Consent to Participate in a Research Study
Women’s Experiences of miscarriage in the emergency department
You are invited to participate in a research study conducted by Elizabeth Jacobs-Fitzgerald,RN BSN a student at Nebraska Wesleyan University.  The organizations of Connected Forever and No Footprint Too Small willingly added information about this study to their websites. You are being asked to participate as a woman ages 19 – 40, who experienced a miscarriage in an emergency department, from the time period of 2009 through the present.  You should read the information below and ask questions about anything you do not understand before deciding whether or not to participate.
Purpose of the Study:  The purpose of this research study is to better understand the emotional impact of a miscarriage and improve the care received from healthcare providers for women who experience a miscarriage in an emergency department.  
What You Will Do in This Study: You will be asked to complete an online 18-item survey and three short-answer questions, relating to your experience of miscarriage in an emergency department.  The survey and short-answer items should take approximately 4 minutes or less to complete. 
Potential Risks & Discomforts: Potential risks may include painful emotions and feelings associated with the memories of the miscarriage of your baby. You may feel discomfort during or after the survey, and you may choose how much or how little you want to include in the survey. You can stop participation in the research at any time.  Attached to the survey will be a contact list of Licensed Mental Health Providers (LMHP) who offer to counsel individuals and families who have experienced a  loss either through miscarriage, stillbirth, or newborn death.    
Risks:  As stated earlier, if the survey brings up uncomfortable feelings, you are urged to contact one of the mental health providers on the list at the end of the survey.
Anticipated Benefits:  There are no monetary benefits for participating in this study. This opportunity may contribute to the healing process through the process of remembering your baby.
Confidentiality & Privacy:  To protect your confidentiality and privacy, I will take the following steps:  Participant’s privacy will be protected by not using names or other identifying information in any reports or presentations. The research data will be kept in a locked location; electronic data will be kept on a password-protected computer. Only the researcher and the research advisor will have access to the data. All the anonymous data will be kept on the Nursing Department Administrative Assistant’s password-protected computer for three years after the completion of the study and then destroyed. The organization of Connected Forever will not have access to your information.
 Participation and Withdrawal: You are free to decline to participate in this research study, or to withdraw your participation at any point, without penalty.  Your decision whether or not to participate in this research study will have no influence on your present or future status at Nebraska Wesleyan University.
 Questions: If you have questions about this study, please contact: Elizabeth Jacobs-Fitzgerald at or Dr. Jeri Brandt at
This research has been approved by the Nebraska Wesleyan University Institutional Review Board (IRB). To ask questions about  your rights as a research participant contact
Agreement: Completion of the survey indicates you are age 19 or over and that the purpose and nature of the research have been sufficiently explained to you for you to decide to participate in the study.

Question Title

* 1. Please select the response that most reflects your feeling

  Definitely not true for me Rarely true for me Quite true for me Definitely true for me
1.My miscarriage destroyed my zest for life
2. I feel my body has betrayed me
3. My miscarriage represents a major setback for me.
4. After my miscarriage, I was down for several days but then got over it.
5. I have gotten through with dealing with my miscarriage.
6. Through miscarriage, I feel I lost a part of myself.
7. I feel there will always be a place in my heart for the miscarried baby.
8. Through miscarriage, I feel that I have lost a person. 
9. I get irritated when my miscarried baby is called a fetus.
10. I felt much alone in my loss.
11. Through my miscarriage, I have experienced a loss of pride in myself.
12. I dwell on the fact that my child will only exist in memory.
13. I feel guilty about my miscarriage.
14. I feel very isolated by my miscarriage
15. My miscarriage was a horrendous, devastating event.
16. Miscarriage equals one big loss of control.

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* 2. 17. What actions or statements did you perceive as supportive when you were a patient in the Emergency Department with your miscarriage?

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* 3. 18. What actions or statements did you perceive as non-supportive when you were a patient the Emergency Department with your miscarriage?

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* 4. 19. What words or statements should be spoken by healthcare providers that convey compassion and validation towards a woman who has experienced a miscarriage?

Listed below are the names of counselors who specialize in working with women who have experienced a miscarriage:

Jami Blomstedt, LIMHP, LMFT                                                                    Quinn Lawton, MS, LMHP, NCC

Marriage & Family Therapist                                                                       Take Flight Farms

Growing Together                                                                                           1004 Farnam Street, Suite 400

770 North  Cotner Blvd                                                                                  Omaha, NE 68102

Lincoln, NE 68505                                                                                              402.930.3037




Liz Chalenburg, MS, PLMHP, LADC                                                           

1620 South 70th Street                                                                                   Healing Hearts

Suite 105                                                                                                              Family Life Office

Lincoln, NE 68506                                                                                             3700 Sheridan Blvd

402.809.5790                                                                                                      Lincoln, NE 68506


Karen Marker, MA, LIMHP, CDGC, PLADC

Into Balance                                                                                                       Remembering Our Children Support Group

1620 South 70th Street                                                                                   Madonna Rehabilitation Hospital

Suite 105                                                                                                              Lancaster Room

Lincoln, NE 68506                                                                                             5400 South Street

402.807.0476                                                                                                      Lincoln, NE 68506



2320 South 48th Street

Suite 100

Lincoln, NE 68506