1 TRANSITIONS IN HEALTH AND MOTHERHOOD AFTER STROKE

Transitions in Health and Motherhood: Perspectives of a Woman with an Intracerebral Hemorrhage During Pregnancy

Madeline P. Smith

School of Nursing, University of North Carolina at Chapel Hill

Senior Honors Thesis April 20, 2020

Author Note

Acknowledgements to Beth P. Black for serving as advisor on this Undergraduate Senior

Honors project. I have no known conflicts of interest to disclose.

Abstract

Life is filled with transitions, that is, changes from one state, condition, or role to another.

Changes from health to illness and pregnancy to motherhood are both examples of life transitions. Transitions often leave individuals vulnerable in the process. Turning points are sudden, unpredicted alterations in trajectory. Stroke is an example of a turning point in a person’s life in which they make a transition from health to illness, and can occur during pregnancy. Stroke during pregnancy presents difficulty for the mother beyond the usual transition of becoming a mother post pregnancy. Stroke during pregnancy presents a transition from health to illness in addition to the transition from pregnancy to motherhood, which places the mother in an unusually vulnerable position, where she must adapt to motherhood and the sequelae of stroke. The purpose of this study was to explore in detail a woman’s experience of stroke mid-pregnancy, hospitalization, recovery, long term effects, and how she has adapted to a significant change in her health and subsequent motherhood. A semi-structured interview was conducted to examine the woman’s experience. Transitions theory was a useful framework to analyze the woman’s experience before, during, and after her stroke. Mercer’s theory of Becoming a Mother was also used to understand the woman’s transition into motherhood after the birth of her second child. In practice, nurses need to identify and support patients during turning points that leave them vulnerable physically, mentally, emotionally, and spiritually.

Keywords: transition theory, becoming a mother, motherhood, pregnancy, intracerebral

hemorrhage, stroke

Transitions in Health and Motherhood: Perspectives of a Woman with an Intracerebral Hemorrhage During Pregnancy

Human life is characterized by transitions: the movement from one state or condition to another, and are typically associated with specific domains. Transitions may be developmental, such as transitioning from one age group to another in infancy to toddlerhood. Transitions may also be in roles, such as the transition from student to professional. Transitions as defined by Black and colleagues are “entry points for new states or roles within trajectories” (2009, p. 3), with trajectories being long-term paths in life. For the purposes of this paper, these are the definitions I use when describing transitions and trajectories. Black and colleagues also

described transitions as liminal, a moment between two trajectories where one may not be ready to leave one trajectory and enter another (2009). Transitions are also often associated with acquiring or relinquishing roles, such as becoming a mother or entering retirement (Black et al., 2009). Tyhurst also studied transitions across human experiences, and found transitions were characterized by a phase of turmoil, disturbances in bodily function, mood, and cognition, symptoms of psychologic distress, and altered time perspective (1957).

Turning points are sudden and usually unpredicted alterations in a trajectory (Black et al., 2009). These points bring intense change from one trajectory to another, such as preterm birth, cancer diagnosis, or accidental injury with long term sequelae. Mercer and colleagues described transitions as turning points where a person’s life takes a new direction, “requiring adaptation or change in restructuring behaviors and roles appropriate to the new direction” (1989, p. 2).

Middle aged adults experience many different forms of life transitions. One of these may

be a transition into parenthood. Catanzaro discussed transitions in parenting for middle aged

adults with long-term illnesses (1990). In her four-year study, no participants had or were

expecting children, but some participants had children prior to the study, so they had already transitioned into parenthood (Catanzaro, 1990). Some of her participants discussed not having children due to their newly diagnosed long-term illness, because of the complications and difficulty it may bring in raising a child. Participants making a conscious decision not to have children and enter parenthood due to long-term illness complications implies that the entrance into parenthood is a transition from one role to another which can be largely affected by changes in health. It implies the diagnosis of a long-term health issue is a form of life transition that can change the trajectory where an individual may have planned on having children, towards a trajectory where they no longer plan to rear children. Events out of an individual’s control, such as illness can be considered an event which causes a change in development and adaptation in an individual’s live course (Mercer et al., 1989).

