Medical-Legal Communication Among Emergency Nurses in States With Abortion Bans

Abstract

OBJECTIVE

The objective of this study is to describe how emergency nurses receive and share information about practice concerns related to abortion bans.

BACKGROUND

In the United Sates, details of abortion bans are changing and create confusion around clinical and legal implications with attendant challenges in maintaining communication.

METHODS

A qualitative exploratory descriptive approach was applied, using interview data from 19 emergency nurses working in states with abortion bans and 3 working in states without bans.

RESULTS

Categories of individual, interpersonal, and institutional factors were described, with 11 emerging themes. Participants reported no communication from administrations about practice implications of abortion bans, and distress over implications for both patients and their own practice.

CONCLUSIONS

Nurses working in emergency departments (EDs) in states with abortion bans report anger and frustration at the scarcity of both information and guidance provided by hospital administrators and ED managers, with concern about their ability to provide safe and appropriate care. Normal channels of communication about practice changes go unused, leading to practice challenges and moral distress.

In the United States, laws limiting access to abortion are in a state of flux, and nursing leadership faces significant challenges related to communication about practice changes. At the time of this publication, 20 states have limitations or total bans on abortion. In all those states, there is an exception for the life of the pregnant person. Other exceptions fall into 3 categories: 1) the health of the pregnant person (14 states); 2) rape or incest (10 states); and 3) fatal fetal anomaly (7 states).¹ Some states have abortion laws specifying that the care for ectopic pregnancies or patients demonstrating fetal demise are not criminalized, but these laws are often unclear regarding care for patients actively miscarrying in the presence of some fetal cardiac activity.¹ It is not always clear under what circumstances the conditions of “life or health of the pregnant person” can be invoked.² This confusion has challenged healthcare providers and organizations in offering clear guidance regarding when abortion care may be provided.

Although these new laws are problematic in many clinical contexts, there are specific challenges involving emergency departments (EDs). In the extreme, Idaho has maintained that their total abortion ban should take precedence over the Emergency Medical Treatment and Active Labor Act, making the ED less safe for obstetric patients, and causing significant clinical challenges for staff.¹ In many states, there is an increase in ED visits for obstetric care, driven by increasing maternal care deserts,^2-5 which are defined as counties where there is no provider of obstetric care (OB/GYN or midwife). In these places, EDs often become the default for unplanned obstetric care. However, other studies have demonstrated that ED nurses are not universally trained in the identification and treatment of obstetric emergencies.^3,4 This combination of lack of training and lack of access can have suboptimal results for patients.

Recent findings suggest that ED nurses do not have awareness of the clinical, ethical, and legal implications of abortion bans for both ED staff and for patients.³ Specifically, participants in previous research on this phenomenon^3,4 reported, with varying degrees, limited personal knowledge of the existence of an abortion ban in their state, confusion about what information they could relay to a patient seeking abortion care electively or for a miscarriage, and advocacy processes for patients needing emergency abortion care. The causes of this striking finding remain unclear. There seems to be an active avoidance of discussion of abortion bans as a “political” topic in the workplace.⁴ The 2024 elections, with their implications for access to reproductive care including both abortion and contraception, brought a sense of urgency to understanding such communicative processes and the impact on both nursing distress and patient care.

The current study focused on medical-legal communication experienced in relation to these bans. The approach in this study is grounded in the concept of biocommunicability,^6,7 a framework used within linguistic and medical anthropology to study how health information is produced, circulated, and received.^8,9 Studies of biocommunicability play close attention to how health-related knowledge is articulated by a range of social actors, including healthcare providers, patients, and government officials, tracing how some perspectives gain wide circulation while others are muted or silenced. This framework is premised on a linguistic anthropological understanding of communication as a form of social action and seeks to understand the consequences of the process of biocommunicability. Using this framework, this study explores communication about abortion bans from the perspective of ED nurses. The study aimed to understand the ways in which ED nurses receive and share information about abortion bans and their implications for patient care, examining how discussions are avoided or silenced, and under what conditions they occur. Examining how nurses talk, and do not talk, about abortion bans in the context of caring for obstetric emergencies provides important new insights into how abortion bans impact patient outcomes and clinical practice.

