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Course: Maternity Nursing

Topic: Transition and Tasks of Pregnancy

The Nurses International Community

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Module Goals

The learner will be able to:

Define transition.
Describe phases, elements, and types of transition.
Describe how pregnancy is a transition.
State the importance and purpose of maternal role development
Identify Maternal Tasks of Pregnancy
List factors that demonstrate maternal role attainment
Identify possible barriers to completion of maternal tasks

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What is Transition?

Transition refers to the psychological processes people go through to come to terms with new situations
It involves letting go of old ways
The person adjusts to changes related to health status, role expectations, abilities
It is a complex process, that is related to context and interaction and perception

William Bridges Associates (n.d.)

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Transition is not fixed in time – other things can happen at the same time. It implies movement from one condition or state to another over time. Transition begins at an end. The nurse can help to make it into a positive experience.

Using the change when becoming nursing students as an example:

The change was moving, enrolling, taking classes etc. How did you feel during this process and how did you adjust?

Example: moving to new state/country led to feelings of loneliness, independence, adulthood, loss etc. Additionally, you were expected to be learning new information, in a new environment, may be in a second language, at a new institution. This is a significant transition, and some students may not make this transition and have or will leave the program.

WHAT HELPED YOU TO ADJUST?

Pregnant patient:

What might be her experience?

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Phases of Transition (Bridges Transition Model)

First phase is Ending or Entry

Transition starts with an ending
Starts when one realizes what is being lost and how to manage those losses

Second phase is Neutral zone

Core of the transition process
A passage, adaptation, which takes time

Third phase is New beginning

Integration of the change is complete
In place of instability and vulnerability there is stability, new patterns of coping, and an understood meaning of the experience.

William Bridges Associates (n.d.)

Contact info: info@nursesinternational.org

According to Bridges Transition Model (https://wmbridges.com/about/what-is-transition/) :

Endings

Transition starts with an ending. This is paradoxical but true. This first phase of transition begins when people identify what they are losing and learn how to manage these losses. They determine what is over and being left behind, and what they will keep. These may include relationships, processes, team members or locations.

Neutral Zone

The second step of transition comes after letting go: the neutral zone. People go through an in-between time when the old is gone but the new isn’t fully operational. It is when the critical psychological realignments and repatternings take place. It is the very core of the transition process. This is the time between the old reality and sense of identity and the new one. People are creating new processes and learning what their new roles will be. They are in flux and may feel confusion and distress. The neutral zone is the seedbed for new beginnings.

New Beginnings

Beginnings involve new understandings, values and attitudes. Beginnings are marked by a release of energy in a new direction – they are an expression of a fresh identity. Well-managed transitions allow people to establish new roles with an understanding of their purpose, the part they play, and how to contribute and participate most effectively. As a result, they feel reoriented and renewed.

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Elements of Transition

Awareness of the change(s) occurring
Engagement in the process
Change and difference
Time span
Critical points and events

Meleis et al (2000).

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Elements of Transition: Awareness

According to Meleis et al (2000):

Awareness:

Awareness is related to perception, knowledge, and recognition of a transition experience
Level of awareness is often reflected in the degree of congruence between what is known about processes and responses and what constitutes an expected set of responses and perceptions of individuals undergoing similar transitions

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Elements of Transition: Engagement

According to Meleis et al (2000):

Engagement

Defined as the degree to which a person demonstrates involvement in the processes inherent in the transition
The level of awareness influences the level of engagement in that engagement may not happen without awareness
The level of engagement of a person who is aware of physical, emotional, social, or environmental changes will differ from that of a person unaware of such changes

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Elements of Transition: Changes and Differences

All transitions involve change, but not all change is related to transition

Transitions are the result of change and result in further change

One might have to confront with differences during transition

These differences do not affect everyone same way or mean same thing to everyone

It is suggested that nurses should consider a client’s level of comfort and mastery in dealing with change and differences to examine client’s transition experiences

Meleis et al (2000).

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Example of change and difference:

Once the family and friends know about a woman’s pregnancy, they become more focused on her. Pregnancy comes with many physical, psychological and emotional changes and emerging roles of parenthood. It might change a woman’s perception towards her pregnancy. Some might feel special and have positive pregnancy experience (loves the way her body is changing and likes the care she is receiving). She perceives pregnancy as a thrilling experience.

Where as, some might feel vulnerable and helpless (hate her new body image, might others invading her personal space due to excess care, might not want to restrict her career due to upcoming parenthood) in her case she experience negative pregnancy experience. She might perceive pregnancy as a negative experience.

Some change may not involve transition

… going from first year into second year courses at your school

Where as, some changes may involvetransition

…once you started practicums, you experienced a change in status in relation to junior students. How did you feel?

