The Future of Nursing 2020-2030 report describes nurses as the bridge–builders who connect with people and communities to ensure they have what they need to be healthy and well. There is, however, an essential step that must be done before those connections can be made. That essential step is to listen. Listening to women, in particular, guides the research and daily practice of three College of Nursing faculty, Drs. Lisa Segre, Julie Vignato, and Ann Weltin.
By Riza Falk | Office of Communications & Marketing
Listening to Women: Pain
For Julie Vignato, PhD, RN, RNC-LRN, CNE, the focus on listening is personal. Her brother struggled with mental health issues before committing suicide eight years ago.
“He’d be frustrated,” she said. “He’d say, ‘Julie, why doesn’t my brain work right?’ Ever since then, I’m like ‘OK, so that’s it, this is my focus for my Ph.D., this is how I’m going to honor him.”
“But it’s perinatal mental health,” she said, adding with a laugh, “my experience is in maternal child nursing, so I don’t know what to do with males.”
Vignato’s current research focuses on the comorbidities of depression and pain during the perinatal period—the third trimester of pregnancy and one year postpartum.
“We’ve found, in my postdoctoral work, that when women have pain, they go to their providers, and they’re minimized. They might be told to do non-pharmacologic pain management, to stay home and put your feet up, or to get a massage; but women can’t. They have to work, or they are taking care of their toddlers,” she said.
Vignato noted that pain in pregnancy has been under treated historically because it is thought of as an acute problem that’s not long term or chronic. Her research shows, however, that not treating this pain can have lasting effects.
If you say ‘well, this starts from untreated pain,’ pain is still stigmatized, but not as much as mental health.
“If the untreated pain prevents a woman from sleeping, causes her to feel helpless and hopeless, she can’t function and she’s minimized, then that can lead to depression, and depression may continue after pregnancy into the postpartum period. And we know that perinatal depression can affect the child up to the age of five years, if not longer.”
Vignato is currently the investigator on a University of Iowa Center for Advancing Multimorbidity Science pilot project to develop a clinical predictive model of preeclampsia based on longitudinally collected information on multiple chronic conditions, and to further the understanding of the biological mechanisms that may be able to serve as early biomarkers for preeclampsia.
“We’re focusing on headache pain, because that’s a really common symptom of depression, and how that might predict adverse maternal outcomes such as preeclampsia—one of the highest diseases of mortality during pregnancy,” Vignato said.
“We look at patients holistically anyway, and so this CAMS multimorbidity study is a great way to provide that holistic viewpoint and to see—can we predict these adverse outcomes and, if we can predict them, we’ll look at interventions to prevent these outcomes.”
Anecdotally, Vignato has heard of women who hid their symptoms because of the stigma associated with depression and the fear that their babies could be taken away. She hopes to influence the narrative around perinatal mental health to reduce this stigma and increase the likelihood of treatment.
“If you say ‘well, this starts from untreated pain,’ pain is still stigmatized, but not as much as mental health,” she said.
In the long term, Vignato’s research boils down to one simple-sounding goal: pregnant women are listened to and their pain is treated. She is determined to continue her research until these women are supported and solutions are found to help take the pain away, prevent depression, and improve their mental health.
Listening to Women: Gynecological Health
As a family nurse practitioner who is also a certified nurse midwife, Ann Weltin, DNP, FNP-BC, CNM spent twenty years listening to and caring for women and their children at a low-income clinic in Milwaukee, Wisconsin.
During that time, Weltin delivered 400 babies and described it as incredibly rewarding to “walk with women during the best times of their lives and sometimes the worst times of their lives, when things didn’t go right.”
After moving to Dubuque 15 years ago, Weltin found another way to focus on women’s health: the federal family planning program, Title X. Administered by the Health and Human Services Office of Population Affairs, Title X offers a wide range of reproductive health and pregnancy–related services, including wellness exams, sexually transmitted infection testing, cancer screening, birth control, and health education.
Since the program’s inception in 1970, the network of nonprofit health and community service agencies that receive Title X funding have served more than 190 million low-income or uninsured clients, the majority of whom were women. The program prioritizes providing access to high-quality services regardless of a patient’s ability to pay and advancing equity for all.
Weltin currently runs the Title X program at Crescent Community Health Center, a Federally Qualified Health Center.
She has also been teaching future nurse practitioners for the past 12 years and joined the College of Nursing as a clinical associate professor in 2021.
Nurses can have a key role in [health] education and in women’s health care in general because their training teaches them to be cognizant of the total person.
She views gynecologic health, from period-onset to post-menopausal changes, as a huge part of a woman’s quality of life. “We also know that worldwide, cervical cancer is still one of the leading causes of death among women, so low-income women, especially those who haven’t had the opportunity to be screened regularly–that’s an unbelievably essential service,” she said.
For Weltin, women’s health care education is fundamental.
“The youngest person I delivered a baby for was 12,” she said. “We are seeing children younger and younger who don’t know what to do with their bodies. They’ve never been educated about sexually transmitted infections, birth control, pregnancy, and how easily it occurs.”