Methods

Sample

A sample of ED nurses practicing in states with and without abortion bans was recruited using networking and snowball techniques via social media and email. There were no exclusion criteria.

Data Collection

A qualitative exploratory approach¹⁰ using interview data was used. Before data collection, this study was reviewed and approved by the University of Massachusetts Amherst institutional review board. Demographic information was collected via an online platform (Qualitrics) during the registration process about individual participants (eg, age, gender, education, general nursing experience, specific emergency nursing experience) and the practice settings in which they work (eg, type of ED, number of annual patient visits, geographic location, presence/absence of abortion bans). Eligible participants were interviewed via Zoom in 1-hour-long semistructured interviews. The interview guide was developed from both nursing and anthropological perspectives in recent literature, with the intent of examining the presence or absence of communication about abortion bans, as well as the specific communicative strategies used by ED nurses in this context. Each interview participant read an informed consent document explaining the study before their interview. Each participant provided both verbal assent and sent a signed form. Interviews were conducted between March 15 and May 10, 2024. Interviews were recorded and transcribed in their entirety using the Zoom software and corrected by trained research assistants. Confidentiality was maintained via study codes using role, participant number, gender identification, and role in the ED department (staff nurse = SN; charge nurse = CN; educator = EDU) and deletion of audio recordings once transcripts were verified. Participants were mailed a $75 gift card upon completing the interview.

Data Analysis

Demographic data were exported to an SPSS database (SPSS v 28.0., Armonk, NY), and descriptive analyses were conducted (SDC 1, http://links.lww.com/JONA/B256). Interview data were analyzed by each member of the research team, and thematic meaning was agreed upon. Saturation was discussed between interviews and determined by interview 18; the last 4 interviews were conducted to ensure appropriate geographic representation in the sample (Table 1). Procedures were maintained for trustworthiness, credibility, transferability, and dependability via triangulation, member checking, and external review.¹¹

Table 1.

Demographics of Participants' Primary Practice Sites

ED patient population (n = 22)
General ED	91%
Adult only	9%
Pediatric only	0%
Facility type (n = 22)
Nongovernment, not for profit	76.5%
Investor owned, for profit	4.5%
State or local government	20%
Federal government/VA/military	0%
Geographic location (n = 22)
Urban	31.8%
Suburban	54.5%
Rural	13.6%
Facility designationa (n = 22)
Academic medical center/teaching hospital	91%
Community hospital	54.5%
Critical access hospital	18%
Free-standing ED	9.1%
No. yearly ED visits (n = 22)
1–5000	4.5%
5001–10 000	0%
10 001-20 000	4.5%
20 001-30 000	9.1%
30 001-40 000	13.64%
40 001-50 000	4.5%
50 000-75 000	13.64%
75 000-100 000	18.14%
More than 100 000	22.73%
US state representation by region (n = 22)
Northeast (ME, NH, VT, MA, RI, CT, PA, NJ, MD, DE)	9.09%
Southeast (DC, WV, VA, NC, SC, KY, TN, AR, LA, MS, GA, FL)	40.89%
Midwest (ND, SD, NE, KS, MO, IA, IL, IN, MN, MI, OH)	4.5%
Southwest (TX, AZ, NM, OK)	45.37%
West (WA, OR, CA, MT, ID, NV, UT, WY, CO, AK, HI)	0%
Care-limiting legislation (n = 22)
Reproductive healthcare including abortion	20%
Gender-affirming care	10%
Both reproductive and gender-affirming care	35%
No care-limiting legislation	5%
Do not know	30%
Means of communication about practice changes/clinical issuesa (n = 22)
Staff meeting	91%
Email	91%
Posted notice	59%
Shift huddles	63.6%
1:1 in person training	22.7%
Communication book	0%
Online education (ie, HealthStream)	31.8%
Word of mouth	63.6%

^aPercentages do not equal 100 as multiple responses were allowed.

Findings

A total of 22 ED nurses participated in the study. Nineteen of the 22 nurses worked in states with some care-limiting legislation. Most participants were female (82%), White (72.7%), between the ages of 35 and 44 (50%), held a bachelor's degree (45%), and worked as staff nurses (59%) in general EDs (91%). Seventy-three percent identified as Christian. Sixty-five percent reported care-limiting legislation (abortion bans, bans or limitations on gender-affirming care, or both) in their state; 30% of the nurses who worked in states with abortion bans reported they did not know if there were any bans on care in their state. See Table 1 and SDC 1 for demographics of the sample, http://links.lww.com/JONA/B256.

