POSTPARTUM DEPRESSIONTHEORY

Theorist: Cheryl Tatano Beck

POSTPARTUM DEPRESSION THEORY

~Cheryl Tatano Beck~(1949-present)

I. Background of the Theorist

She graduated from the Western Connecticut State University with a baccalaureate in nursing in 1970.

After graduation, Beck worked as a registered nurse at the Yale New Haven Hospital on the postpartum and normal newborn nursery unit.

In 1972, Beck graduated from Yale University with a master’s degree in maternal-newborn nursing and a certificate in nurse midwifery.

In 1982, she received a doctorate in nursing science from Boston University.

She has served as consultant on numerous research projects for universities and state agencies in the northeastern United States.

She has given more than 30 awards, including Distinguished Researcher of the Year by the Eastern Nursing Research Society in 1999.

She has authored more than 100 journal articles and given scores of research presentations locally, nationally, and internationally.

Served on the executive board for the Marce Society, an international society for the understanding, prevention, and treatment of mental illness associated with childbirth and on the advisory

committee of the Donaghue Medical Research Foundation in Connecticut.

Fittingly, she began her research career with women in labor, examining their cognitive and emotional responses to fetal monitoring. Beck’s research wound its ways through the labor and birth process and became firmly

planted in the postpartum period, with a specific focus on postpartum mood disorders.

This body of work resulted in a substantive theory of postpartum depression and the development of Postpartum Depression Screening Scale (PDSS) and Postpartum Depression Predictors Inventory (PDPI).

A. Major Concepts and Definitions

1.Postpartum Mood DisordersPostpartum depression- a nonpsychotic

major depressive disorder with distinguishing diagnostic criteria, postpartum depression often begins as early as 4 weeks after birth.

Maternity blues- is a relatively transient and self-limited period of melancholy and mood swings during the early postpartum period.

Postpartum psychosis- a psychotic disorder characterized by hallucinations, delusions, agitation, inability to sleep, along with desire and irrational behaviour

Postpartum obsessive-compulsive disorder- symptoms include repetitive intrusive thoughts of harming the baby, a fear of being left alone with the infant and hyper vigilant in protecting the infant.

2. Loss of Control- it was identified as the basic psychosocial problem in the 1993 substantive theory development phase of Beck’s work. Loss of control was an aspect women experience in all aspects of their lives. The process of loss of control left women “teetering on the edge” and consisted of the following four stages:

Encountering terror- consisted of horrifying attack, enveloping fogginess, and relentless obsessive thinking.

Dying of self- consisted of alarming unrealness, contemplating and attempting self-destruction, isolating oneself.

Struggling to survive- consisted of battling the system, seeking solace at support groups, praying for relief.

Regaining control- consisted of unpredictable transitioning, guarded recovery, mourning lost time.

3. Prenatal Depression- was found to be the strongest predictor of postpartum depression. It occurs of any or all of the trimesters of pregnancy.

4. Child Care Stress- is stressful events related to child care involve factors such as infant health problems and difficulty in infant care pertaining to feeding and sleeping.

5. Life Stress- is an index of stressful life events during the pregnancy and postpartum.Stressful life events could either be positive or negative and can include experiences such as the following:

Marital changes- divorce, remarriageOccupational changes- job changeCrises- accidents, burglaries, financial crisis

and illness requiring hospitalization

6. Social Support- consists of receiving both instrumental support (eg. Baby-sitting, help with household chores) and emotional support.

Structural features of a woman’s social network (husband or mate, family, and friends) include proximity of its member, frequency of contacts and number of confidants with whom the mother can share personal matters.

7. Prenatal Anxiety- it can occur during any trimester or throughout the pregnancy. Anxiety refers to feeling of uneasiness or apprehension concerning a vague, non-specific threat.

8. Marital Satisfaction- the degree of satisfaction with a marital relationship is assessed and includes how happy or satisfied the woman is with certain aspects of her marriage, such as communication, affection, similarity of values (eg. Finances, child care), mutual activity and decision making, global well-being.

9. History of Depression- any report by a mother of having had a bout of depression before this pregnancy must be noted. 

10. Infant Temperament- refers to the infant’s disposition and personality. Difficult temperament describes an infant who is irritable, fussy, unpredictable and difficult to console. 

11. Maternity Blues- was defined as non-pathological condition found in many women after birth. Prolong episodes of maternity blues (lasting more than 10 days) can be predictive of postpartum depression. 12. Self-esteem- refers to a woman’s global feelings of self-worth and self-acceptance. It is her confidence and satisfaction in herself.