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Elements of Transition: Time Span

All transitions show flow and move over time.
According to Bridges Transition Model, time span of transition constitutes an identifiable end point followed by a period of instability, confusion, distress, to eventual ‘ending’ with a new beginning or period of stability
It is suggested that it might be difficult or impossible, or even counterproductive to put boundaries on the time span of certain transition experience

Meleis et al (2000)

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Elements of Transition: Critical Points and Events

According to Meleis et al (2000)

Most transition experiences involved critical turning points or events
Critical points or events often increased awareness of change and difference or more active engagement in dealing with transition experience
These critical points/events required the nurse’s attention, knowledge, and experience in different ways

What are some of the critical points in pregnancy?

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Types of Transitions

Developmental Transition

Life cycle changes are predictable such as adolescence, parenthood, midlife changes, etc.

Examples- childhood to adolescence, adolescence to parenthood, etc.

Situational Transition

Examples- Professional role changes, relocation, leaving an abusive relationship, etc.

Health and Illness

Examples- Impact of illness on the person and family, hospitalization, etc.

Schumacher & Meleis (1994)

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Critical Thinking Exercise:

Reflect on a transition you (or one of your patients) experienced:

Describe the transition
What elements were involved?
How did you know you were in transition? How did you act?
What influences/conditions helped or hindered the transition?
What were the indications of a healthy transition?

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Critical Thinking Exercise continued:

Now, interpret your transition in terms of properties of transition. i.e. What could be the critical points of that transition

How did your level of awareness of those changes influence your transition experience?

Analyze the changes or difference caused by the transition

How long did transition last?

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Goal of Nurses during Transition

The goal is for the client to emerge from any nursing encounter not only more comfortable and better able to deal with the present health problem but also better prepared to protect and promote health and well-being for the future (Schumacher & Meleis, 1994)

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Pregnancy a Transition

Time for enormous changes

Physiological: hormonal, body weight, physical strength, etc.
Psychological: new to role of mother, anticipations, fear of difficult pregnancy, fear of loss, etc.
Social: might have to leave work, change in dynamics of friendship, expectations of new mother, etc.
Financial: financial readjustments

How women and her significant others adapt to this period influence woman’s adjustment and directly affect her emotional state

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Maternal Role Transition

Social Identity is shaped largely by group membership and shared characteristics
As pregnancy progresses, the woman’s role in relation to her infant, her family, and the community changes

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The Significance of Maternal Role Transition

Mothers must adapt to:

New societal expectations
Changing familial needs
Changes to body function and appearance
Shifting interpersonal obligations

The transition to motherhood is a journey of developing a new self-identity.

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The Effect of Maternal Role Transition

Successful role transition is needed to facilitate:

Positive self-identity
Confidence as a mother
Adaptation to a new social status
Emotional bonding with the newborn child

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Group Identity Transition: Example

A new mother may form new friendships with more experienced mothers

Newly formed friendships with more experienced mothers may offer:

Emotional support
Helpful advice
Assistance with physical tasks
Social companionship
Mentorship

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Self-Identity Transition: Example

A new mother provides the safe environment and the source nourishment for the development of her unborn child
She needs to accommodate adjustments to her own physical comforts
Her self-identity shifts from taking care of herself and her partner to the caregiver for the infant

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Familial and Societal Role Changes in Pregnancy

Members of the family and the extended family also experience role change

Consider the following:

Ways that a family’s role in the community may change after the birth of a child
Ways that the family may utilize the healthcare systems, faith/social support systems, and government systems differently after the birth of a child
Ways that a culture may view a woman differently after the birth of a child

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Maternal Role Attainment

The successful transition to a positive and productive identity as a mother.

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Theory of Maternal Role Attainment

Ruben, 1967

Progressive stages of integrating the role of motherhood through methods including

Mimicry
Role Play
Seeking Expert Models
Fantasy about the future with the child

Ruben (1967)

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Tasks of Pregnancy

Ensuring safe passage during pregnancy and delivery
Seeking support and acceptance of family for infant
‘Binding in’ and acceptance of the infant
Learning to give of oneself

Ruben (1984)

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I. Ensure safe passage of the infant through pregnancy and birth

Pregnancy becomes primary focus of the woman’s attention

First Trimester: Focus on self
Second Trimester: Develops attachment to her fetus
Third Trimester: A concern for herself and her infant as a unit

Participates in positive self care activities to benefit self, infant and pregnancy (diet, exercise, and well being)

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What Would the Nurse Do?

Anna, G3P2, is experiencing uncertainty regarding her capacity as a mother. She is newly pregnant and has been the primary caregiver for her two other children who are both under the age of 5.