Transitions and Stroke

Stroke is an illness with long term sequelae affecting physical, social, emotional, and spiritual facets of one’s life course. Transition in stroke patients were analyzed in Kosasih and Boonyasopun’s 2014 study. They found stroke patients underwent a transition after stroke during the recovery and rehabilitation processes. Themes associated with the transition were changes in temporal life order, change in sense of self, change in the experience of time, change in

connectedness, and change in community integration (Kosasih & Boonyasopun, 2014).

Transitions and Pregnancy

Pregnancy is a biological event with a predictable trajectory. Gestation lasts 40 weeks,

the woman experiences three trimesters, attends prenatal appointments, and the pregnancy ends

in birth of an infant. Pregnancy usually occurs at a time in women’s lives when they are younger

in age, and therefore have not developed any chronic illnesses yet. This allows pregnancies to often progress normally to term without harm to the mother or fetus.

The time during and after pregnancy is used to become a mother through psychosocial development, that while not rigid, is fairly predictable. “Women adapt their mothering behavior according to their infants’, families’, friends’, and other important persons’ responses to their actions,” said Mercer (1986, p. 2). She described the process of becoming a mother as involving redefining the self through four operations: taking-on behaviors, taking-in behaviors, letting-go behaviors, and maternal identity. The process of maternal role attainment has been observed to take place over three to ten months, consisting of “attachment to the infant through identifying, claiming, and interacting with the infant, gaining competence in mothering behaviors, and expressing gratification in the mother-infant interactions” (Mercer, 1986, p. 6). Mercer’s later work replaced the term “maternal role attainment,” with “becoming a mother,” because this term more accurately encompasses the continuous lifelong journey of adapting to motherhood as the child grows and new challenges in parenting arise (Mercer, 2004). Mercer also suggested complications in health and birth may interrupt or delay the maternal adaptation process (1986).

Serious Illness During Pregnancy

Serious illness during pregnancy represents a substantial turning point in both the

pregnancy trajectory, and in the woman’s health, especially when the illness results in long-term sequelae. The physical and psychosocial parts of the woman’s life, and adaptation to motherhood are affected by the illness. The turning point presents a change in the physical characteristics by affecting the woman’s health and ability to functionally take care of herself, and the newborn.

Psychosocial aspects of her life are affected by the turning point because the turning point

absorbs time, energy, and attention for the mother to focus on her own health, it takes away from

her ability to focus on the remainder of her pregnancy, and form a relationship with the child after birth (Mercer, 1986). This study looks at how stroke during pregnancy acts as a turning point and life transition in the pregnancy trajectory and motherhood to follow.

Stroke in Pregnancy

Stroke is a sudden, unexpected, abnormal change in cerebrovascular circulation that can result in long-term sequelae. Common symptoms of stroke include a sudden onset of a severe headache, visual changes, muscle weakness or paralysis, ataxia, dysarthria, dysphagia, aphasias, cognitive and emotional deficits, and paresthesia (Hinkle & Cheever, 2018). Patients with hemorrhagic stroke may also experience nausea or vomiting, changes in level of consciousness, and sometimes seizures (Hinkle & Cheever, 2018). Stroke may cause many different sequelae, some of which may be improved over time, and some of which are long-term. Examples of sequelae of stroke are muscle weakness, hemiplegia, cognitive, behavioral, and emotional deficits, aphasia, dysphagia, urinary incontinence, decreased sensation, and decreased field of vision (Hinkle & Cheever, 2018). Many risks for stroke during pregnancy have been identified, such as age, migraines, smoking, heart disease, hypertension, obesity, and diabetes (Cunningham et al., 2018). Other risk factors related to pregnancy are gestational diabetes, obstetrical

hemorrhage, cesarean delivery, and most commonly pregnancy-associated hypertensive disorders (Cunningham et al., 2018).

Women are at a higher risk of stroke than men, and have higher mortality rates. The risk

of both ischemic and hemorrhagic stroke are increased during pregnancy (Cunningham et al.,

2018). While stroke during pregnancy is not common, it occurs in 10 to 40 per 100,000 births,

and the rate is rising (Cunningham et al., 2018). In the United States, 6.6% of pregnancy-related

mortality is related to cerebrovascular accidents, and 9.8% of maternal deaths after 42 days

postpartum are due to cerebrovascular accidents (Cunningham et al., 2018). In 2005, researchers in one study found that of 2,850 cases of pregnancy-related stroke, 11% occurred during

antepartum (James et al.); however, a study in 2016 by Leffert and team found that 44.8% of 145 pregnancy-related strokes occurred during antepartum.

