nurse-mother collaboration and led to mothers to mistrust their nurse. Mothers then felt isolated in their self-advocacy for pain management and newborn feeding in an already foreign and intimidating postpartum environment. One mother shared, MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 109 “I felt like I had to strongly advocate for [myself in] the postpartum area” (P3). Instead of fostering a collaborative partnership with this mother by inquiring about and supporting her feeding preferences, the nurse took an authoritative role in the nurse-mother relationship. The mother saw this interaction as the nurse saying: “We're the experts here, we’ll check you and baby” (P3). Another mother, who had participated in preparation for childbirth by attending breastfeeding seminars experienced resistance when sharing her learned knowledge with the nurse: “We had learned like a whole bunch of different tips and tricks for breastfeeding, especially when things aren't going well. There's like the supplemental feeding system where you have a tube and you put that in formula and then the baby can like breastfeed, but they're getting formula… I just felt like really like I wasn't heard and that she didn't take me seriously… It didn't necessarily feel like my wishes were as respected as they could have been” (P4). Another mother, who was also a nurse, had similar feelings in that her persistent selfadvocacy was necessary in her receiving effective pain management. She said, “I felt like I had to be very like pushing for my own self, my own pain management a little bit, instead of her just trying to offer me a few things” (P1). In these moments, trust was broken due to the disregard for mothers’ experiences, expertise, and preferences, leaving mothers without the support, care, and treatments that only the nurse could provide. During moments of vulnerability and uncertainty in the perinatal experience, mothers valued the inclusion of their partner in collaborative care and shared decision-making. Mothers described moments during the TCE when their partner was excluded from the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 110 decision making and care planning. Mothers’ trust in perinatal nurses was broken when they sensed their partners were dismissed and not included in the birthing process. While one mother laid scared on the operating room table in an emergency caesarean section, her husband was left waiting, infrequently informed by the nurses regarding his wife’s and newborn’s status: “My husband was outside in the OR waiting to come in, and they're just like, “Hey, so there were complications. You can't come in. Go out to the hallway.” They push him out to the hallway waiting area and didn't really tell him what was going on other than you can't come in” (P6). Recalling her husband’s experience reminded this mother of how important it was for nurses to include mothers’ partners in the child birthing process and nursing care as a means to foster trust in the nursing team. When this did not occur, trust was difficult to maintain with her nurses: “Just to know that he is just kind of another object in the room, even though it was still his, is still his baby. This is still affecting him. The person he loves. But yeah, he was just like another piece of furniture in the room. He had to pack up the bed thing at four in the morning to sit in a chair for five hours and not do anything… He was fantastic to have there, but he would have at least had the tools because he knows me…the tools to just keep me reassured throughout” (P6). When mothers’ partners were neglected and not included in the birthing process, they were not able to support mothers during a time of great fragility. This resulted in mothers’ mistrust towards nurses. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 111 Questioning of the Perinatal Nurse’s Expertise Mothers’ expectations of nurses’ competence and expertise provided the development of a basic level of trust in the nurse-mother relationship, but this foundational trust could be disrupted during TCEs. When nurses displayed a lack of confidence in their assessments and interventions, mothers questioned the nurses’ expertise, and in turn their own and their newborn’s safety. Doubt in the nurses’ competence arose during various stages of the childbirth experience, leading to the shared question of, “if she didn't know about this, then what else does she not know about?” (P4). Such questions and doubt regarding nurses’ abilities and expertise resulted in mothers’ mistrust towards nurses. In triage, one mother felt she could not trust the nurse who had difficulty removing a vaginal insert from her induction: “she tried herself to take the Cervidil out, but it was very far up, and she couldn't do it” (P1). Another mother panicked during a fetal heartbeat assessment, sharing, “I had a couple times where nurses couldn't find the heartbeat and so that really made me very scared like and when you talk about trust like I was like not trusting” (P5). Later, when a senior nurse, with implied competence, finally found the heartbeat, she felt relief and trust in that nurse. For these mothers, their first interaction with the nurse was that of perceived incompetence, inhibiting trust in the nurse-mother relationship. During labour, mothers felt their nurses were incompetent when they showed uncertainty in their assessment findings. An example of this was when a nurse was determining the position of the fetus: “at this point they were still really unsure which way she was facing. The nurse was kind of like, ‘Oh, I don't know, maybe it's this’” (P1). Another nurse exhibited confusion when interpreting progress in labour, requesting the physician’s and another nurse’s insight on the fetal heart monitoring and vaginal exams. She shared: MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 112 “Every single time she'd read the chart, she'd bring in someone else to review it. And every time they would check me as well, how far I was progressing, both her and the doctor would not completely confidently say how far along I was” (P6). When asked if this impacted her trust in her nurse, she expressed a loss of trust in that nurse, saying, “Definitely, because it started out strong, but it's really tapered out throughout that shift because she constantly needed second opinions” (P6). This same lack of confidence was felt in student nurses when they did not exude confidence in their answers to mothers’ questions or in reaffirming mothers that labour was progressing well. Trust was lost, or was unable to be built, when mothers perceived their nurses lacked expertise or confidence in their assessment skills. Mothers also recalled trust was inhibited when they noticed varying approaches to care among the nurses. Inconsistent methods of care caused mothers to question which nurse they should trust or led to a mistrust in the nurses altogether. A primiparous mother, during her extensive labour, shared her encounter with an oncoming nurse: “They came in and she was like “Why are you on your back?” I don't know. I don't know why I am on my back. That was one of the first things she asked me… that was a little bit of a like a flag that raised. Why are you asking me this?... It's just odd to me that two people in the same unit could have completely different views on how I should be laboring” (P6). This confusion was shared by a postpartum mother whose oncoming nurse questioned the previous nurse’s feeding approach: “The second night for one of the nurses to come in to be like “Why have they not brought a breast pump like a breast pump into like help you stimulate”… even when MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 113 she came in with the breast pump, I was like, Oh my God, like, I didn't know I supposed to be doing this” (P3). Inconsistent approaches to labour and feeding resulted in mothers experiencing confusion, embarrassment, and discouragement, questioning whether progress would have been possible had there been consistency in care. It was difficult for mothers to develop trust in nurses who did not demonstrate expertise and who contradicted one another. Chapter Summary Data from mothers’ interviews were rich and elucidated how trust developed in the nurse-mother relationship amidst TCEs. Thematic analysis of mothers’ experiences revealed an overarching theme, three main themes, and associated sub-themes about trust-building. The overarching theme spoke to the importance of trust between nurses and mothers as they partnered together during the storm of a traumatic birth. The shelter of trust was possible through the development of nurse-mother relationships and the maintenance and strengthening of trust throughout the birthing experience. Trust served as a protection to mothers knowing they were supported, were not alone, and that they were a valued participant in their delivery, despite the unfortunate circumstances of the TCE. The trajectory of trust was shown to be fragile amidst traumatic experiences, yet trust could also be rebuilt when broken. Mothers’ past experiences in healthcare, their personal connections and expectations of the labour experience, and their definition of trust made up the foundation of trust they entered the birthing process with. From this foundation, the perinatal nurses’ words and actions could develop, maintain, or break trust. For trust to be developed, a level of relationship needed to exist, to build trust amidst a TCE. When this relationship was formed, nurses’ developed trust with mothers through a caring presence, MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 114 effective communication, a trauma-responsive approach to care, and competently supporting mothers’ birth plans. While trust could be formed, it could also be broken. Moments of mistrust were expressed by mothers when they were impacted negatively by the structural processes of the perinatal unit, felt unseen, experienced unsupportive communication, sensed a lack of collaboration, and questioned the nurses’ expertise. The following chapter discusses these themes further, how they answer the research questions, and their contribution to existing literature. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 115 Chapter Five: Discussion Mothers’ perspectives on the experience of developing trust with perinatal nurses amidst a TCE were raw, emotional, and enlightening. The purpose of this study was to explore experiences of trust and mistrust between mothers with a TCE and perinatal nurses on maternal-child hospital units within Canada. Through the analytic process, it became evident that each mother’s experience and trajectory of trust amid a TCE was unique, yet there were common threads of trust-facilitating and trust-limiting factors in the perinatal nursing area. As defined by Leinweber et al. (2022), traumatic childbirth is “a [mother’s] experience of interactions and/or events directly related to childbirth that caused overwhelming distressing emotions and reactions; leading to short and/ or long-term negative impacts on a woman’s health and wellbeing” (p. 691). Mothers’ vivid descriptions of their trauma in this study reflected Leinweber et al.’s (2022) emphasis on the subjectivity of traumatic childbirth and provided insights into the development of trust between mothers and perinatal nurses within this tumultuous context. The knowledge gap identified in the Chapter Two literature review was that little is known about the development of trust within perinatal nurse-mother relationships specific to those mothers who have experienced traumatic childbirth. My study findings from this study address this gap and have important implications for nursing practice, as at least one-third of mothers have reported experiencing childbirth as traumatic, and it is estimated that the actual percentage is even higher (Baptie et al., 2021; Koster et al., 2020; Türkmen et al., 2020). TCEs have negative impacts on mothers, their newborns, and their families (Elmir et al., 2010; Fenech & Thomson, 2014; Simpson & Catling, 2016; Soet et al., 2003). Trusting relationships with nurses hold potential to buffer mothers and their newborns from the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 116 trauma of TCEs (Baptie et al., 2021). Therefore, this research that aimed at understanding how nurses can establish trusting relationships with mothers is of great value to perinatal nurses. My findings offer hope to perinatal nurses in building, maintaining, and reclaiming trust with mothers amidst traumatic childbirth so that their relationships can become a shelter in the storm. Thorne (2016) described a study’s discussion section as an “opportunity to reflect differently on your findings and understand them in other ways” (p. 217), highlighting key findings and applying them to existing literature. Thus, this discussion will further explore the main themes of the research findings and situate them within previous knowledge, drawing mainly on the literature described in Chapter Two. In this chapter, trust will be discussed in the perinatal nurse-mother relationship as Possible, Dependent, and Necessary amidst TCEs. These explorations of trust reflect on the main study themes of The Foundations and Fluid Trajectories of Trust (trust is possible and necessary), Development and Maintenance of Trust (trust is dependent), and Barriers to the Development of Trust (trust is dependent) with the additional frameworks of relationship-centred care (RCC), respectful maternity care (RMC) as lenses through which to view the findings. The overarching theme of a Shelter in the Storm (trust is necessary and possible) will be discussed throughout the chapter, highlighting the importance of trusting relationships in protecting mothers during and following a TCE. Trust Amidst Traumatic Childbirth is Possible: The Fluidity of Trust Explored This section discusses the hope and possibility of trust amidst traumatic childbirth, because of and despite heightened responses to nursing care during traumatic events. The fluidity of trust, as introduced in my findings, reflects Goldberg’s (2004) claim that trust in MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 117 perinatal nurses is something that can be lost but also something which can be reclaimed even amidst a TCE. Nurses may not be able to eliminate all contributing factors of trauma yet can still pursue trust and the positive impacts of it in the nurse-mother relationship. The following section will further discuss the Foundations and Fluid Trajectories of Trust as hopeful for perinatal nurses in developing trust amidst TCEs, while cautioning against the risk of broken trust in the