13. Socioeconomic Status- is a person’s rank or status in the society, involving a combination of social and economic factor such as income, education, and occupation. 14.Marital Status- this demographic characteristic focuses on a woman’s standing  

in regard to marriage. The ranking denotes whether a woman is single, married or cohabiting, divorce, widowed, separated, or partnered.

15. Unplanned or Unwanted Pregnancy- this refers to a pregnancy that was not planned or wanted by the woman. 

16. Sleeping and Eating Disturbances- this disturbances consist of an inability to sleep even the baby is asleep, tossing and turning before actually falling asleep, waking in the middle of the night with difficulty going back to sleep, loss of appetite, consciously being aware of the need to eat but still unable to eat.

17. Anxiety and Insecurity- manifest in hyperattention to relatively minor issues, feeling as if one is jumping out of her skin and feeling the need to keep moving or pacing.

18. Emotional Lability- refers to a woman’s sense that her emotions are unstable and out of her control, commonly characterized as crying for no particular reason, irritability, explosive anger, and fear that she may never be happy again.

19. Mental Confusion- is a marked inability to concentrate, focus upon a singular task, or make decisions.

21. Loss of Self- women sense that those aspects of self that reflected their personal identity have changed since birth, so that women cannot identify who they really are and become fearful that they might never be able to become their real selves again. 

21. Guilt and Shame- feeling of guilt and shame are related to a woman’s perception that she is performing poorly as a mother and has negative thoughts regarding her infant. It results in an inability to be open with others about how she feels and contributes to delay in diagnosis and intervention. 

 

22. Suicidal Thoughts- concern women’s frequent thoughts of harming themselves or ending their own lives to escape the living nightmare of postpartum depress.

 B. Major Assumptions 1. Nursing is a caring profession with caring obligations to persons we care for, students and each other. Interpersonal interaction between nurses and those for whom we care are the primary ways nursing accomplishes goals of health and wholeness.

2. Persons are described in terms of wholeness. Persons have biological, sociological and psychological components.

3. Health is the consequence of women’s responses to the context of their lives physically and to the context of their environments. All context of health are vital to understanding any singular issue of health.

 

4. Environment in broad terms might include individual factors, but also includes the world outside of each person. The outside environment includes event, situation, culture, physicality, ecosystems, and socio-political systems.

A.Empirical Evidence

In 1993, after 4 major studies regarding postpartum period, Beck developed a substantive theory of postpartum depression using grounded theory methodology. This theory developed was entitled “teetering on the edge” with the basic psychosocial problems identified as loss of control. Also during this period, meta-analyses were

conducted on predictors of postpartum depression, the relationship between postpartum depression and infant temperament, and the effects of postpartum depression on mother-infant interaction. In addition, two qualitative metasyntheses were conducted on postpartum depression and mothering multiples.

SELF-CARE DEFICITNURSING THEORY

Theorist: Dorothea Orem

America’s one of the foremost nursing theorists was born in Baltimore, Maryland, in 1914.

She began her nursing career at Providence Hospital School of Nursing in Washington, D.C.

In 1939, she later received a BS in nursing education from the Catholic University of America (COA) and in 1946, she received an MS in nursing education from the same university.

From 1940-1949, Orem held the directorship of both the nursing school and the department of nursing at Providence Hospital, Detroit.

In 1957, she worked as a curriculum consultant at the office of education US department of Health, Education and Welfare.

She became an assistant professor of nursing education at CUA. Subsequently became acting dean of the school of nursing.

In 1971, her first published book was Nursing: Concepts of Practice.

In 1972, she was the editor for the Nursing Development Conference Group (NDCG) as they prepared and later revised Concept Formalization in Nursing: Process and Product.

In 1976, Georgetown University conferred

on Orem the Honorary Degree of Doctor of Science.

She was awarded the Doctor of Nursing Honoris Causea from the University of Missouri in 1998.

Subsequent editions of Nursing: Concepts of Practice were published in 1980, 1985, 1991, 1995, 2001.

She retired in 1984 and continued working alone and with colleagues on the development of Self Care Deficit Nursing Theory (SCDNT).

A. Major Concepts and Definitions 1. Self-Care---comprises the practice of

activities that maturing and mature persons initiate and perform, within time frames, on their own behalf in the interest of maintaining life, healthful functioning, continuing personal development, and well-being through meeting known requisites for functional and developmental regulation.