Hemorrhagic stroke is a type of stroke where bleeding into or around the brain occurs (Hinkle & Cheever, 2018). The bleeding can increase intracranial pressure, and result in cerebral ischemia due to the reduction in blood flow, both of which disrupt brain metabolism (Hinkle &

Cheever, 2018). Symptoms of hemorrhagic stroke are caused by the bleeding’s mass effect, toxic effects of the blood, or by the increase in intracranial pressure (Hinkle & Cheever, 2018).

Roughly half of all strokes in pregnant women are hemorrhagic (Cunningham et al., 2018).

Hemorrhagic strokes can be categorized further into intracerebral and subarachnoid

hemorrhages. Intracerebral hemorrhages bleed into the brain, often due to chronic hypertension, which may be associated with pregnancy, or preeclampsia (Cunningham et al. 2018).

Intracerebral hemorrhages have a higher rate of morbidity and mortality than subarachnoid hemorrhages (Cunningham et al., 2018).

The Case Study

Intracerebral hemorrhages are rare in pregnancy, but its occurrence presents the opportunity to learn from a 35-year-old woman’s experience of stroke while six months

pregnant, and her continued recovery while transitioning into motherhood of her second child. In

this paper the participant is referred to as “Jane.” Her experience was unique, and despite the

trauma, she has lived to tell the story of her and her child. The purpose of this study was to

explore in detail her experience of stroke mid-pregnancy, hospitalization, recovery, long term

effects, and how she has adapted to a significant change in her health. During this case study, I

conducted a semi structured interview to examine Jane’s experience and drew themes from the interview. The goal was to determine how theory can make sense of these situations in order to influence future practice and knowledge when patients with unique or unusual experiences enter the hospital.

Methods

After the IRB determined the research did not constitute human subjects research as defined under federal regulations, I conducted a semi-structured interview with Jane regarding her experience of pregnancy, stroke, birth, and motherhood. I then transcribed the interview and analyzed it for themes, quotes, and nonverbal responses of significance. These themes were then organized into a timeline. The timeline consisted of three parts: before, during, and after. The before category was information Jane shared about her life and her pregnancy prior to the stroke.

The during category was information Jane shared from the day of the stroke up until she left the hospital. The after category focused on information shared by the patient about her recovery, moving back home, and how things have changed. Once all pertinent information was organized within the timeline, the data was analyzed again for themes.

Results Interview

Jane cited the interview as an emotional experience, which is supported by how she teared up and cried on several instances. She said it felt good to talk about it all, and wanted to do it again, or speak more with someone else in the future. She described the experience if interviewing as “cathartic.”

Pregnancy

This pregnancy was Jane’s second, where she reported her first pregnancy as being easy and having no complications. She reported using her first pregnancy as a comparison for her second pregnancy. Jane said, “Having had my (first child) prior I knew what to expect, so this crazy journey that I went on with (second child) I would not have expected any of it.” When Jane regained consciousness in the hospital after her stroke, she said she was happy to feel that her baby was still inside of her. She described feeling happy it was not the “other option” for her baby. After waking up she noted, “How I was normally to that particular moment it was like a 180 completely. Um, yeah it’s just the moment in my life that I knew I was going to be different from that point on.”

Birth

Jane’s first pregnancy ended successfully in a cesarean birth. She detailed how her birth had to be planned very specifically and she had to get an epidural. When describing the birth of her second child after her stroke, Jane teared up and cried, noting that she was happy she could be there for that moment. She remembered the delivery room and hearing her baby cry which she said was amazing, beautiful, and she was so happy to hear her cry after everything they had been through. After her daughter’s birth, Jane decided it was the last time she would be giving birth, because she did not desire to become pregnant again. Therefore, she found her daughter’s birth to be a beautiful beginning to her daughter’s life, in addition to a beautiful close to her pregnancy trajectory.

Turning Point

During the interview, Jane only spoke the word “stroke” once in reference to a stroke support group. Throughout the interview she instead referenced the stroke as “the problem” or

“it”. Jane described herself prior to the stroke as an independent person who had the attitude of

not needing any help. When in the hospital, she stated appreciation for the nurses and therapists and all that they would do for her. She reported their encouragement during her recovery as being very helpful and positive. Due to the stroke Jane had difficulty finding words, but she said the nurses:

They were really good a trying to fi- like they would, say like well try to describe it, try to think like um they kept saying like close your eyes and think of what it looks like, think of what it smells like, think of what it feels like, so trying to get words out of me that instead of just saying well tell me what it’s like, that was very helpful to me to get things out that way.

