A Conceptual Model for Obstetric Nursing

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  • Volume 5, Number 2, MarchlApril 1976

    JOGN Nursing

    Journal of The Nurses Association of The American College of Obstetricians and Gynecologists

    A Conceptual Model for Obstetric Nursing NANCY H. LEVINE, B S N , MA

    The author discusses the need for and purpose of a more comprehensive theoretical basis for nursing practice, research, and education. She then presents her own theoretical model of the pregnancy experience, with implications for nursing interuention. Also included (see box) is a discussiop of the definition, development, and use of theory.

    As health science develops, the need for theo- retical concepts for health care becomes increas- ingly important. Nursing, with its multidisciplinary approach, is the logical profession to initiate such theoretical concepts and to implement them in practice. Yet, the profession has been satisfied to absorb most of its information base from other disci- plines and has been too slow in formulating its own theoretical frameworks for practice. This has been due in part to an inadequate amount of scientific nursing investigation or research and to the reluc- tance of the profession-to break away from the medical model with its focus on pathology, the episodic nature of sickness, and technologic inter- vention in disease. There has been in recent years, however, a tentative movement away from depen- dence on medical research and the theoretical basis of medical practice.

    Nursing can never be fully independent of medi- cine, nor should it be. Both disciplines are based on psychobiosocial theories as well as on pathophysical biologic sciences; both professions do something for or with a patient; both deal with the patients re- sponses to pathology or therapy. The two interact

    constantly in helping the patient, but the com- parisons have limits, and nursing must further as- sess attributes that differentiate it from medicine, i.e., nursings focus on holistic man constantly inter- acting with his environment along the health- illness continuum. Nursing is not defined by the ability to treat pathology or perform activities or processes, but rather by what the patient and family receive from such activities and the short- and long-term effects of the processes.

    Nursing and other health professions function by perceiving, defining, protecting, and potentiating strengths in individuals and families, and by per- ceiving, defining, and meeting, to the extent pos- sible, those needs which cannot be adequately dealt with by the individual or family. Nursing has an extensive educational base that allows practitioners, educators, and researchers to perceive, and inter- vene in, the pregnancy experience. Using this col- lective experience and educational resource, I worked out an experiential field concept of preg- nancy. In originating my theory, I limited the focus to obstetrics so that I could fully develop a theory based on psychobiosocial aspects of humans during

    March/April 1976 JOCN Nursing 9

  • one stage of the health-illness continuum. This the- ory, or conceptual model, suggests that a females energy field contracts during the eighth and ninth months of pregnancy in response to the psycho- physiologic changes within her body, severely dimi- nishes for expulsion of the fetus during labor and delivery, and reexpands with lactation on the third or fourth postpartal day.

    UNDERLYING ASSUMPTIONS The theoretical assumptions on which the expe-

    riential field concept of pregnancy is based are as follows: -Energy maintains human and environmental

    field boundaries that are coexistent and contin- uously interacting.

    -Tension states, e .g . , needs, drives, and conflicts, exist within or without the human field and cause field contraction or expansion in order to accom- modate these states.

    -Progress toward releasing the tension state is de- pendent on biologic or genetic potential, contin- uing interaction with the total environment, and motivation.

    -Every individual possesses a unique combination of constantly changing strengths, field bound- aries, and needs.

    -The family is the basic unit of behavior and so- cialization patterns.

    -Health is an active state of physical, emotional, and social well-being that contributes to the achievement of human potential. More simply, basic to this model is the concept

    that a human is surrounded by a dynamic energy field, the boundary of which encircles the individual and which responds to internal or external needs by contracting or expanding the periphery-con- tracting in response to internal stimuli or needs and expanding to deal with external needs.