same circumstances. Heightened Sensitivity in a Traumatic Transition to Motherhood The findings of this study elucidated the fluidity of perinatal nurse-mother trust amidst TCEs and how it rarely followed a steady or predictable trajectory. In childbirth, mothers’ definitions and expectations of trust, combined with the various interactions, ways of care, and relational capacities of perinatal nurses, demonstrated mothers’ experiences of trust as fluid, impressionable to the impacts of traumatic childbirth. Childbirth, in and of itself, involves heightened sensitivities (Hwang et al., 2022). Traumatic events in the childbirth experience add an additional layer of vulnerability and intensity to the mothers’ already heightened sensitivity. Trauma is known to cause major stress, overloading the nervous system, and causing heightened sensitivity and emotions (Amstadter & Vernon, 2008). Trauma-related literature has discussed peritraumatic emotions, those experienced during or following a traumatic event, as negative (e.g., fear, sadness, anger) (Amstadter & Vernon, 2008). Nevertheless, heightened sensitivity does not necessarily predict the trajectory of trust in the nurse-mother relationship. Findings in my study revealed that mothers may experience heightened negative responses to nurses’ ineffective provision of care due to the intensity and vulnerability of trauma. This intense emotional response to trauma was also found in Amstadter and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 118 Vernon’s (2008) quantitative study on peri-traumatic responses. An example of this in my findings was a mother’s recollection of her nurse assessing her epidural efficacy by yelling at her to determine whether she felt pain or pressure. Following her delivery, her partner reassured her that although the nurse spoke firmly, he did not recall yelling, suggesting the mother’s heightened response amidst a traumatic event. My study adds to Amstadter and Vernon’s (2008) findings, that mothers can experience not only negative heightened responses but also positive ones in response to perinatal nurses’ words and actions during a TCE. The wide spectrum of mothers’ emotional responses to their TCE, as seen in my findings, is consistent with the fluidity of trust, highlighting the heightened impact of perinatal nurses’ words and actions on trauma and the experience of trust. For example, what could be perceived as a micro moment of trust in my findings, such as a nurse cleaning up a mothers’ blood following delivery, significantly heightened the mother’s positive perception of her experience and the trust in her nurse. Overall, my findings regarding the possibility of trust amidst a heightened sensitivity during a TCE both confirm and add to what is known about the fluid trajectories of trust in the nurse-mother relationship. My findings evoke both caution about mothers’ possible negative responses to nursing care during TCEs and hope of rebuilding trust during nursing care moments marked by mothers’ heightened responses. Hope and Possibility for Rebuilding Trust Amidst Traumatic Childbirth The hope and possibility for rebuilding trust presented in my findings are an encouragement to both mothers and nurses partnering in relationship amidst TCEs. Goldberg (2004) reported that reclaiming of trust within the perinatal nurse-mother relationship was important. Similarly, this importance of reclaimed trust was revealed in my findings specific MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 119 to trust amid TCEs, advancing understandings of how this reclamation can also occur with those who have experienced traumatic childbirth. Some of my findings highlighted how the rebuilding of trust happened within moments of the break in trust. An example of this in my findings was a mother’s experience of reclaimed trust in perinatal nurses when following hours of little labour progress and ineffective pain management, a new nurse began care for her who demonstrated competence and a desire to move labour along. For some multiparous women with previous traumatic births, a reclaiming of trust became possible much later, during the traumatic birth of her second child. These findings were also consistent with Goldberg’s (2004) discussion of the potential for reclaimed trust following mothers’ negative experiences with nurses in the perinatal setting. Therefore, regardless of previous or present difficulties developing trust, each interaction amidst a TCE offers the possibility for trust to be built, maintained, or reclaimed. Trust Amidst Traumatic Childbirth is Dependent: Facilitators and Barriers of Trust Mothers’ experiences of developing trust were clearly dependent on nurses’ words and actions, which is a finding supported by other researchers (Chunuan, 2002; Cricco-Lizza, 2006; Dalton et al., 2021; Fleming et al., 2011; Goldberg, 2004; Goldberg, 2008; Murphy et al., 2022; Othman et al., 2020; Renbarger et al., 2020; Sapkota et al., 2014). Trust, or the lack thereof, was found to be dependent on nurses’ words and actions, and also dependent on the experience of traumatic childbirth. Notably, my findings elucidated several other factors that enabled and prevented the development of perinatal nurse-mother trust unique to TCEs. In this section, I will discuss the dependent facilitators that resonated with existing literature, MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 120 the evolution of facilitators amidst a TCE, barriers of to developing trust, and how these findings add to current knowledge about this topic. Facilitators of Trust Amidst Traumatic Childbirth That Resonate with Existing Literature Several factors that positively influenced the development of mothers’ trust in perinatal nurses in my study are also reflected in the existing literature. During labour, my findings revealed that mothers who felt informed regarding interventions and complications, were guided through various stages of labour, and sensed their nurses advocated for their birth and newborn care preferences facilitated nurse-mother trust. These findings were consistent with existing literature which identified nurse-mother communication (Goldberg, 2008; Renbarger et al., 2020; Sapkota et al., 2014), nurses guiding mothers during labour, and feeling heard regarding birth plans and preferences (Cricco-Lizza, 2006) as facilitative of trust. Relational characteristics of the nurse, such as a non-judgemental and authentic demeanor, also enabled the development of trust in this study and are reported in existing literature (Goldberg, 2008; Renbarger et al., 2020). Further, in previous literature, confidence in the perinatal nurses’ competence strengthened trust, for example, through the changing of labour positions (Fleming et al., 2011) and administration of effective pain management (Chunuan, 2002; Renbarger et al., 2020), which were also reflected in my study findings. Each of these "acts of care” in existing literature were also noted by mothers in my study as facilitative of trust amidst a TCE. Communication in the nurse-patient relationship was emphasized, both in the current literature and in my findings, as vital in the development of trust (Dalton et al., 2021; Goldberg, 2008; Mackay et al., 2022; MacKay et al., n.d.; Renbarger et al., 2020; Sapkota et al., 2014). As described in my findings, effective communication was evident when nurses MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 121 acted as an encouraging coach, a messenger or informant, an active listener, and mothers’ advocates within the wider interdisciplinary healthcare team. These acts of communication, verbal and non-verbal, have been noted as the most commonly identified facilitators of trust in a scoping review of trust between medically fragile infants, their caregivers, and nurses (MacKay et al., n.d.). This importance of communication in developing trust is consistent with mothers and perinatal nurses, as further demonstrated in my findings, through the enactment of RCC (Ryan, 2022) and TIC (Kuzma et al., 2020), both of which require communication to be effective. In line with previous studies, mothers in my study noted continuity of care as facilitative of trust in the nurse-mother relationship. These findings were similar to that of O’Brien et al.’s (2021) qualitative study regarding the importance of trusting relationships in shared decision-making among childbearing women. Despite limitations of the nurses’ time constraints during labour and delivery, quick turnovers, and inconsistent nursing personnel, mothers could still develop and maintain trust with their nurses when care was consistent, through consistent nurses or similarities in the care provided by different nurse. Consistency of nursing personnel was seen during obstetric appointments, triage visits, and subsequent deliveries. Mothers reflected on the value of regular interactions with specific nurses because this helped them establish and maintain trust with nurses. This trust-building factor is reflected in Murphy et al.’s (2022) insight into how the continuity of care provided during the prenatal period led to strengthened trust in perinatal care providers. In summary, there were connections to the existing literature, specifically regarding communication, nurses’ relational characteristics, and continuity of care that were noted by my participants as crucial to developing trust with their nurses. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 122 Evolved Needs for Developing Trust Amidst a Traumatic Childbirth: Advancing Understandings of Facilitators My study findings add to the existing literature by elucidating mothers’ needs for developing trust with their nurses specific to when a TCE occurs. Trust-building factors unique to this study were noted as a caring presence, an intuitive-responsiveness, and a trauma-informed and trauma-responsive approach to care, all incredibly impactful in mothers’ relationships with nurses amidst TCEs. These findings of physical closeness and intuitive responsiveness to mothers’ needs are minimally noted in existing literature regarding trust in the perinatal nurse-mother relationship, suggesting the impact of traumatic childbirth on mothers’ facilitative factors in developing trust. In my study, facilitators of trust in a TCE evolved from a solely communicationbased approach to care to care which was deeper and more relational. The intensity of the traumatic birth leaves mothers in a vulnerable state (Goldberg, 2008), requiring a closer relational connection beyond nurses’ communication or competence. No longer was the nurses’ expertise or ability to communicate sufficient to meet the trust-building needs for a traumatized mother. Instead, mothers in my study expressed that trust depended on being seen, being known, and being close to those they trusted to care for them and their newborns. Communication remained vital in this approach to care, and was seen as the backbone of trust, necessary to enact a caring presence and to provide relational, trauma-informed, and trauma-responsive care. Nurses who enacted a caring presence were noted to be highly effective in developing trust with mothers during and following a TCE. Covington (2005) defines caring presence as a relationship in which nurses and patients share of themselves and involves mutual trust and MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 123 connectedness. In my findings, the physical closeness of the nurse ensured a competent and dependable partner in the birthing journey, sharing in the difficulties that mothers had to endure. This caring presence was enacted in the one-to-one nursing assignments, never leaving mothers alone in their experiences, and through therapeutic touch during interventions and uncertain moments in the birthing journey. Nurses’ conscious choices to enact a caring presence displayed an investment in mothers’ care and well-being, choosing to be close when they needed it the most. This investment communicated the nurses’ commitment and connectedness with the mother, and a trust in and respect of her experience. These findings are supported by Chunuan (2002) and Murphy et al. (2022), who found that the acknowledgement and valuing of mothers’ humanity and experiences were other facilitators of trust in the nurse-mother relationship. When mothers felt seen in their entirety, as humans capable of growing, birthing, and caring for their newborn, despite the traumatic encounters of childbirth, this holistic and trauma-informed care approach helped mothers recognize that nurses held trust in them. Thorne and Robinson (1988) describe this as reciprocal trust, effective in developing relationships between patients and their nurses. These findings of reciprocal trust also resonated with the works of Goldberg (2004) and Murphy et al. (2022), who reported that when mothers knew that their nurse trusted them, this helped strengthen their trust in their nurse and deepen their relationship. This reciprocal trust was seen in my findings as the nurses’ acknowledgement of mothers’ pain or labour progression, and in the support of their birth plan, demonstrating trust in mothers’ choices for their delivery and newborn care. Mothers could then trust that their nurse saw them for who they were and cared for them accordingly. Mothers trusted that the nurses understood, to the best of their abilities, the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 124 trauma mothers endured and were equipped to support them in their transition to motherhood following a TCE. The nurses’ active acknowledgement of mothers’ experiences was described as an intuitive-responsiveness, an ability to anticipate the needs of mothers based on an acknowledgement of their humanity and their trauma, which built reciprocal trust. Findings from my study also reflect Goldberg’s (2008) conceptualization of embodied trust in the perinatal nurse-mother relationship, citing: “an assumption of embodiment is that all parts of the body are integral to the human being; no part can be separated from the rest or objectified” (Wilde, 1999, p. 26, as cited in Goldberg, 2008). Embodied trust involves mothers’ sense of wholeness, in which developed trust in the perinatal nurse simultaneously establishes mothers’ trust in their own birthing abilities (Goldberg, 2008). This embodiment of trust seemed to be particularly important in my findings. For nurses to embrace mothers’ humanity as “embodied and whole” (Goldberg, 2008, p. 80) not only strengthened trust in the nurse-mother relationship but also supported self-trust in mothers’ abilities in birthing and caring for themselves and their newborns. An example of embodied trust in my findings