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Survey for Healthcare Providers Caring for Families Experiencing Perinatal Loss
Indicates required field
1. Which of the following best describes you?
Parent (please return to the PARENT SURVEY and complete the survey that was created especially for parents experiencing the loss of a child)
If Other please specify:
2. What state are you from?
3. Please select all of the services currently provided by your hospital and/or the items routinely given to your patients experiencing perinatal loss
baby is bathed
baby is diapered and dressed
written information about grief and perinatal loss
information about community resources and/or support group
clay mold of feet or hands
lock of hair (when appropriate)
memory box to keep baby's item in
blanket and clothing worn by the baby
memorial video (provided by hospital, NOT outside organization)
4. If your hospital provides pictures, please choose what type of pictures are ROUTINELY offered. Select all that apply.
35mm film given to family for developing
35mm film developed by hospital
pictures from digital camera and printed in hospital
pictures from digital camera and printed OUTSIDE hospital
CD of pictures taken with digital camera
We encourage family members to take pictures with their own cameras
we do not routinely offer pictures
5. If your hospital offers PRINTED pictures (or Polaroids), how many are ROUTINELY given to the family? If you routinely take pictures with a 35mm camera ONLY and then give this film to the patient (undeveloped), please select only this choice below.
One or two
10 or more
a roll of undeveloped 35mm film (or disposable camera)
CD of pictures only
6. Do you feel as though your hospital does enough to support families experiencing perinatal loss?
Yes, but I think we could still do more
NO! I cringe when we get a patient with a fetal demise because we don't have the proper resources/staff/time to properly care for her.
7. Please rate how satisfied you are with your perinatal bereavement program / standard of care.
8. What area(s) do you think your hospital could improve on when caring for patients experiencing perinatal loss?
Time available to spend with patient/family
Written information given to patient/family
Mementos (memory box, clay molds, lock of hair, etc)
General staff training
9. Does your hospital utilize NILMDTS (Now I Lay Me Down to Sleep)?
Yes, frequently (For at least 75% of all demises encountered, regardless of gestational age)
Yes, sometimes (50% or less)
Yes, but rarely (Less than 20%)
Not really (perhaps a couple of times each year)
I have never heard of NILMDTS
10. How many losses does your facility encounter each year (approximately)? Please include losses of any gestation but only those cared for OR followed up with by NICU, L&D, OR a perinatal bereavement coordinator/team member. If any of the previously mentioned services are provided on the GYN unit, you may included these losses also.
Less than 10
10 - 25
26 - 50
More than 100
I have NO IDEA
Please leave any comments, suggestions, or requests for information here. Thank you for your time.