    Needs, defined as subgrouped tension systems with psychophysiologic, sociocultural, or sociobio- logic sources, produce tension-like states that mobi- lize energies for their satiation or destruction. Needs, with their encircling tension states, exist either within the human field boundaries or in the environmental field, and vary in intensity among individuals as well as within the same individual at various points in the time-space continuum. The human and environmental fields are coextensive and in constant interaction. Although needs can be created and destroyed, the reservoir of energy which meets these needs, ix., furnishes force for need gratification and maintains field integrity, re- mains constant and particular for each individual.

    When a need arises within the human energy field, the boundaries contract to supply energy for

    gratification of that specific need. Pain, as an ex- ample, causes a person to focus on the site of its occurrence. The more severe the pain, the harder it becomes to distract the persons attention from it. The individual may discover that his pain dimin- ishes if he assumes a particular position, or if he alters his rate of breathing, so he will combine these physiologic responses with his already inner-di- rected attention. If this psychophysiologic process releases the tension state, or pain, the persons field will assume its premorbid integrity. The pain created a sufficiently strong tension state within the human field to mobilize energies for need grat- ification. Since the reservoir of available energy is constant and since the need arose within the human energy field, the boundaries contracted to supply energies for need satisfaction. Once this occurred, the tension was released and the original field integ- rity was restored.

    Note that it is rare, if ever, that a need will arise from an isolated source, i e . , that a need will be purely physical, since need sources are fluid and unified. The human energy field is a dynamic unity.

    If the need and encircling tension state exist within the environmental field, the individual field must expand to satisfy that need. For example, a babys hunger creates a tension state in the environ- mental field of its mother. If this tension is to be resolved, the maternal energies must not only be directed to the tension site (the baby), but also focus on a tension-releasing process (feeding the infant). If or when the need is satisfied, the maternal and infant fields will resume their premorbid conditions. Human and environmental field boundaries are coextensive with human field integrity, fluctuating in response to need location and intensity.

    CONCEPTUAL MODEL OF LATE PREGNANCY, CHILDBIRTH, AND THE

    POSTPARTUM

    Late Pregnancy How this field phenomena occurs in pregnancy

    can be seen when one examines various stages of the cycle. During the last half-month, changes oc- cur in the pregnant womans field that cause her to become inner-directed. The uterus lightens and becomes a pelvic organ as the fetal head moves into the pelvic inlet, whereas prior to this the uterus was an abdominal organ that displaced the diaphragm and impeded respiration. Greater ease of respira- tion, however, is combined with more difficult loco- motion, frequent urination, and increased cramping in the lower extremities since the gravid uterus exerts pressure in the pelvic area. Increased venous pressure in the lower extremities predisposes the

    10 March/April 1976 JOCN Nursing

  • As we face health crises in hospitals, in- stitutions, and communities, and as health- care consumers increase demands for com- petent, comprehensive care, nursing has to identify and utilize the theories that underlie the practice. Nursing theory development and utilization is the only way the profession can differentiate from medicine, realize opti- mum potential for service to people, and maintain equality among health profes- sionals.

    Scientific investigation for nursing theory implies research relevant to helping individ- uals cope with health problems when their own resources, strengths, or information are insufficient. Nursing science theory should enlighten us about the person, what happens to the individual in the health-illness contin- uum, and how we can effectively intervene and validate our actions. However, these the- ories do not happen a priori, intuitively; they must be developed from research into the practice of nursing.

    Definition

    Dickoff and James, in Nursing Research, have operationalized the concept of theory into workable, understandable terms. They propose the following points:

    -Theory is a conceptual framework or sys- tem invented to some purpose.

    -Professional purpose requires a com- mitment beyond mere understanding or describing .

    -Significant theory, at the highest level, must be situation producing.

    -A profession or practice discipline has built-in advantages that facilitate theory development.