Jane repeatedly expressed how grateful she was towards the nurses that helped to take care of her during her time at the hospital. She said they were there for the good and the bad, she said “I loved that the nurses laughed with me, cried with me, everything. It was just really; it was great to see them as people too.” During her hospital stay, she said staying in bed all day could be depressing, and she was thrilled when the nurses would help her get up and walk to get out of her room. When she returned home, she thought she may be able to accomplish her recovery tasks and goals without difficulty, but found some of the short term goals took longer than she expected. She cited home health as a service that assisted in her recovery, such as speech and occupational therapy who visited her during the week at home in order to continue recovery outside the hospital.

Transition to Motherhood

The transition from pregnancy to motherhood was a different experience after her second

birth when Jane compared it to her experience after the birth of her first child. She said she had

difficulty remembering when to feed the baby, or when diapers had been changed. To overcome

some of these difficulties, Jane used phone timers, voice texts, and reminders to keep a record.

She said there has been a lot more challenges with her transition into motherhood the second time, but receiving help at home with taking care of the baby has been beneficial. The extra help at home even allowed her to go back to work for a short time.

Family

Jane spoke a lot about her family, in particular her husband, supporting her through this experience. She said she is extremely thankful towards her husband for sticking with her through the stroke and her entire journey. She feared other men would have left, but is very thankful he has stuck by her and been so helpful and supportive in many ways, such as reminding her to take her pills, going to appointments with her, and helping with the kids. She said she has learned a lot about him, as well as herself because of the stroke. Jane also said the rest of her family has been very supportive. Although she and her sister “did not get along” while growing up, they are now best friends. Jane noted that she could not imagine going through this without her. Her sister understands what can be made light of, and helps to make Jane laugh to feel better about the situation, but also knows when to show more love and support. Jane’s father told her when she was young, “You’ll have certain friends in your life, but that you, that at the end of your life you’ll be able to count your true friends on one hand,” which Jane said has been absolutely true for her during this experience.

Career

Jane worked as a teacher before her stroke, and took time off during her recovery process. At the beginning of her transition home when Jane believed she would be able to recover quickly, she thought she would return to work soon after coming home. After

discovering that some of the recovery goals were taking her longer than she expected, Jane came

to realize she was not going to go back to work the way she had been prior to the stroke.

However, she did return to work for a short time, and cited her love for teaching and being around kids, in addition to wanting to get out of her house because she felt trapped, as the reason.

Finding her work to be more physically and mentally demanding than she anticipated, Jane decided working at that time was too much too soon. Even though going back to work turned out to be too much for her to handle at the time, she was still happy she gave it a try. Jane had to accept things in her life, including work, would be different now, but she reminds herself she is alive and that is the most important part, “so everything else, it will, it’ll be what it’ll be

(laughs).” Going back to work for that time motivated her to keep working on her recovery because it made her realize her journey is not complete, so she is looking into attending outpatient facilities.

I recognize now that that was not the best idea, so now what I’d like to do is just really work on myself physically like get in the best possible shape that I can and um, just keep working on my brain.

Religion

Religion was brought up as something Jane had recently struggled with. She said she was

previously very religious, would volunteer and go to church often. After her stroke, she said, “I

was very angry about it and (asked), “why, why, why, why me, why this?”” She said she could

not understand why this happened to her when she was devout and helped those in need. When

describing the birth of her second child however, Jane said she thanked the Lord for her birth and

getting her daughter there safely, even though Jane was in pain physically. Now, Jane says she

copes with the situation the best she can. She thanks God for her baby’s safe birth, both of their

lives, as well as her son’s birth and life. Her personal realization that God was responsible for

bringing all of their lives into the world safely, and their current good health is helping her to become more religious again. Jane said questioning did her no good. She says she has to accept what is, move forward, and be thankful that they got through it. Jane wants to return to church again.