This qualitative analysis focused on the following 3 categories, and several themes emerged for each area, as shown in Figure 1 and SDC 2, http://links.lww.com/JONA/B257. Each theme reflects key aspects of biocommunicability in the experiences of ED nurses navigating abortion bans.

Figure 1.

Categories and themes.

• Institutional factors included processes by which nurses are informed of changes in policy and practice in this context and participants' understanding of the roles of hospitals. Themes in this category included left in the dark, clear directives, it's political, and plausible deniability.

• Interpersonal factors included how participants engaged with colleagues and administration to manage the clinical implications of care-limiting legislation. The themes here included silence, jumping through hoops, and reading the room for allies.

• Individual factors included how participants obtained information about care-limiting legislation, as well as their concerns about providing care to pregnant people in the context of abortion bans. Themes that emerged comprised do no harm, what should we do, active information seeking, and future actions.

At the institutional level, participants in this study described robust communication structures in their institutions for most practice changes (eg, new equipment, new processes, or infection control) that included emails, staff meetings, online education, communication books, and 1-to-1 instruction with educators or charge nurses. Participant SN11F told researchers about the standard deployment of education in their department:

“There will be usually like an email that will go out … to notify everybody that there's a new policy or protocol. There will be links to the actual document for the system. The ED educator will then usually come around and do quick in services during shift, or [come to] the nurses station to do in the moment teaching. There will be some sort of online learning module assigned. You know, this required education will have to be done. I will say that this hospital system is really good, too. They do quarterly education like throughout the hospital.”

Participant SN22F added to this, about daily education and updates at their institution:

“So the initial measles thing was up in there. Any Covid thing was always up in there. But nothing about this [abortion bans new to the state].”

Several participants were able to give examples of practice changes related to the pandemic that had been communicated to them by hospital administration, often in multiple ways. Although nurses who worked in states without abortion bans reported that they got clear directives from their administrations to accept and care for patients coming from states with abortion bans, from these participants, these communication structures were not used to inform nurses in states with abortion bans about practice changes. Nurses described this lack of communication as being left in the dark.

Participant SN9F voiced their concerns this way:

“I feel like we're fairly informed … about most things … why have we been left in the dark about this like, where are the physicians with this? Where's the hospital system with this? How come every time you know you're gonna call me in to talk about why I put somebody in the waiting room to charge their phone so they could call for their ride. I have to answer that, but I don't have to have a conversation about this (abortion) which has huge implications on the way we practice, the way we care for our patients, the way the patient should expect to get care like, do they know that when they come here, and something like this is happening, and that we're very limited to what we can do. This should be a massive conversation.”

Eighteen of 19 participants who worked in states with care-limiting legislation reported receiving no information of any kind from their administrations. Only 1 participant (EDU20F) reported verbal information being conveyed:

“So they're [the hospital admin] supporting legislation 100% and telling them [providers and nurses] don't even think about helping a patient that needs any other service, any kind of way to help them get to another state, or to get to another country or not even starting a conversation with the physician. None of that can happen in our ED.”

This participant emphasized that the communication was deliberately conveyed verbally only, with no policy or written documentation.

Another participant (SN15M) reported that months after this initial conversation, no information was provided:

“Our medical director has come into our meetings we have …. And it's like, “Hey, do you know anything about this?” [they say] “We've heard it. We don't know what it's gonna look like. We'll keep you updated.”

Although there was confusion about the clinical implications of abortion bans in states that had them, those nurses surmised the lack of communication was due to other considerations, generating the theme it's political.

A nurse highlighted the complex social nature of the conversation:

“It's political, it's religious. It just kind of stems on a bunch of issues you don't really want to talk about work.” (CN21F)

The lack of hospital communication was also described as motivated by this same avoidance of “politics,” yielding the theme of plausible deniability. ED12F reported:

“Maybe that is part of our administration is like, you know, that plausible deniability like we just won't talk about it, and then we … don't have to do it.”