Nurses can have a key role in this education and in women’s health care in general, Weltin noted, because their training teaches them to be cognizant of the total person.
“When we’re looking at the ability to care for women from multiple cultures, to meet the sensitive needs of women, perhaps who have been traumatized in some way sexually, the needs of people who may identify sexually with a different gender, those kind of sensitive issues—I think nurses today are uniquely equipped to handle all of those very, very sensitive issues that are tied in with our women’s health care needs,” she said.
Listening to Women: Postpartum
Although we know that one in seven women experience postpartum depression, providers and health systems struggle with the best way to support and treat this group of women. Logistical issues such as cost, time, and transportation may preclude treatment. Other times, the reasons are rooted deeper, such as stigma and lack of trust. According to decades of research conducted by College of Nursing Professor Lisa Segre, PhD, adding Listening Visits to the array of treatment options providers choose from is one way to increase the likelihood that women get the treatment they need.
First instituted by a British public health nurse in the 1980s, Listening Visits are non-directive counseling interventions delivered by home–visiting nurses. The nurses are trained in postpartum mental health, empathic listening, and problem solving. In sharing with a non-judgmental nurse who fully listens, the patient often develops a clearer perspective and is open to collaborative problem-solving.
“The underlying rationale for this intervention is that women often just need someone to listen to them as they sort out their own situations, rather than necessarily requiring mental-health specialist care,” said Segre.
While many things may be different between the United States and British health systems, the perception women have of nurses as trusted, caring providers is not one of them. Through her research, Segre has shown that women of all economic levels find it acceptable for postpartum depression screening and counseling to be provided by nurses, and more than half the women surveyed were ‘definitely willing’ to be counseled by a nurse. The nurses agree. Ninety percent of the nurses surveyed ‘agreed’ or ‘strongly agreed’ that nurse-delivered counseling was a good idea, nearly 50 percent were regularly providing some form of counseling already, and approximately 75 percent were willing to participate in a counseling skills training program.
The next step in Segre’s work was assessing the effectiveness of Listening Visits in the United States. She found a statistical and clinically significant improvement in depressive symptoms among participants who had six listening visits in their home or Ob-Gyn’s office during an eight-week period, and qualitative assessments indicated that the women valued this approach. What’s more, the improvement was sustained, and the mood continued to improve during the following eight weeks. Additionally, a cohort of participants who began their Listening Visits eight weeks postpartum also experienced significant improvement.
After discussing the Listening Visit concept with Segre, neonatal nurse practitioner Rebecca Chuffo Davila, DNP, NNP-BC, FAANP, recognized the potential value of this intervention for mothers of hospitalized newborns. The two decided to team up and take the Listening Visit model to a new location—the neonatal intensive care unit.
The research shows that listening matters. My one goal in life is to have Listening Visits be implemented as a standard of care in all NICUs.
Mothers with babies in the NICU are at increased risk for depression, but treatment referrals are often unsuccessful because they prefer to spend any free time with their babies and see their needs as secondary to those of their baby. Delivered by nurses, the Listening Visit intervention counteracts this by bringing the treatment to these moms at the infant-point-of-care. NICU moms develop close relationships with their neonatal nurses, and nurses are knowledgeable about the newborn’s medical status, leaving these nurses uniquely positioned to deliver the Listening Visits.
A NICU clinical trial conducted by Segre and Chuffo Davila’s team—the first of its kind—found that moms who participated in a series of Listening Visits reported lower anxiety and depression symptoms, and improved self-esteem. A subsequent trial, which concluded in 2020, found higher rates of improvement four weeks after enrollment among recipients of Listening Visit (56.3%) compared to recipients of usual care (23.8%). Adapting to the limits of clinical studies during a pandemic, the team is now piloting the idea of Listening Visits delivered by nurses via Zoom.
A psychologist by training, one thing Segre loves about nursing and nursing science is that it doesn’t stop with the research. “Nurses get the point of putting it into practice,” Segre said, and moving away from studies and into the community is an important aspect of her work. Largely due to her research and community connections, the Listening Visit model has been adopted by the Iowa Department of Public Health, and Listening Visits delivered by maternal health agency staff even have their own Medicaid billing numbers. Segre visits IDPH every other year to train new staff on the Listening Visit model.
The NICU research is moving into the community as well. Segre and Chuffo Davila are currently bringing together a broad group of collaborators, including the Iowa Neonatal Quality Collaborative, the Advanced Practice Institute in the University of Iowa Hospitals and Clinics Department of Nursing, Mercy Health in Waterloo, Iowa, two medical anthropologists, and a NICU parent advisory board to create a pathway for implementing Listening Visits in community NICUs.
The research shows that “listening matters,” said Segre. And now, “my one goal in life is to have Listening Visits be implemented as a standard of care in all NICUs.”
Read more from our winter 2021/22 alumni newsletter here.