    Discussion

    Theory must be communicable if it is to structure purpose as a guide, control, or shaper of reality; it is not reality itself. Con- cepts, laws, and propositions are the basic elements of theories, and they provide con-

    THEORY: DEFINITION, DEVELOPMENT, USE

    ceptualization intended to shape reality to the d isci pli nes professional purpose. Nu rsi ng s professional purpose reflects the desire to help individuals cope with health problems; therefore, any improvement of practice that achieves this function is the appropriate goal of nursing theory development. The goal de- fines the need for theory development, and determines what theory is significant.2

    Significant theory must have scope in cov- ering and relating a smaller number of concepts, and providing a framework for ordering observations about a variety of phenomena. The broader the scope, in terms of the number and variety of facts or con- cepts related, the greater the significance of the theory. For nursing, the scope should be judged in terms of the generalizations and phenomena pertinent to an individual along the health-illness continuum. Theories should be complex in that they take into account multiple variables or relationships and they should be amenable to experimentation. Test- ability of the theory at the general levels is not requisite for use or significance, even though it is desired; testability can be sacri- ficed in favor of scope, complexity, and clini- cal usefulness.2

    Theories must be useful as a framework in clinical practice; conversely, clinical practice must test theory by determining significance and relevance. The framework must allow for constant repatterning, reorganization, and change if it is to be pertinent in practice. The- ory and practice must be interrelated, coexis- tent, and must constantly shape each other in order for nursing care innovations and new information to occur. A theory that generates many new hypotheses, with or without high probability, will contribute to understanding and enable situation predictability in future interactions.-N.H.L.

    1. Dickoff, D., and P. James: Theoretical Con- structs. Nursing Res. 17:197-203, May-June 1968

    2. Ellis, R.: Theory for Nursing. 17:217-222, May-June 1968

    March/April 1976 JOGN Nursing 11

  • female to dependent edema of the ankles and legs and further hampers locomotion. Decreased phys- ical activity, along with descent of the fetus and consequent relaxation of smooth muscle throughout the body can and very often does lead to constipa- tion and partial bowel obstruction.' Heartburn, due to refluxing gastric contents into the lower esopha- gus, is quite common during this period because of uterine compression of the stomach and decreased gastrointestinal mobility.'

    Body image during this late third-trimester pe- riod is discontinuous with the usual physical state, and many women complain of feeling sloppy and clumsy. Coitus at this time is not contraindicated, but it may be impossible because of an insur- mountable belly.' There is an increased likelihood of slipping and falling during this period since the size of the late pregnancy uterus creates balance disturbances. This is also the time women quit their jobs. (The time to discontinue routine jobs has been regulated by law in some areas, and the limits, although arbitrary, are generally from 6 to 8 weeks prior to the predicted date of delivery.')

    False labor pains, exagge'rations of the painless, intermittent uterine contractions that occurred throughout gestation, now become noticeable and uncomfortable.' Many women experience anxiety with these false labor contractions since they may be perceived as the onset of actual labor. With each contraction the immediacy of the impending labor and delivery is brought to attention.

    Decreasing locomotive abilities, increasing dis- comfort, a discontinuous and possibly disturbing body image, plus changes in daily routines provide not only time but direction for field contraction. Manifestations of this field contraction can be seen when the female rarely strays from conversation concerning her physical changes, labor, delivery, or her new role as mother. The complaint of insomnia, the most common symptom of late p regnan~y ,~ in- dicates a rather high tension state as well as a very intense inner-directed focus. Field contraction, a necessary behavior at this point, mobilizes energy for the reduction of these internal tension states. The female must confront the pressing realities of labor and delivery if she is to accept differentiation and final separation from the fetus. Not only will she soon terminate her exclusive protective, nurtur- ing relationship with her fetus, she will forcefully expel it from her body. As severely as the mourner contracts his field during the grieving process, so too must the female contract hers in labor and delivery. Similarly, she must grieve the death of the fetus before she reexpands her field in acceptance of the neonate.

    Since her future relationships with her neonate

    and husband require thoughtful preparation, the woman's contracted field amasses energy for these tasks. While the female experiences this contracted field state, she is less responsive and aware of envi- ronmental needs. This is not to say she is oblivious, but most of her energies, flowing toward the tension states within her field, are not readily available for environmental...