This participant's interpretation suggested that the lack of communication may be based on, or at least allow, avoidance of implementing the serious restrictions of abortion bans. Other participants posited that hospitals deliberately did not inform nurses of the potential threat to their licensure under abortion bans for fear that nurses would leave, exacerbating the current nursing shortage. SN11F stated:

“My personal belief is, it comes down to the business side of it. If they made more people aware of the potential ramifications …, you're going to lose more staff.”

Regardless of their precise explanation, participants suggested that hospital administrations were making conscious decisions not to communicate with nursing staff about abortion bans.

At the interpersonal level, this reported lack of communication made it very difficult for nurses to communicate with patients. Participants maintained that they would not discuss abortion as an option, yielding the theme of silence. Some participants saw this as communication that, without clear guidance from administration, should only be between the patient and provider. The vague threat of prosecution for “aiding and abetting” an abortion in some states was also a factor. One participant from Texas reported:

“If somebody else finds out that I gave that patient that information … they could potentially bring a civil lawsuit against me.” (SN11F)

Participants reported responding to the challenges that the lack of communication presented to them through interpersonal efforts, taking on additional labor to manage the situation created by the lack of official workplace directives or policies. Many nurses worked to help their patients avoid experiencing the worst impacts of abortion bans and reported these actions as being driven by an understanding of disciplinary ethical duty. In this case, reported by ED12F, a patient came into the ED after a medication abortion:

“It was the OB/GYN that we had consulted and said that you know you have to call that in and report it, and the ED doctor's like ‘I'm not reporting that.’ And the ED nurse was like, ‘I'm not reporting that,’ and which I was very proud of them for saying like, ‘No, we're not doing that.’”

Participants also described “workarounds”—navigation around colleagues opposed to abortion—to ensure the necessary care.

SN5F reported an interpersonal system of jumping through hoops to get patients the care they need in a state where abortion is restricted but legal until 12 weeks of pregnancy:

“We have an ER doctor, … he's an avid Christian, and he will not prescribe the morning-after pill for rape victims [researcher note: Plan B is not an abortifacient]. We have to jump around hoops, even calling other sister EDs to get a provider to write the prescription, because he will not do it.” Similarly, participants who worked as charge nurses reported assigning patients to nurses who would care for patients with abortion care needs.

Some nurses reported a 2nd interpersonal strategy of reading the room for allies, which they described as a process of environmental surveillance, looking for clues as to the positionality of the people around them on abortion, and thus the safety of engaging in conversation, information seeking, or planning patient care. Participants reported that coworkers who had specific views on other topics (gun control, immigration, etc) sent clear signals through conversation, apparel, and opinions about their position on abortion even if that topic never specifically got discussed. Participants reported they would avoid those people when trying to obtain or manage information about a patient who needed abortion care. Even with those efforts, though, 1 nurse from Texas told us:

“But there's no safe person. There is no safe person in the hospital. I can tell you that there is no safe person.” (EDU20F)

At the individual level, many participants voiced anger about lack of information. Participants became upset when they understood and could articulate the differences in communication between potential changes related to abortion bans and other practice changes, reflecting the theme what should we do? SN22F, told us the following:

“So do I go ask them what should we do? You know, who do I get that information from because I don't trust that my corporation that owns hospitals in multiple states, some that have no abortion ban and some that have huge bans, I don't know if they're gonna put information out.”

Participants reported distress over knowing what they should do and not being able to do it; specifically, the theme do no harm arose from these data. As SN9F told us:

“ … that's like a moral thing, do no harm … everybody is taking that oath. So how are we actually doing that? Are we doing no harm?”

The lack of information amplified this distress. EDU20F reported:

“[Administration] won't discuss it like outright, and they certainly won't say what they would do or would not do, or what they support, or what they don't support.”

Here, the dearth of communication resulted in heightened levels of moral distress for nurses who were aware of the care trajectory for some pregnancy emergencies such as ectopic pregnancies and incomplete miscarriages; this care trajectory includes ending the pregnancy so the pregnant person does not die. With a lack of information provided at work, participants reported individual strategies of active information seeking, which they reported as including reading the legislation, sometimes with their professional organizations. As one of them (SN4M) told us

“We constantly look for legislation that would affect patients and their families and ED nurses and nurses in general. Not just on the state side, but also on the Federal side…. And then to collaborate with other professional nursing organizations in [state].”