was a mothers’ expressed confidence in her birthing abilities, reinforced by a trusted nurses’ positive affirmations during the pushing stage of labour. These additional trust-building factors of a caring presence, reciprocal trust, and an intuitive response to mothers’ humanity and trauma highlight the importance of a relational and trauma-responsive approach to perinatal care for those with prior, potential, or present traumatic birthing experiences. Reflections on Trauma-informed and Trauma-responsive Care MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 125 Drawing from Kuzma et al.’s (2020) framework of trauma-informed care (TIC) in the perinatal period, the development of trust and a trauma-responsive approach to nursing care can occur simultaneously. This study contributes to what is known about trauma within the perinatal setting, and presents ways of caring which positively impact the trajectory of mothers’ trust in perinatal nurses and support a trauma-informed and trauma-responsive approach to care. A nurse’s knowledge of traumatic childbirth must consider the subjectivity of the mother’s experience, acknowledging that “individuals respond to trauma in unique ways, making it difficult to predict how an individual with a history of trauma will respond to their experiences when accessing healthcare” (Kuzma et al., 2020, p. E25). Similarly, mothers’ experiences of trust varied, dependent on their past experiences and expectations of perinatal nursing care, therefore, to assume how a mother will respond to her birth, or what aspects of perinatal care may be triggering could be pernicious. Thus, nurses are encouraged to identify signs that the mother is experiencing distress, physically or emotionally, and adapt their care accordingly. Practical and active applications of TIC principles have recently been described as a trauma-responsive approach to care (TRC) (Covington & Bloom, 2018). In consideration with this study’s findings, the active process of TRC is an appropriate pursuit for perinatal nurses due to the unpredictability of the birthing experience. In addition to prioritizing retraumatization (Kuzma et al., 2020), perinatal nurses can work to minimize the impacts of trauma as it occurs, or shortly following, requiring a competent and caring response to the changing needs of the mother amidst the birthing experience. Identified facilitators to trust, such as an intuitive response to mothers’ needs, effective communication, supporting MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 126 mothers’ birth plans, and providing options in care, all reflected TIC principles which can be applied during and following a TCE. Findings from this study reflect a trauma-responsive approach to care as both facilitative of trust and having the potential to reduce the impacts of traumatic events during childbirth. This section has provided discussion on the dependency of mothers’ trust on nurses’ words and actions, and a relationship-centred, trauma-responsive approach to care, leading to the hopeful proposal that trust amidst TCEs is possible. Difficulty building or maintaining trust was also dependent on nurses’ words and actions, as discussed in the following section. Barriers to Trust Amidst Traumatic Childbirth While trust could be built, maintained, or reclaimed, various barriers could result in perinatal nurse-mother trust being broken or the prevention of trust from being established. Specifically, when trust had already been established in the nurse-mother relationship, moments of hinderance in trust led to mothers’ senses of betrayal and abandonment from the nurses. At times, the break in trust contributed to mothers’ experiences of trauma, demonstrating the importance of trust amidst TCEs. For the most part, the barriers to the development of trust in perinatal nurses amidst a TCE reflected those found in existing literature on perinatal-nurse relationships in general. The contribution of my findings to knowledge on mistrust between perinatal nurses and mothers specific to TCEs is the experience of mothers’ feeling unseen or insignificant during or following their traumatic birth, hindering the development of trust with their nurses. Mothers in my study recalled nurses’ blaming communication, such as disagreements or judgement towards mothers’ feeding plans for their newborn, as a barrier to the MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 127 development of trust. These findings were consistent with mothers’ experiences of mistrust in Renbarger et al.’s (2020) report of mothers when sensing blame from their nurses for their newborns’ poor status. A lack of relationship between the nurse and mother (Goldberg, 2004), or a sense of hurriedness in nursing care (Murphy et al., 2022), prevented the development of trust. In my findings, this lack of relationship between mothers and nurses was a result of nurses’ task-oriented approach to care, such as rushed admission and discharge processes. Mothers in this study who recalled receiving ineffective pain management during and following delivery reported decreased trust in their nurses due to a lack of collaboration in their care, which is reflected in the literature as well (Fleming et al., 2011; Goldberg, 2008). The same mothers in my study noted they experienced uncertainty in nurses’ expertise from this lack of collaboration. Renbarger et al. (2020) also noted this trusthindering factor in their qualitative study among perinatal mothers. Many of the barriers noted in both my findings and previous literature in this area were related to communication, interventions, and structural factors impacting the provision of care, yet previous research did not address the barriers to psychosocial support and connection. Unique psychosocial barriers to the development and maintenance of trust in the context of traumatic childbirth discovered in my findings were mothers’ experiences of feeling unseen, abandoned, or insignificant during and following their TCE. When nurses failed to acknowledge mothers’ trauma, a level of mothers’ humanity was stripped, leaving them to process the unexpected dread they had endured on their own. In these cases, it was not possible for embodied trust (Goldberg, 2004), as previously discussed, to develop in the nurse-mother relationship. As a result, mothers experienced a lack of self-confidence, wholeness, and sense of worth due to nurses’ inattention to their emotional needs. In their MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 128 scoping review of trust between pediatric caregivers and nurses, MacKay et al. (n.d.) found that the absence of trust negatively impacted caregivers’ mental wellbeing. In contrast, where trust was established with nurses, caregivers had increased confidence in caring for their child (MacKay et al., n.d.). Similarly, my findings of barriers to trust amidst a TCE, such as feeling unseen, abandoned, or insignificant, at times hindered mothers’ perceived abilities to care for their newborns. Trust Amidst a Traumatic Childbirth is Necessary: A Shelter in the Storm Mothers’ powerful reflections of care from a trusted nurse during or following their TCE revealed the necessity of trust in perinatal nurse-mother relationships. This trusting relationship was seen in my findings as a shelter in the storm. As the existing literature reveals, trust in relationships with perinatal nurses fosters mothers’ trust in their own abilities in the birthing process, leading to a sense of empowerment in the transition to motherhood (Goldberg, 2008). Successful transition to motherhood is associated with benefits to mothers, their newborns, and their families (Hwang et al., 2022) and as expressed in my findings, trust can positively impact this transition. Considering the subjectivity of both trauma and trust, nurses must consider mothers’ descriptions of what trust meant to them in order to guide perinatal nursing care to create this shelter. The following sections will explore my findings about the mothers’ definitions of trust, the impact of a trusted nurse, and how they make a compelling case for the necessity of trust amid TCEs. When Trust Occurs Amidst Traumatic Childbirth Experiences: Defining Trust When mothers were asked to define trust in their own words, two main themes emerged: a comfort to ask for what they need and confidence in the nurse’s intent and abilities in caring for them and their newborn. These definitions of trust reflect existing MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 129 definitions of trust found in my literature review, which included relational and professional applications to the perinatal nurse-mother relationship (Chunuan, 2002; Dalton et al., 2021; Goldberg, 2008). Trust in the literature was also described as a confidence in another’s actions (Goldberg, 2004), which was further explicated in my findings as an expectation that nurses have the mothers’ best interests in mind. My study contributes to definitions of trust specific to the perinatal nurse-mother relationship with those who had experienced traumatic births, as existing literature generally speaks to perinatal nursing care as a whole. The trauma that each mother endured during childbirth inevitably altered their experiences, and in turn, their definitions of trust with perinatal nurses. This study advanced the definition of trust between perinatal nurses and mothers in the literature by adding an understanding of the element of vulnerability, meaning trust was a safe space to truly be seen in their entirety. Dinc and Gastmans (2012) speak to the vulnerability that mothers experience as patients during childbirth, and how trust requires confidence in the competence of the nurse. Definitions provided by the mothers in my study provide insights into the personal elements of trust. Knowing that their values were heard, understood, and respected, enabled mothers to trust their nurses, similar to the trust arising from confidence in the nurses’ expertise. Many aspects of the definitions of trust in my findings also reflected principles of respectful maternity care, which are grounded on mothers’ human rights (Shakibazadeh et al., 2018; White Ribbon Alliance, 2021; World Health Organization, 2018), and are discussed further in following sections. Impact of Trust and Mistrust in Perinatal Nurses on Traumatic Experiences The findings demonstrated that experiencing trust with the nurse was necessary for mothers to endure, and in some cases, emotionally withstand, the traumatic childbirth. Many MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 130 mothers clung to their nurse during the perinatal experience as the trusted person amidst the emergent and unpredictable storm of a TCE. Trust, therefore, was not only a desirable piece of the nurse-mother relationship, but a necessary contributor to a sense of safety. Ryan (2022), in a discussion of relationship-centred nursing care, demonstrated that trusting relationships create relational safety, congruent with my findings of trust as a shelter in the storm. Mothers expressed that a trusted nurse was a safe place during frightening interventions such as epidural insertions or emergency caesarean sections. At times, a trusted nurse was the saving grace, so much so that mothers could not imagine the trauma they would have experienced without them. Trust in the perinatal nurse-mother relationship seemed to provide a layer of protection over the mother, positively influencing the birth experience despite the trauma that they had endured. The findings drawn from mothers’ stories of their TCEs also prompted the following questions about the necessity and trajectory of trust: does a lack of trust lead to an experience of trauma? Or does traumatic childbirth lead to a break in trust? The main theme of Foundations and Fluid Trajectories of Trust and the overarching theme of a Shelter in the Storm, as well as previous literature, suggest that these both may be true and that it is an iterative process. Beck (2004a) and Kuzma et al. (2020) discussed the association of traumatic childbirth with a lack or break in trust with healthcare providers. In both studies, this association was shared by mothers who felt abandoned following delivery, endured prolonged unnecessary labour, or experienced a lack of consent during assessments or interventions, which hindered trust and contributed to their trauma. Some mothers in my study had experiences of mistrust with perinatal nurses which appeared to contribute to their traumatic childbirth. Findings in my study demonstrate that MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 131 nurses can exacerbate the storm of a TCE through their words and actions instead of providing a needed shelter. For example, what may have appeared as a healthy and normal delivery from an objective standpoint of the nurse, was often described by mothers as one of the more traumatic moments of their lives, congruent with Leinweber et al.’s (2022) subjective definition of traumatic childbirth. This gap in perception of the experience of childbirth between healthcare providers and mothers has been noted in existing literature and is associated with decreased trust between nurses and mothers (Beck, 2004a; White et al., 2022). In my findings, mothers also described factors that contributed to their trauma yet felt disregarded by their nurses (refer to Chapter Four), such as unmanaged pain during or following labour, difficulties with feeding, and reflections of the lack of inclusion of their partner. The nurses’ misconceptions of these experiences are noted in the literature as having a negative impact on mothers’ abilities to develop relationship and trust with their perinatal nurses due to a disaffirmation of mothers’ experiences (Kuzma et al., 2020). These constraining factors demonstrate how nurses can have a negative impact on mothers’ experiences of a traumatic birth and cause further harm instead of providing shelter. Further, some authors highlighted how trust impacts experiences of trauma. Baptie et al. (2021) found that mothers who felt their care was personalized reported increased levels of trust and were less likely to describe their birth experience as traumatic. Contrastingly, when trust was lacking between mothers and their healthcare providers, an increased risk of additional interventions, such as emergency caesarean births, have contributed to mothers’ experiences of trauma (Greenfield et al., 2022). Existing literature also reports the healthcare providers’ potential to contribute to TCEs through a disregard for dignity, removing mother’s sense of control, unsupportive communication, and a lack of acknowledgement of mothers’ MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 132 experiences following delivery (Beck, 2015; Watson et al., 2021). The negative consequences of TCEs discussed in my findings and the presented association between trust and trauma suggest that a trusted nurse is necessary to minimize such negative factors in mothers’ experiences. Application of Theoretical Frameworks on Trust and Traumatic Childbirth Interpretation of my findings was guided, in part, by the frameworks of RMC and RCC. I found that facilitators of trust in the nurse-mother relationship aligned with these frameworks and TIC (Kuzma et al., 2020) principles, as presented in Chapter One, and enabled nurses and mothers to partner in building a Shelter in the Storm. The shelter of trust in the storm that nurses provided for mothers of a TCE provided a layer of protection for mothers during childbirth. Viewing the findings through these theoretical perspectives can help us to understand the findings in a new way and reveal the gaps, similarities, and expansions to the existing literature for these approaches to care. Respectful Maternity Care and Traumatic Childbirth Experiences The facilitators described above that fostered perinatal nurse-mother trust with mothers experiencing a traumatic childbirth reflected components of the global initiative, and theoretical framework, of respectful maternity care (RMC). First and foremost, an aim of RMC is to reduce maternal mortality and improved maternity care for childbearing women across the world (Shakibazadeh et al., 2018), which is highly relevant for TCEs. Current RMC frameworks do not specifically address traumatic childbirth and the effects it has on mothers, prompting the need to “understand the prevalence of prior and potential trauma and its effect on the birth experience” (Cantor et al., 2024, p. 64) to further expand the theoretical framework RMC. Findings from my study demonstrate that the establishment of mothers’ MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 133 trust in perinatal nurses reflects components of RMC. For example, as existing literature and the present study support, trust within the nurse-mother relationship has been shown to increase mothers’ participation and satisfaction within the perinatal experience (Dalton et al., 2021; Kuzma et al., 2020). Many similarities were found between the domains of RMC and the contributors to trust in nurse-mother relationships. The first similarity was that of informed consent. Mothers in my study expressed increased trust in their nurses when they were involved in conversations regarding their care, enough so that they felt equipped to provide informed consent for interventions. Effective communication, such as providing helpful guidance throughout the pushing stage or updating mothers on the health status of their newborn, strengthened trust in the perinatal nurse. Informed consent and effective communication are components of RMC (Shakibazadeh et al., 2018). Shakibazadeh et al.’s (2018) systematic review of RMC also identified emotional support and non-verbal communication as contributors to more respectful maternal care, which were also identified as facilitators of trust for mothers with a TCE in this study. Efficient and competent care, exhibited by provision of pain management and careful monitoring of the newborn, created a sense of safety for mothers in this study. Mothers’ safety and dignity were reflected in RMC (Shakibazadeh et al., 2018). Preserving dignity was also an important component of trust building in my study. This dignity was achieved by treating mothers as human and individuals worthy of respect, shown by actions such as closing the curtains during intimate interventions or acknowledging the trauma that they have endured. Another aspect of respectful maternity care which was present in the data was a respect for mothers’ preferences that in turn, strengthened their ability to give birth. White MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 134 Ribbon Alliance (2021) regard this respect for choice as a human right, a non-negotiable in the realm of perinatal care. Mothers recalled receiving options in care, such as being offered alternative labour positions, newborn feeding strategies, or choices in pain management. When these choices were respected, mothers felt an increase in trust in their nurse through a sense of empowerment and competence in caring for themselves and their newborns. Goldberg (2008) also made the connection of trust in the perinatal nurse-mother relationship with mothers’ ability to “explore self-trust and actualize her own birthing power” (p. 82). Within mothers’ descriptions of their traumatic childbirth experience were graphic examples of emotional and physical distress. From the findings of this study, ways in which nurses can reduce harm amidst TCEs were presented, reflecting the RMC principle that mothers must be free from harm (Shakibazadeh et al., 2018). Although preventing all traumatic births may be an unreachable goal, perinatal nurses can still aim to be equipped in improving maternal experiences, even amidst traumatic childbirth, and thus preventing harm. The domains of respectful maternity care “include recognition of the unique needs and preferences of birthing people and families” (Cantor et al., 2024, p. 64), stressing the subjective experience of each mother and each delivery, aligning with theorizing surrounding TCEs (Leinweber et al., 2022). Findings on trust in the nurse-mother relationship in this study were consistent with principles of RMC and provided specific insight of these principles for mothers experiencing traumatic childbirth, tying to RCC. Relationship-centred Care Within Traumatic Childbirth Experiences Perinatal nurse-mother relationships were found to lay the groundwork for the development of trust amidst TCEs for mothers in this study. As well, perinatal nurse-mother trust helped establish relationships. The theoretical perspective of RCC guided the study MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 135 through consideration of the key indicators of RCC (Beach et al., 2006) and those more recently applied to nursing practice (Ryan, 2022). Principles of RCC that resonate with the findings from this study are that of building relationships, maintaining identities, the sharing of power, and holistic engagement (Ryan, 2022). The principles and facilitators of RCC reflected many of the factors described by mothers as facilitative of trust amidst TCEs. Ryan (2022) describes relationship as providing mutual benefit to both mothers and nurses, as seen in my findings as nurses’ personal desires, and in turn benefit, in improving the well-being of the mother-newborn dyad. In my findings, mothers sensed when their nurses had their and their newborns’ best interests at heart, which was also shown to be an indicator of trust. Further, an effort to understand mothers holistically for who they were, what they had experienced, and how care must look differently for each mother, was evident in mothers’ experiences of trust and reflected RCC principles (Ryan, 2022). In my findings, relationship and a respect for the unique identities of mothers allowed space for shared decision-making amidst childbirth, partnering to make decisions with, not for, mothers. This reflects the principle of sharing power in RCC (Ryan, 2022). In existing literature, respect for identity also included self-reflection of the perinatal nurse, ensuring that a position of dominance was not enacted, and ensuring mothers’ subjectivity was heard and valued (Goldberg, 2008). Time was also noted to be a catalyst to the development of perinatal nurse-mother relationships in both my findings and current literature (Murphy et al., 2022). Despite the quick turnaround of patient-stays on maternal-child units, the one-to-one ratios during labour and delivery that allowed nurses to spend time with birthing mothers was a distinct facilitator to the establishment of trusting relationships. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 136 There is a purpose within perinatal nursing care that reaches beyond the provision of skills or thoroughness of assessments, and that pursues relationship by “gaining access to knowledge and experiences of the person that they care for” (Ryan, 2022, p. 893). This pursuit of trusting relationships, which is an anticipated outcome of RCC (Beach et al., 2006), requires a “learner’s stance” (Humbert & Roberts, 2009, p. 594), a willingness to learn from the person you are caring for, and a partnership to reach mothers’ goals of care amidst a TCE. This relationship-centred approach to nursing is consistent with the goals of an interpretive descriptive study design (Thorne, 2016), as evident in my findings. Reflections of the study design, trust, and traumatic childbirth are discussed in the following section. Reflections on Interpretive Description, Trust, and Traumatic Childbirth Due to the subjective nature of traumatic childbirth and the phenomenon of trust, an interpretive descriptive qualitative approach was chosen as an appropriate guide to address the clinically oriented research questions of this study (Thorne, 2016). Interpretive description aims to uncover the relational and personal components of the human experience by exploring the lived phenomena of those the research is aimed towards (Thorne, 2016). The theoretical framework of RCC also values the “subjective, relational and personal narrative of people who use care [as] important in establishing person and relationshipcentred care” (Ryan, 2022, p. 897) supporting the use of ID in improving practice and patient outcomes through research (Thorne, 2016). My findings revealed applied, disciplinary-specific strategies and approaches in which perinatal nurses can modify their approach to care for mothers who experience trauma within childbirth. These findings were inspired by a desire to hear mothers’ voices, value MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 137 their experiences, and acknowledge the trauma they have endured. Interpretive description guided my research design, and elucidated findings that both confirm and advance current knowledge about trust within the perinatal nurse-mother relationship by contributing the experiences of mothers with traumatic childbirths. Interpretive description values the researcher’s experience and the contribution to research (Thorne, 2016), which allowed for me to deeply immerse myself, and my nursing expertise and perspective, in data collection, analysis, and interpretation. The flexibility of ID gave space for rich interpretation, while offering the necessary structure for the study design. Limitations of this study and the chosen methodological direction will be discussed in Chapter Six. Chapter Summary The concept of nurse-patient trust is deeply embedded in the nursing profession, whether it is explicitly labelled as such or not. When trust is missing in the nurse-mother relationship, nursing care can become unsafe and not focused on mothers’ well-being, leaving mothers more vulnerable to the impacts of traumatic childbirth. Perinatal nurses have a responsibility to pursue improved maternal experiences and outcomes and are in a unique, yet challenging, position to do so considering the inevitable vulnerability of birthing mothers and the closeness experienced with mothers during the transition to motherhood (Hwang et al., 2022). Facilitators of trust found in the data reflected RCC (Ryan, 2022), traumainformed care (Kuzma et al., 2020), and RMC (Shakibazadeh et al., 2018). Nurses who uphold the principles of these frameworks bring trust-building approaches to maternalnewborn care, providing a Shelter in the Storm of traumatic childbirth for birthing mothers. Such mothers are well positioned to establish trust in relationships with their nurses, where MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 138 they can be sheltered from the storm of a TCE and report increased satisfaction in their birth experience, despite enduring traumatic childbirth. The purpose of this study was to explore mothers’ experiences of trust and mistrust in perinatal nurses amidst TCEs. Existing literature provided insight into the development of trust in the perinatal nurse-mother relationship, and my study adds insights to this process for mothers who experience TCEs. This discussion further reflected on the possibility, dependency, and necessity of trust within TCEs. Trust was discussed as possible, within the fluid trajectory of trust, providing encouragement and hope to mothers and nurses partnering together in the perinatal journey. Trust was described as dependent on nurses’ words and actions during care, as well as dependent on the experience of trauma in childbirth. Literature and study findings also revealed an evolution in mothers’ expression of facilitating factors of trust during and following a TCE. These facilitators of trust found in existing literature were complemented by a caring presence, RCC, and TRC amidst a TCE. Finally, trust amidst a TCE was discussed to be necessary, highlighting the powerful impact of a trusted nurse on mothers’ experiences of their birth. Mothers’ reflections on trust amidst their traumatic childbirth experiences have graciously given insight into the practical ways that perinatal nurses could improve their care, adopt RCC, RMC, and TRC principles, and simultaneously be encouraged by the trust they have fostered in relationship with the mothers they care for. Chapter Six provides summative conclusions of the study, limitations of the study, and recommendations for various realms of the nursing profession (Thorne, 2016). MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 139 Chapter Six: Conclusions and Recommendations The last chapter of this thesis summarizes the research that was conducted; identifies implications and recommendations stemming from the study findings for nursing education, practice, policy, and research, and acknowledges study limitations. Recommendations in this chapter invite clinical nurses, educators, researchers, leaders, and policymakers to promote relationship-centred and trauma-responsive perinatal care in all nursing areas of childbirth, but specifically amidst traumatic births, in a movement towards the global initiative of RMC (Shakibazadeh et al., 2018; White Ribbon Alliance, 2021; World Health Organization, 2018). Summary of the Study Trust in the nurse-patient relationship is an increasingly researched topic although little attention has been paid to trust within relationships between perinatal nurses and mothers with traumatic experiences of childbirth. The purpose of this qualitative study was to explore mothers’ experiences of trust and mistrust in perinatal nurses amidst traumatic childbirth in Canada. This study was conducted using an interpretive descriptive qualitative design to develop an understanding of how trust is developed between perinatal nurses and mothers and inform relevant, nursing-specific recommendations for perinatal nurses (Thorne, 2016). Inductive, immersive, and thematic analysis took place concurrently with data collection, and interpretation of themes occurred during data analysis that informed the adaptation of the semi-structured interview guide (Thorne, 2016). The overarching theme of perinatal nurses being the Shelter in the storm for mothers who experienced a TCE arose from mothers’ powerful stories and reflections of trust and mistrust with perinatal nurses. Three main themes were identified within mothers’ experiences of trust and mistrust with their nurses: The foundations and fluid trajectories of trust amidst traumatic childbirth, MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 140 Developing and maintaining trust through relationship and trauma-responsive care, and Barriers to trust amidst traumatic childbirth experiences. From situating these findings within existing literature, several conclusions and recommendations have been made, which are outlined in the remainder of this chapter. Conclusions The following conclusions have been formed based on my interpretation of the research findings and discussion of the existing literature. 