How can the nurse assist this mother?

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II. Seeking Acceptance of Infant by Others

First Trimester: Acceptance of pregnancy by herself and others
Second Trimester: Family relates to the fetus as a member
Third Trimester: Unconditional acceptance by society

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What Would the Nurse Do?

A newly pregnant woman is spending a large amount of time surrounding herself with women who have children of various ages. The nurse understands that identifying support and acceptance is one of the tasks of pregnancy.

How can the nurse facilitate this task?

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III. Acceptance of self as a mother in a new role

First Trimester: Mother accepts the idea of pregnancy but not of the infant
Second Trimester: With sensation of fetal movement the mother accepts the fetus as a separate entity within her
Third Trimester: Mother becomes tired of pregnancy and longs to see and hold infant

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What Would the Nurse Do?

A woman presents to the clinic with her two-month-old child. She is attentive to his needs and the infant responds to her attention. When the child begins to fuss, she is quick to explain that she anticipates him to be more tired due to morning disruptions and she plans to get him down for a nap. She chats about how herself and another mother have decided to go on walks together in the mornings to get some exercise.

What clues about the mother’s successful role attainment do you see in this scenario?

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IV. Giving of Oneself

First Trimester: Identifies what she needs to give up or needs to begin doing to assume the new role of motherhood
Second Semester: Identifies with the infant and learns to put aside her own desires for the good of the infant
Third Trimester: Eager to see new infant, but unsure of her new role and ability to become a good mother to her baby

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What Would the Nurse Do?

Anna, G1P1, is experiencing uncertainty about her ability to parent. “ My baby cries a lot and doesn’t seem to like me. I don’t know what I am doing wrong. I just cry a lot.”

What is the nurse’s role ?

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Red Flags

Postpartum mother showing signs of distancing from newborn
Newborn cries inconsolably
Mother does not seem to react when baby is distressed
Mother does not respond or react to baby’s needs

hunger, crying, needing a diaper change, etc.

Mother does not make eye contact or smile at baby

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Cultural Considerations

Social and familial expectations during pregnancy and early maternity are largely shaped by culture

Many countries and cultures (Thailand, Korea, Mexico, Amish, etc.) have a prescribed period of rest at home after the woman has given birth where it is the duty of the husband and the immediate family to tend to her needs

A lack of socialization during this time may be an indicator of cultural norms

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Summary

The transition to motherhood and successful role attainment is a multifaceted process whereby new expectations and a new social identity are incorporated into a sense of self.

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References:

Chou, Cecilia, "“Traditional postpartum practices and rituals: a qualitative systematic review” (2007), by Cindy-Lee Dennis, Kenneth Fung, Sophie Grigoriadis, Gail Erlick Robinson, Sarah Romans and Lori Ross". Embryo Project Encyclopedia (2017-08-17). ISSN: 1940-5030. Accessed from: http://embryo.asu.edu/handle/10776/12977

Dennis, C.L., Fung, K., Grigoriadis, S., Robinson, G.E., Romans, S., Ross, L.(2007). Traditional postpartum practices and rituals: a qualitative systematic review. Women’s Health,3(4):487-502. Accessed from: https://journals.sagepub.com/doi/full/10.2217/17455057.3.4.487

Lindmark, U., Bülow, P.H., Mårtensson, J., Rönning, H., & A.D.U.L.T. Research Group (2019). The use of the concept of transition in different disciplines within health and social welfare: An integrative literature review, Nursing Open, 6(3), 664-675. Retrieved from: https://onlinelibrary.wiley.com/doi/10.1002/nop2.249

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References:

Meleis, A. I., Sawyer, L. M., Im, E.‐O., Messias, D. K. H., & Schumacher, K. (2000). Experiencing transitions: An emerging middle‐range theory. Advances in Nursing Science, 23(1), 12–28.

Rubin, R. (1967). Attainment of the maternal role. Part 30, 496–506. 1. Processes. Nursing Research, 16, 237–245.

Rubin, R. (1975). Maternal tasks in pregnancy. Maternal–Child Nursing Journal, 4, 143–153. Research, 19, 63–85.

Rubin, R. (1984). Maternal identity and the maternal experience. New York: Springer

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References:

Schumacher, K. L., & Meleis, A. L. (1994). Transitions: A Central Concept in Nursing. Image: The Journal of Nursing Scholarship,26(2), 119-127. doi:10.1111/j.1547-5069.1994.tb00929.x

Symes, E. (2017). The transition to motherhood: Psychological factors associated with pregnancy, labor, and birth. InPsych, 39 (1).

William Bridges Associates (n.d.) Bridges Transition Model. Retrieved on May 2020, from: https://wmbridges.com/about/what-is-transition/

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