Although most participants had not read the legislation banning or restricting abortion in their own state, almost all interviewees concluded the interview by saying that they were leaving our conversation with a future action goal of becoming more informed.

Discussion

This study aimed to understand biocommunicability in EDs, that is, the ways in which ED nurses receive and share information about abortion bans, and the implications of this communication for patient care and the nurses' well-being. This is the 1st study known to the authors to explore communication about abortion bans to, from, and between ED nurses, adding important information about how nurses receive and communicate information individually, interpersonally, and institutionally, about the practice implications of abortion bans in a polarized political environment.

Although the National Council of State Boards of Nursing specifically called out this knowledge gap in their 2024 Environmental Scan,¹² many participants in this study were not aware of the details or implications of abortion bans in their state. Literature suggests that the preferred source for practice information was Google or a peer,¹³ which aligns with the findings in this study. The motive to search for information can arise from personal beliefs and values.¹⁴ In this study, participants who reported a deliberate search for information often discussed a clear motive of personal connection to the problem. This echoes recent work by Wolf and Noblewolf¹⁵ about the moral courage of ED nurses, which found that participants were motivated by personal ethical frameworks and not professional ethical directives.

Participants described interpersonal strategies to determine when and with whom information sharing was safe, aligning with work by Zhu et al¹⁶ about safe spaces for “political chatter” that is outside of policy and decision-making. Authors¹⁶ describe how conversations deemed “political” can provoke anxiety and fears of social sanction, and thus are often avoided, a sentiment that participants in this current study discussed as a challenge to obtaining information about the nature and extent of care-limiting legislation and the practical impact on nursing care. Communication necessary to provide safe patient care was reported as absent on the institutional and interpersonal levels, shaped by institutional and interpersonal silence and individual fears. Although nurses responded to a lack of communication from nursing leaders and hospital administration by developing individual and interpersonal strategies of jumping through hoops, reading the room for allies, and information seeking, it is nursing leadership and administration that bear some responsibility. Specifically, nursing leaders have an ethical responsibility to communicate vital information to their direct care staff to ensure the provision of quality care¹⁷ and to provide a safe environment for both patients and nurses.¹⁸ Communication is an essential element of care at every level of nursing practice, and the use of effective communication as a management tool is essential for sharing critical information.¹⁹ Ineffective communication can jeopardize both patient safety and healthcare quality, resulting in poor patient outcomes.²⁰ Participants in this study reported high levels of moral distress due to this lack of communication.

The literature on the professional obligations of nursing organizations is sparse. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.¹⁸ Provision 9 of the American Nurses Association (ANA) Code of Ethics¹⁸ articulates this as a duty of nursing. Thus, there is a compelling need to remedy this silence on the part of nursing organizations. Nurses participating in this study spoke about looking to the professional organization (in this case the Emergency Nurses Association) for information and support.

Recommendations for Nursing Leaders

The ANA code of ethics.¹⁸ requires that nursing leaders in all settings maintain the voice of advocacy for both nurses and the patients they care for. It is a clinical and ethical responsibility of nurse leaders to communicate vital information to their direct care staff to ensure the provision of quality care.¹⁷ Participants in this study reported feeling that by not providing critical practice information, their leaders and institutions were neither supporting nursing practice nor addressing the care needs of their patients. Given the changing legislative landscape and the increase of obstetric patients turning to EDs, it is imperative for both the integrity of nursing practice and the provision of patient safety that nursing leaders develop policies and discuss practice implications with their staff.

Limitations

This sample was a self-selecting group of ED nurses recruited by networking and snowball techniques. It is unknown what information would be provided by ED nurses who did not participate in this study thus, the findings may not be generalizable. The strength of this study is triangulation by region, investigator, and presence or absence of abortion bans.

Conclusions

Participants in this study report anger and frustration at the lack of information and guidance provided by hospital administrators and ED managers. Normal channels of communication about practice changes go unused, leading to practice challenges and moral distress as nurses fear for both their patients and themselves. Future work should focus on the evolving clinical and legal implications of abortion bans and changes in biocommunicability around these issues, especially at personal communication, management, and institutional levels.