1. Mothers’ experiences of trust with perinatal nurses are subjective in nature, fluid, and responsive to mothers’ personal experiences of traumatic childbirth and individual needs. 2. Nurses should approach establishing trust with each mother individually, and in a manner that honours and values each mother’s experience, context, and birth preferences. 3. The establishment of nurse-mother relationships is often the groundwork for the development and maintenance of trust because trust occurs within nurse-mother interactions. 4. Trust in perinatal nurses is influenced by mothers’ pre-existing confidence in the nurses’ expertise and past experiences with nurses. 5. Mothers’ stories identified the development and maintenance of nurse-mother trust as dependent on nurses’ words, actions, and approaches to perinatal care. 6. Positive influences that establish trust are reflective of respectful, relationship-centred and trauma-responsive care principles. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 141 7. Breaks in or hinderances of nurse-mother trust often occur during vulnerable and traumatic moments in the transition to motherhood, emphasizing mothers’ vulnerability and heightened responses to care during a traumatic experience. 8. Perinatal nurses can create trust-building spaces before, during, and following TCEs by enacting a close presence, effectively communicating, and acknowledging and responding to mothers’ experiences and birth plans. 9. Nurses and healthcare organizations have a responsibility to provide care which minimizes the negative impacts of traumatic childbirth, creating an environment where trust can be built in the nurse-mother relationship. 10. Trust can be developed over a short period of time, during intense, vulnerable moments, or through a continuity of care and repeated interactions. 11. Trust can be reclaimed and re-established following broken trust and moments of trauma, giving hope to perinatal nurses caring for mothers who have had a traumatic childbirth. Knowledge Translation I am passionate about the conversation of trust within perinatal nurse-mother relationships and hope to disseminate my findings following completion of this thesis to inform the improvement of care for future mothers who will experience a TCE. I will disseminate by findings in a variety of ways. The research findings are presented here in written form and will be submitted to the thesis committee and external readers for approval, and then be available in an online repository at TWU. Oral presentations will be pursued in both academic and clinical settings to present opportunities for dialogue about perinatal nurse-mother trust and TCEs (Polit & Beck, 2021). Following the anticipated thesis defense, MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 142 I, along with my thesis committee, will prepare a manuscript for publication and submit it to a nursing or an interdisciplinary journal (e.g., Journal of Perinatal Education, Birth) to reach clinical nurses, academics, researchers, and students. To aid in dissemination of my study findings to nurse educators and clinical practice, I will present at a TWU School of Nursing faculty meeting and create a research summary or infographic and post it in the staff room of a maternity unit in which I am employed. The target audience for this research is clinical nurses working in perinatal areas, yet I foresee benefits in disseminating the findings to alternative maternity practitioners (e.g., midwives) and the mothers themselves. Thus, I will also seek to present my findings to a patient group (e.g., Pacific Postpartum Support Society) with an interest in trauma-informed and traumaresponsive maternity care. As study participants will be provided with the findings upon request, I will encourage mothers to share the findings they receive with friends or family members they believe may benefit from the discussion. From an educational perspective as a nursing instructor, the first steps that I will take in disseminating my findings for integration into curriculum development for perinatal specialty nursing programs or baccalaureate maternal-child nursing courses are to meet with course instructors to integrate findings into the relevant courses within undergraduate nursing education at TWU. Study Limitations I encountered several challenges and limitations when conducting this study. One challenge was my pre-existing knowledge which inevitably influenced the data collection and analysis. Considering my own experience in maternity nursing, I acknowledged my belief that trust is a desired aspect of the nurse-mother relationship yet understood that not all mothers may share this belief. To be reflexive about my perspectives and to avoid MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 143 overinfluencing the data collection and analysis, I engaged in reflexive journaling following each interview to identify my own biases and assumptions that could influence data analysis and interpretation. Additionally, in respect of being reflexive, I consulted my thesis committee frequently throughout the data collection and analysis process. Researcher subjectivity can be present in qualitative research and influence data collection and analysis (Polit & Beck, 2021). This could have been especially relevant in this study due to my employment and experience as a postpartum nurse. The first step I took to disclose my discipline (Thorne, 2016) with the mothers was to acknowledge my employment status as a nurse and provide an understanding that my position could undoubtedly influence the research. I invited mothers to choose the interview location in which they were most comfortable, hoping to provide participants with a level of control and autonomy in the research process and sharing of their birthing experience. Further, in consultation with the thesis committee, I aimed to use layperson language with participants throughout the research process, specifically when asking interview questions during data collection. I also attempted to distance myself from the role of a clinical nurse and embrace the role of an active listener as a researcher (Callister, 2004), utilizing journaling as a tool towards reflexivity. Another potential limitation of this study is the ability to transfer findings to alternative populations or settings. The sample of mothers in this study gave birth in a Canadian public healthcare system. All of the mothers were married, one mother was of southeast-Asian descent, one of both south-Asian and White/European descent, and six participants were White. This lack of diversity limits the transferability of the findings to populations outside of the included participant demographics and does not address impacts of MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 144 racial or marital factors on incidences of traumatic childbirth. Caution is recommended in transferring findings to healthcare systems outside of Canada as the TCEs occurred in publicly funded hospitals, which may have an impact on the care that these mothers received. In consideration of the feasibility of this study, only one retrospective interview was required from each participant. Interpretation of singular sourced data was approached with caution in this qualitative study due to the inability to “effectively represent whole experience in context” (Thorne, 2016, p. 86). Therefore, findings were interpreted accordingly, with a detailed report of information of the demographics and context of the participants. Further, although there are no fixed sample size requirements in qualitative research (Polit & Beck, 2021) and ID (Thorne, 2016), it is important to acknowledge that a specific or limited sample only provides understandings of the phenomenon to that specific context. In order to promote transferability of the qualitative findings, all steps of the research and the participants’ sociodemographic data were presented in rich detail to allow readers to determine whether the findings are applicable to their context (Polit & Beck, 2021). Recall bias was considered when developing the inclusion criteria of participants. Specific details of mothers’ birth experiences have been known to decrease three years following delivery (Casas-Guzik et al., 2020), while traumatic childbirths have also been associated with sharper memory and recall (Altuntuğ et al., 2023; Laney & Loftus, 2005). Alternatively, caution is encouraged when interpreting recalled traumatic events due to the malleability of memory (Laney & Loftus, 2005). With these considerations, maternal participants were included if their traumatic birth experience was within the past two years MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 145 (from the time of recruitment) and following six weeks after delivery to allow time for physical and emotional recovery. The first seven interviews took place within a four-week period which limited, but did not restrict, my ability to conduct data collection and analysis concurrently. Despite the minimal time between interviews, I manually checked transcripts for each interview immediately following completion and met frequently with my thesis committee to discuss interpretations and adapt interview questions accordingly. A final interview was conducted three months following the preceding interview to member check my interpretations from initial data analysis and interpretation. Guidance and engagement from the thesis committee ensured high quality data collection and analysis, and that all decisions throughout the research process were accurately reported, with appropriate rationales. Recommendations In light of these research findings, recommendations are provided for various realms of the nursing profession, including education, practice, policy, and research. These recommendations reflect the mothers’ experiences and hopes for the future of perinatal nursing, and are informed by the theoretical frameworks of RCC (Ryan, 2022) and RMC (Shakibazadeh et al., 2018; White Ribbon Alliance, 2021; World Health Organization, 2018). Education Perinatal nursing care is introduced in undergraduate nursing programs and this learning is carried into nursing practice. The Canadian Association of Schools of Nursing (CASN) (2017) have existing entry-to-practice competencies of nursing care for the childbearing family, including identifying principles of family-centred and trauma-informed care and describing implications of and responses to trauma. Holistic approaches to care are MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 146 already implemented in many nursing curricula, with increasing attention to person-centred care. Findings from this study support an additional inclusion of RCC principles and how to build trusting relationships during a TCE in the undergraduate nursing curriculum. Due to the significant findings on communication in developing trust with mothers experiencing traumatic births, communication courses should include trauma- and trust-specific discussions highlighting mothers’ experiences during the perinatal period and identifying specific communication strategies that were noted to develop trust. The comprehension and application of the facilitators of trust (e.g., communication, a caring presence, TIC, TRC, and RCC) would be strengthened through standardized competencies and curriculum on these topics. Thus, it is also recommended that maternalchild nursing courses provide space for discussion and learning regarding birth trauma and its negative consequences, and ways of incorporating RCC and TRC to develop trusting relationships with mothers. In order for faculty to teach about the value of and how nurses can develop trusting relationships with patients, they must also seek to develop trusting relationships with nursing students. In their discussion of the nursing educator as a facilitator of trust, van Dyk et al. (2022) conclude that in the nursing student-faculty relationship, “trust is dependent on, and facilitated by, professional conduct, ethical behaviour, competencies, knowledge and skills of the role-players in the teaching and learning environment” (p. 1). As nursing educators take conscious steps to develop trust with nursing students, trust is likely to be carried over into their clinical practice, in a caring pursuit of trust in the nurse-mother relationship. Nursing educators teaching in relevant courses are encouraged to seek out learning opportunities in trust-building and trauma-responsive care, such as attending applicable MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 147 conferences, webinars, or presentations. Perinatal nurses in current practice should be orientated to various support services (e.g., social work) and offered courses and training in areas of TIC and TRC. Clinical nurse educators are encouraged to promote mandatory continuing education for perinatal nurses, with online learning modules or workshops focused on traumatic births and trust-building care. In addition to education, recommendations are offered for those providing direct nursing care on perinatal units. Practice When asked what advice mothers would give to perinatal nurses to develop trust amidst TCEs, three main ideas were identified: be present, keep me informed, and listen to and respond to my needs. Thus, recommendations for clinical practice include effective communication, collaboration with mothers in their care, inclusion of birth trauma in discharge teaching, and effective handover between nurses regarding mothers’ birth experience. For a nurse to be present meant more than a physical presence, but a caring presence that encompassed the emotional aspects of the mothers they are caring for. Perinatal nurses should be encouraged to pursue closeness with mothers by promoting collaboration in the birthing experience, in keeping mothers informed, and valuing their preferences and experiences. Clinical implications for perinatal nurses drawn from data are presented in Table 7. Table 7 Key Clinical Implications for Perinatal Nurses Caring for Mothers with TCEs • Upon initial introductions, inquire about the mother’s previous delivery experiences, expectations for this birth, and potential birth plans. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH • 148 Stay close to the mother, especially during interventions, intense conversations, or moments of uncertainty. • Frequently check in on the mother, to both update and give space for their experience and wishes moving forward. • Ask for consent when performing intimate assessments or interventions and involve the mother in care when able. • Keep mothers informed of what to expect in all phases of perinatal care. • When options in care are available (e.g., pain management, labour positions, newborn feeding), provide these and respect mothers’ choices. • Include support persons by keeping them informed and having them as active participants, if the mother desires. • Encourage and celebrate with mothers, even in the small victories of birthing and postpartum. • Be the mothers’ advocate to the interdisciplinary team to provide safe, relationshipcentred care. Beyond frequent updates with mothers amidst the perinatal experience, specifically during obstetrical or newborn emergencies, one example of a practical recommendation for keeping mothers informed is through utilizing whiteboards in the patient room, where perinatal nurses can update the status and priorities of care (Rickard et al., 2022). Mothers should be encouraged to contribute to this “handover” by writing their own priorities of care. This visual and interactive tool supports collaboration and connection (McMillan et al., 2023) between perinatal nurses and mothers and ensures mothers’ preferences and experiences are being communicated to oncoming nurses. Keeping mothers informed can also occur during preparation for discharge from the hospital through patient teaching. Topics such as postpartum depression and postpartum blues are included in discharge teaching in British Columbia (Perinatal Services BC, 2011), MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 149 yet do not include specific information tailored for the needs of mothers with TCEs. A recommendation is to include teaching points about traumatic births, and the supports available during discharge teaching. This way, mothers are aware of the prevalence, subjectivity, and impacts of TCEs. Ideally, this teaching should occur when mothers’ support systems are present to promote inclusion of the partner, or support person, in caring for the mother following a TCE. Additionally, the traumatic birthing experience and emotional status of mothers should be included in all nursing handover tools in addition to interventions and health status, so the traumatic event is not lost in translation between nurses. This knowledge can equip nurses with the information needed to further assess mothers’ physical and emotional wellbeing. Effective handovers, both in hospital and upon discharge to the respective public health units, could bridge the gap of difference in perinatal nurses’ perception and mothers’ experiences of trauma during and following childbirth. Communication of a TCE to external supports, such as public health nurses, could also improve postpartum screening for anxiety, depression, and PTSD by identifying TCEs prior to discharge from the hospital. Policy Consistency of care and messaging were reported as facilitators of trust in the nursemother relationship, especially regarding labour techniques and newborn feeding approaches. To support excellent perinatal nursing care, clinical practice guidelines regarding labour progression and newborn feeding could be implemented to utilize and adapt RCC principles amidst TCE, although, these policies must be implemented with caution and ensure collaboration with and adaptation to mothers’ birth plans or preferences. When possible, continuity of care throughout the perinatal experience should be supported by models of care MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 150 that promote the development of trust in the nurse-mother relationship. An example of this continuity is assigning the mothers’ labour and delivery nurse as their postpartum nurse following the delivery. This continuity is dependent on the hospital’s flow of perinatal care, as some units separate labour and postpartum nursing. Specifically, in the postpartum period, safe workload assignments must be in place to provide the care necessary for mothers who have experienced, or are experiencing, traumatic births, and develop trust. Several of the participants sensed the busyness of the postpartum units and attributed this to the lack in compassionate care that they received. The British Columbia Nurses’ Union (BCNU) and the Ministry of Health are implementing safe nurse-patient ratios, including a 1:3 ratio for postpartum nursing care (2024). Important considerations for this policy are the varying resources and health complexities in various sites, impacting the safe ratios for nursing care. In order to ensure balanced nursing assignments, tools to numerically measure both the physical and emotional acuity of the dyad could be implemented. By doing so, mothers who have experienced a TCE may be assigned to a nurse with a lighter workload, allowing more time for RCC and TRC. It is also recommended that quality improvement projects are conducted in maternalchild healthcare settings to ensure that principles of RMC and RCC are being addressed in the provision of care, as participants referred to facilitating factors aligned with these principles. To ensure mothers’ experiences continue to be heard, accessible complaint policies or patient experience surveys are recommended for mothers who have experienced a TCE. Standardized handover tools are also recommended to improve communication between nurses, other healthcare providers, and mothers to ensure accurate representation and acknowledgement of mothers’ experiences of childbirth. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 151 Research Due to the small scale of this qualitative study and the evolving research fields of nursing care, additional research is recommended on the topic of trust in perinatal nurses amidst traumatic childbirth. It is recommended that research is conducted to further understand peritraumatic responses during childbirth, such as an application and evaluation of mothers’ responses to the Peritraumatic Distress Inventory, developed by Brunet et al., (2001). This tool is a self-reported measurement of distress during and immediately following a traumatic event, which may also provide insight on the level of impact nurses’ words and actions have amidst a TCE. An increasing amount of research has been dedicated to the global initiative of respectful maternity care (Shakibazadeh et al., 2018; White Ribbon Alliance, 2021); therefore, attention now must be focused on the implications of this initiative for nursing care amidst traumatic childbirth. An example of this is support of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) research initiatives that prioritize the address of trauma-informed care, with specific attention to current or prior birth trauma in pregnancy and delivery (2024). Various angles of research that would expand knowledge of trust in perinatal nurses amidst traumatic childbirth would include first implementing education sessions for perinatal nurses on the barriers and facilitators of trust. Following these sessions, qualitative interviews with nurses, along with birth satisfaction surveys from mothers, would provide a mixed-methods approach to further both the nurses’ and mothers’ understanding of trust in the perinatal nurse-mother relationship during and following a TCE. Interdisciplinary research (e.g., obstetrics, midwifery, general practitioners, neonatal) initiatives on these topics are encouraged due to the collaborative nature of maternal-child care. Additionally, MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 152 implementation of handover tools on improving communication, trust, and birth experiences and evaluation are also recommended. Specific limitations to this study also encourage further insight into recruiting a wider range of population groups to understand intersecting social identities which influence experiences and increase transferability of the study findings. Chapter Summary This qualitative study has examined experiences of trust and mistrust between mothers who have had a TCE and perinatal nurses amidst traumatic childbirths. Findings and discussions reflected the following themes: the foundations and fluid trajectories of trust, facilitators and barriers to trust, the impact of trauma on the development of trust, and intricacies of how mothers who have experienced trauma develop trust with their nurse. Driven by a personal desire to understand mothers’ experiences of childbirth and to improve nurses’ approaches to maternal-child nursing care, I was motivated to dig deeper into what is known about trust in the nurse-mother relationship. An objective of this thesis was to bridge the gap in perceptions of childbirth experiences between perinatal nurses and mothers, and provide recommendations for nursing education, practice, policy, and research. This chapter has revisited the identified gap of knowledge in nursing literature regarding trust amidst traumatic childbirth, provided conclusions derived from the findings of this study, identified limitations, and offered discipline-specific recommendations in pursuing RCC and TRC in perinatal nursing amidst TCEs. These findings are significant in identifying nurses’ ways of being and doing which develop, maintain, or break trust with mothers who experience traumatic childbirth. This study provided space for mothers to share their stories in hopes of guiding future perinatal MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 153 nursing care in co-constructing a shelter for them in the storm of traumatic childbirth. It was an honour to hear the personal stories of mothers who experienced traumatic childbirths and learn how nurses can establish trust during such vulnerable situations. This learning has changed the way in which I practice nursing, teach nursing students, and interact with those around me. Goldberg (2008), in their discussion of embodied trust in the perinatal nursemother relationship, accurately and meaningfully describes the challenge I have been left with after completion of this thesis: The real challenge is to work in relation with women who are not like ourselves. Those women who challenge our principles and values, who make us question our very being. 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WHO recommendations: Intrapartum care for a positive childbirth experience. https://www.who.int/publications/i/item/9789241550215 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH Appendix A Keyword Search Table NurseAND Trust patient relationship NURS* Trust* AND Perinatal Perinatal OR Birth* OR Childbearing OR Childbearing OR Obstetric* OR AND Mother Patient* OR mother* OR women* OR woman* Pregnancy outcome* OR Childbirth OR Postpartum OR Post-partum OR Intra-partum OR Intrapartum OR Maternal* OR Labour and delivery OR Maternity OR Postnatal Controlled Vocabulary CINAHL Nurse-patient relations AND Trust AND Maternal-Child Nursing OR Perinatal Nursing OR Childbirth OR Delivery, Obstetric Medline Nurse-patient relations AND Trust AND Perinatal Care OR Parturition OR Labor, Obstetric, OR Pregnancy Outcome OR Postpartum Period 169 MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 170 Appendix B PRISMA Flowchart Included Screening Identification Identification of studies via databases and registers Records identified from*: Databases (n = 476) Records removed before screening: Duplicate records removed (n = 161) Records removed for other reasons (n = 2) Records screened (n = 315) Records excluded** (n = 218) Reports sought for retrieval (n = 97) Reports not retrieved (n = 2) Reports assessed for eligibility (n = 95) Reports excluded: Reason 1 (n = 19) – MW/PHN/MD Reason 2 (n = 4) – not primary study Reason 3 (n = 25) – not specific to trust Reason 4 (n = 2) – less than 50% nurses Reason 5 (n = 7) – prenatal care Reason 6 (n = 5) - breastfeeding Reason 7 (n = 17) – not perinatal – NICU/Peds/healthcare system Reason 8 (n = 5) – self-trust Studies included in review (n = 10) Systematic review (n = 1) From: Page, M. J. et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 2021, 37271. https://doi.org/10.1136/bmj.n71 For more information, visit: http://www.prisma-statement.org/ MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 171 Appendix C Literature Review Matrix Citation Purpose/R Methodolo Participants esearch Q gy Definitions Facilitators of Trust Barriers of trust Other on Trust TCEs Nurses’ Satisfaction with pain Planned Trusting N/A characteristic control, pregnancies = relationship as a s that support birthing experience, lower satisfaction significant patient-nurse childbirth care with trust than predictor in pt interaction associated (not unplanned satisfaction with and necessarily Primips showed pain control communicati predictive of) less trust than Q:s 1) on such as trusting relationship multips Attentiveness 2) interest in Labourers/farmers Patience 3) Able patients, had higher trusting to talk to nurse 4) sensitivity to relationships than Level of business patients and housewives and 5) their skilled workers Communication feelings, and Multips showed more 6) Nurse listening to trust than primips. understanding patients' how they feel 7) problems. Nurse educators Friendliness/pleas should include ant Trusting nursing relationships communication skills may be in undergraduate predictive of nursing to promote patients’ trusting relationships. satisfaction of care. Cricco-Lizza, To Ethnograph Black, nonN/A Personal connections Impersonal or Trusted, N/A R. (2006). describe ic research Hispanic “She was really nice insensitive care. caring Black nonreports of primiparous and she was helping Did not “know relationships Hispanic lowwomen me and telling me her infant” with the mothers' income enrolled in a how to breathe” organization’s perceptions Black nonSpecial Listened to her and lactation about the Hispanic Supplemental followed-up counselors and promotion of women Nutrition Continuity of care nutritionists infant-feeding about the Program Communication facilitated the methods by pro motion Caring adoption of nurses and of Competence breastfeeding physicians. infantJournal of feeding Obstetric, methods by Gynecologic & nurses and Neonatal physicians. Nursing Dalton, E. D., This study Normative 22 RNs, NPs, Trust is High quality Patients pushing Vulnerability in Nurses Pjesivac, I., qualitativel theoretical and CNMs who relational, it communication back against pregnancy and “Saw Eldredge, S., & y examined approach. have is a voluntary increases trust. Status nurses’ actions. birth that requires the Miller, L. how experience response of trust depends on Birth plans, trust presenc (2021). From nurses, caring for based upon communication doulas, trust was vital e of a Vulnerability nurse pregnant and expectations 1) Important that disconfirming and absolutely doula to Disclosure: practitioner laboring about the they feel like they communication necessary to as A Normative s, and women in are behaviors, and signali Chunuan, S. K. Identify the Cross50 postpartum (2002). Patient predictors sectional women in satisfaction of patient design Thailand with health care satisfaction combined during their services with the with a hospital stay received during health care retrospectiv intrapartum in services e chart one regional received review. hospital in the during southern part of intrapartum Thailand [Unpublished doctoral dissertation], University of Kentucky. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 172 Citation Purpose/R Methodolo Participants esearch Q gy Definitions Facilitators of Trust Barriers of trust Other on Trust TCEs trustee’s in good hands with surveillance, nurses’ ability to ng a future me and trust me these were do their job and woman behavior, it ‘You know, interpreted as reach that ’s involves you’ve got to let patients’ ultimate goal of previou vulnerability someone take care of attempts at good pregnancy sly and risk, and you, we have to do control, and and birth traumat it assumes this job, therefore outcomes ic birth the so you have to trust indicative Specifically, trust experie trustee will us.’ of distrust means that the nce and have concern 2) Willingness by the “their way or no woman (1) her for the patient way” accepts the ensuin trustor’s to accept and follow Partner vulnerability and g interests the nurses’ directions referencing risks associated distrust (Gilson, without complaint: WHO studies with her state, (2) of the 2006). explained seen as distrust relinquishes “medic that he needs the in nurses control of the al laboring woman to Nurses see process to the establis trust him so she “can doula’s as nurse, (3) hment. relax distrust in system concedes that the ”” and listen to my “distrustful nurse’s expertise instructions.” women often do is greater than Direct and assertive not communicate her own, (4) feels – conceding to with her at all” as though she has nurses’ expertise Distrust blocks a voice and is “Feeling heard” nurses’ control being “Involved in their Lies = distrust heard, and (5) care” discloses all Disclosure of relevant personal information information to the as a sign of trust – nurse and is crucial for caring for the health of mom and baby “Confiding patients reaffirm nurses in their identities as trustworthy providers.” Fleming, S. E., Explored Qualitative 13 grand N/A Providing guidance Misunderstandin Trust allows N/A Smart, D. & grand descriptive multip women that made a g of triage reliance on the Eide, P. (2011). multiparou approach. who had given difference (ex. process (not nurse’s personal Grand s women’s birth in a changing position and calling dr. prior care and expertise Multiparous perceptions hospital at least feeling baby move) to admission). – Relied on nonWomen's of the four times, Felt nurse didn’t verbal cues Perceptions of evolving birthed five trust that their Establishing Birthing, changes times, not labour was trust was one of Nursing Care, in birthing, within the last progressing. eight identified and Childbirth nursing 12 months in themes Technology. care, and Washington Journal of technology State. Perinatal Education. Approach to Understanding Trust in Obstetric and Intrapartum Nurse-Patient Communicatio n. Health Communicatio n nurse midwives construct the meaning of patient trust in their work caring for pregnant and laboring women. southeastern U.S. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 173 Citation Purpose/R Methodolo Participants esearch Q gy Definitions Facilitators of Trust Barriers of trust Other on Trust TCEs “You must believe her. Perhaps there was a trauma of some kind. There are rules that you have to examin e her, but to me, the woman is more importa nt than those rules, and I will listen to her” (Nurse) Goldberg, L. S. To explore Feminist 8 perinatal Embodied Trust in relation: the Not hearing the “a trusting HCPs (2008). an phenomeno nurses and 8 ‘trust, it is state of being whole voice of the relationship with impatie Embodied trust experiential logy using postpartum true, restores revealed in the patient a perinatal nurse nce in within the understandi interviews women from the body to honesty simultaneously past perinatal ng of the and low-risk its integrity.’ and the integrity of Void of trust = established a experie nursing relationship observation facilities (Irigaray, the nurses’ lack of birthing woman’s nces relationship. s that . approximately 2001, p.13) conversations and engagement and self-trust” may Midwifery. perinatal 2 weeks after interactions while silence in the Trusting the body lead to nurses delivery in engaged with the relationship Trust can be misplac fostered Western women themselves Prioritizing reclaimed ed trust with Canada “Only one that told physician over pt. by the birthing me” why things were Negative/hurtful pt in women happening. experiences their within their Nursing voice was a own clinical trusted voice, despite body practices. vulnerability. Delicate communication, “Very caring”, use of physical touch. Anticipating needs Open dialogue, authenticity, nonjudgmental approach Goldberg, L. S. (2004). The perinatal nursing relation: In search of a womancentered experience [Unpublished doctoral dissertation], University of Alberta (Canada). Understand Feminist 8 labour and the phenomeno childbirth relational logy. nurses and 8 practices of birthing perinatal women nurses approximately within the 2 weeks after context of birth from a clinical low-risk practice facility in Edmonton Support, help Introductory or elicit engagement: using confidence first names. (Oxford Negotiation, Concise discussion and Dictionary of communication. English Established at Etymology, beginning. Mutual 1996; James, respect “beyond 1997). medicalization of Dependent birth” on another’s Embodied trust: goodwill and trusting the body in one is the birthing process. necessarily Honesty and vulnerable to integrity. the limits of Trusting language that goodwill encouragement, Baier (1994). intelligence, and Agreed on by relational both parties. Strength Realizing dominant position of the nurse but not negating pt’s experience. Not hearing the voice of the patient (ex. not getting an epidural when requested). Silence. Prioritizing Dr. over pt. Pts feeling pressure from physicians (not trusting body) Negative experiences = misplaced trust, forced to trust body (may be misguided) HCP using “Scare tactics”. Reciprocal. Explores Selftrust of the birthing body. Trusting the uterus “grounds the birthing process in the body” = embodied. “Motherly” metaphor. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 174 Citation Purpose/R Methodolo Participants esearch Q gy Definitions Facilitators of Trust Barriers of trust KantrowitzTo explore Cross89 RNs N/A Gordon, I., the stigma sectional employed on Price, C., of perinatal survey units caring for Rudolf, V., nurses design with mothers who Downey, G., & toward quantitativ use opioids or Castagnola, K. OUD and e and newborns (2022). NOWS qualitative withdrawing Exploring during questions. from opioids in Perinatal the the Pacific Nursing Care postpartu Northwest, for Opioid Use m period. U.S. Disorder: Knowledge, Stigma, and Compassion. Journal of Perinatal & Neonatal Nursing. Murphy, L., To Systematic “African N/A Liu, F., Keele, synthesize review American” (in R., Spencer, B., the current PubMed), Kistner Ellis, body of “Black” (in K., & Sumpter, evidence Scopus), or D. (2022). An regarding “Black” OR Integrative the “African Review of the perinatal American” (in Perinatal experience CINAHL) Experiences of s of Black AND Black Women. women “pregnancy” Nursing for AND Women’s “experiences”. Health 23 studies. N/A Mothers feel let down by healthcare systems making it hard to build trusting relationships Other on Trust TCEs The lack of trust History prevented open of communication sexual about care needs trauma and development can be of a a therapeutic concurr partnership. ing issue with opioid use. Black Making If provider Many women with positive connections and showed empathy other experiences reported establishing trust and humanity, Black that they trusted with the provider provided the best women their providers was difficult for possible medical describ (Dahlem et al., 2015; many Black care, and built ed care Roman et al., 2017) women, given trust, then race experie Patient–provider time concordance nces as communication constraints. would not be a stressfu was found to be Trust in factor l or positively associated providers was Black women traumat with trust in the found to be desired providers izing provider and prenatal decreased when who empower and care satisfaction, women them, trust them, reporte Having the same perceived and listen to them d being provider for prenatal receiving biased lack of trust in unsatis care and birth was or different care providers, the fied identified as helping because of race provider’s lack with to establish trust (Kalata et al., of trust in the aspects (Janevic et al., 2020). 2020). woman, a lack of of Humanity and Lack of availability of the empathy as continuity the providers, care facilitators for trust. specific to and a lack of they healthcare effective receive insurance. communication d structural and from providers implicit biases in often health care. lead to Black The historical women turning mistreatment of away from their Black persons in providers health care… often amplify the existent mistrust. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 175 Citation Purpose/R Methodolo Participants esearch Q gy Definitions Facilitators of Trust Barriers of trust Other on Trust TCEs ʻNurses introduce The lowest scores Watson’s theory N/A themselves and tell of satisfaction for of caring includes me what they doʼ nurses caring building trusting and ʻnurses ask me practices were relationships. what name I prefer to trust (antenatal be called. and birth) out of 1) Explaining care 2) Providing comfort 3) Trust 4) Monitor (nursing competence) 5) Human respect and listening 6) Accessible (timely meds and pain control) 7) Healing environment (privacy) 8) Affiliation needs (family included in care) Renbarger, K. To identify Qualitative 10 women who Trust occurs Nurses: (a) a) Nurses: Keeping N/A N/As M., Moorman, factors description used when women interpersonal personal distance M., Latham- associated approach substances feel their connections; spent – due to business, Mintus, K., with the during health-care time with them, heard bias, Shieh, C., & formation pregnancy and providers their stories, shared communicating Draucker, C. of trust in 15 maternity care about personal information, difficulties (2020). Factors these nurses in the them, work seeing woman asb) Demeanor: cruel Associated nurse– U.S, who had in their best both “woman and a gestures, With a Trusting patient delivered in the interest, and mother” (b) withheld pain Relationship relationshi hospital within are demeanor toward meds, rolled eyes, Between ps with the past 2 compassionat women; spoke c) Inadequate care: Pregnant and pregnant years. e and kindly, caring for no supplies, Postpartum and culturally infant, fulfilling difficulty IV, Women With postpartum sensitive needs (c) ways of withholding pain Substance Use women (Birkhauer et providing (quality) meds, only Disorders and with al., 2017; care, good pain “basics” Maternity substance Briscoe et mgmt. (d) d) Communication: Nurses. disorders. al., approaches to not about baby, International 2016). providing no parenting tips Journal of information; e) Blaming for Childbirth Informed, infant or IV sites personalized, f) Lacked nonjudgemental (e) knowledge about attitudes toward addiction (ex. substance use; pain) encouragement, Women a) closed reassuring, easing and distant b) guilt, and (f) hostile behavior addiction expertise. c) non-compliant The d) active use e) characteristics of the not active in women were (a) infant care engagement with Othman, F., Liu, Y., Zhang, X., Wang, P., Deng, L., & Cheng, X. (2020). Perinatal women’s satisfaction with nurses caring behaviours in teaching hospitals in China. Scandinavian Journal of Caring Sciences The aim of Descriptive 422 N/A this study , crosspostpartum was to sectional women of two identify the study teaching level of Questionna hospitals in women’s ire on Wuhan, China, satisfaction satisfaction having SVD/ with of nursing CS without nurses’ practices. complications caring behaviours during the antenatal, childbirth and postnatal periods. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 176 Citation Purpose/R Methodolo Participants esearch Q gy Sapkota, S., To explore Qualitative Sayami, J. T., mothers’ interview Manadhar, M. experiences study with D., & of the care 10 firstErlandsson, K. received time (2014). while mothers Nepalese giving birth voluntarily mothers’ in hospital recruited experiences of settings in from care in labour. Nepal. maternity Evidence Based units Midwifery Definitions Facilitators of Trust Barriers of trust 10 primips in N/A the hospital after delivery in Nepal. nurses, (b) demeanor toward nurses, (c) attitudes toward care, (d) investment in recovery, and (e) ways of interacting with infant. Women a) Open and forthcoming b) demeanor: thankful for care c) attitudes towards care; accepting help/compliant d) investment in recovery e) infant interaction and concern Trust = 1. Not considering Accountable caring: individual needs keeping informed, or the wellbeing assisting in of the newborn. positioning/pushing, “consoled”, “good and warm-hearted”, 2. Act of communication: advised on benefits of SVD, shared decision-making, Other on Trust TCEs Importance of N/A preparation of birth to understand nurses’ actions. Trust paves the way for woman feeling ‘cared for’. The main category ‘trust in care providers, both relatives and professionals, was fundamental for mothers to feel cared for MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 177 Appendix D Recruitment Poster MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 178 Appendix E Participant Information Letter UNDERSTANDING MOTHERS' TRUST IN NURSES AMIDST TRAUMATIC BIRTHS You are being invited to participate in a research study exploring the development of trust and mistrust between mothers and perinatal nurses. Please read the information below to help you decide if you are eligible to participate. PARTICIPANT CRITERIA: • • • • • • Term (>37 weeks), hospital delivery within the last 2 years At least 6 weeks postpartum Received care from a nurse during labour and/or delivery English speaking and at least 19 years of age Were discharged from the hospital with your newborn Experienced the birth as traumatic IF YOU PARTICIPATE, WHAT WILL YOU BE ASKED TO DO? If you agree to be in this study, you will be asked to take part in a 30 to 60-minute interview about your experience of trust or mistrust with nurses during your birth. The time and location of the interview will be mutually agreed upon between yourself and I. The interview will be audio recorded and transcribed. You will be compensated for your time with a $50 VISA gift card. Your personal information will be kept confidential and any identifying information will not be presented in the study. HOW CAN YOU JOIN THIS STUDY? If you would like to be a part of this study or have further questions, please click here (link to be provided). If you are interested and eligible, you will be asked to fill out a short survey and will be contacted by the principal investigator to set-up in interview. If you have concerns about the study or would like to know more about Trinity Western University, please contact my supervisors Dr. Kendra Rieger (email) or Dr. Lyndsay MacKay (email). Participation is completely voluntary. Thank you for considering this opportunity to take part in this study. CONTACT Caitlin Friesen (Principal Investigator) (phone)/(email) MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 179 Appendix F Consent Form Participant Consent Form Understanding Mothers’ Experiences of Trust in Perinatal Nurses Amidst Traumatic Childbirth Principal Investigator Caitlin Friesen School of Nursing Trinity Western University (email) As a graduate student, I am required to conduct research as part of the requirements for Masters of Science in Nursing degree. This research is part of a thesis and will be made publicly available following completion. This study is being conducted under the supervision of Dr. Kendra Rieger and Dr. Lyndsay MacKay. You may contact the research supervisors by email: (email) OR (email) Purpose The purpose of this research is to explore experiences of trust and mistrust between mothers who have experienced a traumatic childbirth and perinatal nurses on maternal-child hospital units within Canada. Traumatic childbirth experiences have been associated with significant negative implications for the mother, the newborn, and the family unit. With an understanding of how mothers experience trust within relationships with perinatal nurses, this study aims to equip nurses to provide relational, trauma-informed care to birthing mothers. You are being asked to participate because you gave birth in a Canadian hospital within the last two years and have identified that your birthing experience was traumatic for you. Your account of your experience is incredibly valuable to this research as I explore trust in the nurse-mother relationship amidst traumatic births. What is involved If you voluntarily consent to participate in this research, your participation will include: - A 45-60-minute interview at a convenient location (your home, Trinity Western University campus, or a coffee shop). This interview will be conducted by myself, Caitlin Friesen, and will be recorded using Microsoft Teams or a small audio recorder. o A virtual option is also available and if chosen, will be conducted on Microsoft Teams. - Key areas we hope to explore include: your birth story, your relationship with the nurse and any moments in which you felt trust was built or broken during the birthing and postpartum period. - Prior to the interview, you will also be asked to complete a brief survey which will include information about yourself and your birth. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 180 - If you are willing, you will be contacted for a short (10-20 minute) discussion about your interview to help guide the study. Following the completion of my research, you will have access to the study. You will be contacted by their preferred contact method when the research becomes available. Potential Risks and Discomforts There are some potential risks to you by participating in this research and throughout the interview, including topics you may be uncomfortable talking about or that cause emotional distress. To prevent or to manage these risks, the principal investigator will offer the following: - At any time during the interview, you can skip a question that I have asked, have the right to take a break, or decide you would no longer like to participate with no questions asked . - You will be provided with contacts to local counselling services and mental health crisis services if requested. - The researcher will also allow time for pauses during the interview and will offer a time of debriefing following completion of the interview. Potential Benefits to Participants and/or to Society There are some potential benefits to you as a result of participating in this research, including an opportunity to process emotions associated with your birth experience and begin or continue your personal healing journey. Additionally, an understanding of mothers’ experience of trust amidst a traumatic birth will help equip nurses in providing future care to childbearing mothers. Remuneration/Compensation As a way to thank you for your participation and compensate you for any inconvenience related to that participation, you will be given a $50 VISA gift card. If you choose to withdraw from the study before the interview, you will not receive compensation. If you choose to withdraw following the interview, you will still be compensated for your time. Confidentiality and Anonymity Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will be disclosed only with your permission or as required by law. Although a breach of privacy is always possible, the research has taken steps to minimize the risk. Any information that can be identified with you or your infant (e.g. your name, your child’s name, hospital name) will be removed from the interview and the study. You will be assigned a study ID number and your contact information will be stored safely, separate from the other data, and will only be accessible to the research team. All interviews and data will be stored on a password protected computer and will only be accessible to the research team. Data maintenance Data from this study will be stored in a confidential manner for ten years in the potential case of secondary analysis. Audio recordings will be erased following the thesis evaluation. Any files will be shredded or deleted ten years after completion of the thesis. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 181 Study Information Would you like to receive the results of the study? YES NO Do you consent to allow your data from this study (in anonymous form) to be used in future research? YES NO Confirmation of Study Findings Do you consent to being contacted once throughout the research process for a short discussion to further discuss your experience either via email or virtual meeting? YES NO Contact for information about the study If you have any questions or desire further information with respect to this study, you may contact Caitlin Friesen at (phone) or (email) You may also contact Dr. Kendra Rieger at (email) or Dr. Lyndsay MacKay at (email) Contact for concerns about the rights of research participants If you have any concerns about your treatment or rights as a research participant, you may contact the Ethics Compliance Officer in the Office of Research, Trinity Western University at 604-513-2167 or HREB@twu.ca. Consent Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without any consequences. If you wish to withdraw from the study, please contact Caitlin Friesen (see above contact information). Withdrawal is possible at any point during or before the interview process and up until two days following data collection. At this point, data analysis will have commenced, and the researcher will be unable to identify participant’s responses in order to remove them. Signatures Your signature below indicates that you have had your questions about the study answered to your satisfaction and have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 182 Research Participant Signature Date Printed Name of the Research Participant signing above MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 183 Appendix G Sociodemographic Questionnaire 1. What is your gender? a. Female b. Male c. Non-binary d. Other _________ e. Prefer not to say 2. What is your age? _____ 3. What is your marital status? a. Married or common-law b. Separated c. Divorced d. Never married e. Other f. Prefer not to say 4. What is your highest level of education? a. Some elementary b. Some high school c. Completed high school d. Some university e. Completed apprenticeship/trades schooling f. Bachelor’s degree g. Graduate degree (e.g. Master’s) h. Post graduate degree (e.g. PhD) i. Other ______ j. Prefer not to say 5. What best describes your employment status? a. Unemployed b. Part-time c. Full-time MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 184 d. On leave (e.g. maternity leave, sick leave) e. Other _____ 6. Which best describes your ethnic background? __________ 7. What is your province of residence? ________ 8. What type of delivery did you have? a. Vaginal birth b. Vaginal birth requiring forceps or vacuum c. Vaginal birth after a past caesarean section d. Expected caesarean section e. Unexpected caesarean section 9. Which term best describes you? a. This was my first delivery b. I have had past deliveries. This was my __delivery._ i. 2nd ii. 3rd iii. 4th iv. Other ____ 10. What is the biological sex of your infant? _______ 11. Did you experience any complications during your pregnancy? (e.g. high blood pressure, gestational diabetes, preeclampsia). If so, please list here ______. MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 185 Appendix H Semi-structured Interview Guide for Qualitative Interviews Thank you for being willing to participate in this study. A reminder that you are free to withdraw at any point during the interview. If the topics of conversation are emotionally distressing or uncomfortable, we can pause at any time. The questions that will be asked are in order to get a sense of your traumatic birth experience and the concept of trust within the nurse-patient relationship. Do you have any questions before we begin? - Can you please tell me about your birth experience and especially anything related to your relationship with the nurses? o You have experienced this birth as traumatic, can you describe contributing factors to this experience? - How would you describe your relationship with the nurse(s) during your birth and postpartum maternity care at the hospital? - What does the word trust, in a nurse-patient relationship, mean to you? - Did you feel like you were able to develop trust with your nurse? If so, what helped the trust to develop? - Can you recall and describe a moment where trust was built with a nurse during your traumatic birth experience? o Why do you think you developed trust with that nurse? - What factors do you feel are important in developing a trusting relationship between mothers and nurses during labour and delivery? o What characteristics of the nurse support the development of trust with patients with TCEs? - Was there a moment where you did not feel that you could trust your nurse? o What made it difficult to trust your nurse in this situation? o Or prevention of or/break in trust? - What advice would you give nurses who hope to develop trusting relationships with postpartum patients? - How important is it that your nurse trusts you? MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 186 - Did your relationship with the nurse have an impact on how you experienced your delivery or postpartum care? If so, how? - Is there anything else you would like to share? MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 187 Appendix I Field Notes Template Date/time: Interview number: Interview length: Descriptive Notes: Context of Interview and Participants Actions/Dialogue 1) In-person or virtual interview (include setting if applicable): 2) Observations of non-verbal communication or responses: 3) Participant response to the interview as a whole and/or to specific questions: Methodological Notes 1) What went well: 2) Note any methodological/technological issues: 3) Reflections on interview questions: MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 188 4) Potential adaptions for future interviews: Reflective and Analytical Notes (including recurring themes): MOTHERS’ EXPERIENCES OF TRUST AMIDST TRAUMATIC CHILDBIRTH 189 Appendix J Debriefing Script - Thank you very much for your participation in this study, your experience and your vulnerability are valued greatly. - How are you feeling after sharing your experience? - Would you like to take some time to reflect or discuss any of the questions or feelings that may have been brought up throughout the interview? - If you are experiencing distress, or would like additional support, please let me direct you to the Mental Health Support line: 310 Mental Health Support (3106789) or I can provide a list of local counselling services. - I encourage you to take some time for yourself, and to spend time with those you feel supported around. Please don’t hesitate to reach out if you have any questions.