2. Self-Care Requisites---a formulated and expressed insight about actions to be performed that are known or hypothesized to be necessary in the regulation of an aspect of human functioning and development, continuously or under specified conditions and circumstances.

3. Universal Self-Care Requisites---universally required goals are to be met through self-care or dependent care and have their origins in what is known and what is validated or what is in the process of being validated about human structural and functional integrity at various stages of the life cycle. The following eight self-care requisites common to men, women, and children are suggested:

The maintenance of a sufficient intake of food

The maintenance of a sufficient intake of water

The maintenance of a sufficient intake of airThe provision of care associated with

elimination processes and excrementsThe maintenance of balance between

activity and restThe maintenance of balance between

solitude and social interaction

The prevention of hazards to human life, human functioning and human well-being

The promotion of human functioning and development within social groups in accordance with human potential, known human limitations, and the human desire to be normal.

 

4. Developmental Self-Care Requisites 3 sets of DSCR:Provision of conditions that promote

developmentEngagement in self-developmentPrevention of or overcoming effects of

human conditions and life situations that can adversely affect human development

 

5. Health Deviation Self-Care Requisites---these exist for person who are ill or injured, who have specific forms of pathological conditions or disorders, including defects and disabilities, and who are under medical diagnosis and treatment. 6. Therapeutic Self-Care Demand---consists of the summation of care measures necessary at specific times or over a duration of time for meeting all of an individual’s known self-care requisites particularized for existent condition and circumstances

7. Self-Care Agency---is a complex acquired ability of mature and maturing persons to know and meet their continuing requirements for deliberate, purposive action to regulate their own human functioning and development. 

8. Agent- it engages in a course of action or has the power to do so.

9. Dependent-Care Agent---a maturing adolescent or adult, accepts and fulfills the responsibility to know and meet the therapeutic self-care demand of relevant others who are socially dependent on them or to regulate the development or exercise of these persons’ self-care agency. 

10. Self-Care Deficit---is a relation between the persons’ therapeutic self-care demands and

their powers of self-care agency in which constituent developed self-care capabilities within self-care agency are not operable or not adequate for knowing and meeting some or all components of the existent or projected therapeutic self-care demand.

11. Nursing Agency- comprises developed capabilities of persons educated as nurses that empower them to represent themselves as

nurses within the frame of a legitimate interpersonal relationship to act, to know, and to help persons in such relationships to meet their therapeutic self-care demands and to regulate the development or exercise of their self-care agency. 

12. Nursing Design- a professional function performed both before and after nursing diagnosis and prescription, allows nurses on the

basis of reflective practical judgements about existent conditions, to synthesize concrete situational elements into orderly relations to structure operational units.

13. Nursing Systems- are series and sequences of deliberate practical actions of nurses performed at times in coordination with actions of their patients to know and meet components of their patient’s therapeutic self-care demands and to protect and regulate the

care demands and to protect and regulate the exercise or development of patient’s self-care agency. 

14. Helping Methods- helping method from a nursing perspective is a sequential series of actions which, if performed, will overcome or compensate for the health-associated limitations of persons to engage in actions to regulate their own functioning and development or that of their dependents.

Nursing care and their health-associated action limitations are as follows: Acting for or doing for anotherGuiding and protectingProviding physical or pathological supportProviding and maintaining an environment

that support personal developmentTeaching

B. Major Assumption

1.Human beings require continuous, deliberate inputs to themselves and their environments to remain alive and function in accordance with natural human endowments.

2. Human agency, the power to act deliberately, is exercised in the form of care for self and others in identifying needs and making needed inputs.

3. Mature human beings experiences privations in the form of limitations for action in care for self and others involving and making of life-sustaining and function-regulating inputs.

4. Human agency is exercised in discovering, developing and transmitting ways and means to identify needs and make inputs to self and others.

5. Groups of human beings with structured relationships cluster tasks and allocate responsibilities for providing care to group

members who experience privations for making required, deliberate input to self and others.

C. Empirical Evidence 

Orem formulated her concept of nursing in relation to self-care as part of a study on the organization and administrations of hospitals, which she conducted at the Indiana State Department of Health. This work enabled her to formulate and express her concept of nursing. Her knowledge on the features of nursing practice situations was acquired over many years.

Orem used philosophical and scientific methods in developing her insights and validating her conclusions. Since the SCDNT was first published, extensive empirical evidence was contributed to the development of theoretical knowledge. Much of this is contributed to the theory; however, the basics of the theory remain unchanged.

I. Comparison of the 2 theories (Analysis)

POSTPARTUM DEPRESSION THEORY

SELF-CARE DEFICIT THEORY

SIMPLICITY The development follows a simple and logical progression. Postpartum depression is a complex experience and theory to research. It makes sense, simply and useful.

The development of the theory using the 8 entities (SCDTN) is parsimonious. The relationship between and among these entities can be presented in a simple diagram. The depth of the concepts’ development gives the theory the complexity necessary to describe

POSTPARTUM DEPRESSION THEORY

SELF-CARE DEFICIT THEORY

and understand a human practice discipline.

CLARITY Beck’s purpose was to explain her theory in a clearly understanding manner.Theory is clearly defined and easily understood with clear ideas, definitions, and language for all to understand.

The term Orem uses are defined precisely. The language of the theory is consistent with the language used in action theory and philosophy. The terminology of the theory is congruent throughout.

POSTPARTUM DEPRESSION THEORY

SELF-CARE DEFICIT THEORY

GENERALITY Specific as it focused on a very narrow subject area. General in that within the narrow spectrum it affects different cultures and contexts.

Orem has commented on the generality of the theory:“The self-care deficit theory of nursing is not an explanation of the individuality of a particular concrete nursing practice situation, but rather the expression of a singular combination of conceptualized properties or features

POSTPARTUM DEPRESSION THEORY

SELF-CARE DEFICIT THEORY

It serves nurses engaged in nursing practice, in development, and validation of nursing knowledge and in teaching and learning nursing.

APPLICABILITY or

EMPERICAL

PRECISION

Beck and Gable (2000) examined psychometric properties of the scale with regard to reliability of the measure within the

Orem’s theory has been used for research using both qualitative and quantitative methodologies. The theoretical entities are

POSTPARTUM DEPRESSION THEORY

SELF-CARE DEFICIT THEORY

developmental and diagnostic samples. Validity analyses were conducted with the two samples, as where procedures used to establish cut-off scores for clinical interpretations. These studies indicated that the PDSS is a reliable and valid screening instrument for detection of postpartum depression.

are well defined d lend themselves to measurement; however, instrument have not been developed for all entities. Empirical precision is dependent on the operational definitions constructed by the researcher for the population to be studied.

POSTPARTUM DEPRESSION THEORY

SELF-CARE DEFICIT THEORY

DERIVABLE

CONSEQUENCES

The value of Beck’s is of growing importance within nursing and within other disciplines. The Importance of SCDNT evident in every aspect of the nursing discipline clearly defined nursing and built upon basic concepts to develop an all-encompassing framework all nursing disciplines and areas of

It is useful in developing and guiding practice in research. It gives direction to nursing specific outcomes related to knowing and meeting the therapeutic self-care demands, regulating the development and exercise of self-care agency, and establishing self-care and self-management

POSTPARTUM DEPRESSION THEORY

SELF-CARE DEFICIT THEORY

of specialty can be practiced within this framework.

systems.

It is useful in designing curricula for pre-service, graduate, and continuing nursing education.

Case Study: Sheela’s Story 

Sheela was a 30 year-old mother of four children who had been married for eight years. She lived with her husband and in-laws in a small village. She had given birth to her fourth child three months previously. Her pregnancy and labor had been uneventful, and an untrained traditional midwife helped conduct the home delivery. Because pregnancy was viewed in her village as a normal occurrence that did not require any medical attention,

Sheela did not received any antenatal or postnatal care. For a month after the birth, Sheela felt normal, but then she began to exhibit unusual behavior. She became reclusive and stopped speaking to anyone at home, losing interest in her daily activities and ceasing to care for her children. The rest of the people in her family, however, were busy with their own lives and seemed indifferent to her condition. One day, she decided to visit her friend and share everything about her condition. And she was advised to have a consultation to a doctor.

Sheela was convinced by her friend to undergo consultation. After several assessment, the doctor found out that she have postpartum depression. She was advised to take some anti-depressant drugs and to undergo therapy. The family were also informed about Sheela’s condition and they were able to realize that she needs care and assistance. After several months, Sheela was able to manage her condition.*Being educated and aware of this condition is the best way to be more accepting, accessible, and accommodating to those with postpartum depression.