The New Normal

Overall, Jane said she feels she is coping well, but there are areas she needs to work on as far as being better about accepting help. Emotional support she said she especially needs because she realizes everyone needs help and support sometimes, and there is no shame in it. She does feel like she could use an outside source or an impartial party who is not involved in her life to talk to about her feelings. She has considered talking with those with similar experiences or joining a group. Jane accepts that she went through a huge trauma and she cannot complete this journey by herself. She recognizes she used to be a very “I can do everything” woman, and now she realizes she cannot, but that is acceptable. She is learning to find peace within herself and not compare to what her life used to be. Jane said she feels lucky to be where she is, she does not feel it is possible to be “happy” at the moment, but she can be grateful for her and her daughter surviving the stroke. “I feel so grateful to be where I’m at now and I know I still have a long way to go but I’m happy to be on the road for sure.”

Discussion

Throughout Jane’s interview, she provided descriptions of herself and her life prior to the stroke, during the stroke and hospitalization, and after the stroke while in recovery. She spoke of herself and her life prior to the stroke as being very different to herself and her life at the present.

Her first pregnancy and transition to motherhood was described as a whole different experience

as compared to her second pregnancy when she had her stroke. Jane most significantly described

changes within herself that occurred due to the stroke. She spoke of how she was independent prior to the stroke, but during the stroke she was very reliant on the nurses in the hospital, and after going home she still received assistance through home health and childcare. Her brave decision to go back to work after her stroke also significantly highlighted differences within herself after the stroke as compared to before. She recognized that things in her life, including work would be different since she had the stroke. Beyond her physical self, changes in thought and religion were noted as different during and after the stroke.

Although transition theory is an older theoretical framework first described by Meleis in the 1980’s, it has substantial usefulness for understanding this case study. Meleis and Chick identified pregnancy, birth, illness, hospitalization, recovery, and loss as events leading to a process of transition (1986, p. 241). These are all events that Jane experienced in her journey of becoming pregnant, having her stroke, being hospitalized, recovering, giving birth, and a loss of part of her past self. Meleis and Chick also described patterns of response to transition events, such as distress, anxiety, depression, changes in self-concept, role performance, and self-esteem (1986, p. 242). Throughout the interview with Jane, these patterns can be identified in her journey. She described distress and anxiety when she woke up in the hospital and was worried how her baby was. Jane experienced bouts of depression when questioning “why me?” and when adjusting to changes in her self-concept, which also affected her self-esteem. Jane’s role

performance changed as described when she said she would not be able to return to work the

way she was before her stroke. Transition theory allows us to deconstruct and understand Jane’s

experience, by identifying themes to coincide with her experiences. While not the same for

everyone, transition theory allows us to better understand what Jane experienced.

Jane’s stroke acted as the turning point causing her transition from health to illness. The stroke was the turning point because it was the specific point where there was an unpredictable sudden shift in her life trajectory, resulting in a transition to life with long-term sequelae of stroke. Jane even noted in her interview that she knew at the moment of her stroke “it was like a 180 completely” and it was the moment that she knew she was going to be different from that point on. Simultaneously, Jane was also experiencing a transition towards becoming a mother during her pregnancy. Although she already had one child, each child born brings changes within the home where parenting roles may have to be adjusted to balance caring for the older child and the newborn.

The theory of Becoming a Mother is another theoretical framework that may be used to understand Jane’s experience. Becoming a Mother as described by Mercer consists of

establishing maternal identity through stages of: commitment, attachment, and preparation;

acquaintance, learning, and physical restoration; moving toward a new normal; and achievement of the maternal identity (2004). Mercer’s theory addressed the life-long changes of becoming a mother from pregnancy to long after birth where environmental factors and other life experiences may influence and alter the image of maternal identity (2004). This theory is useful in

understanding Jane’s alteration in maternal identity from her first child to her second child,

because her experience of motherhood previously was unencumbered by long-term sequelae of

stroke. Jane’s preparation stage for becoming a mother was affected by her stroke because it took

place during her pregnancy, which hindered her ability to feel attachment to the fetus because

she did not fully remember her pregnancy. Physical restoration was hindered due to her own

need for additional physical restoration from her stroke. The outcome was that Jane’s new

normal resulted in a different maternal identity from her first child because of the hindrances

following her stroke and sequelae in focusing on and adapting to pregnancy, birth, and motherhood.

Throughout the interview, Jane mentioned the word “stroke” only once. Instead, she referred to her stroke as “the problem” or “it”. Her unwillingness to say the word stroke, and reference her stroke as “the problem” indicates a significant view in her mind as the stroke being a negative event, and possibly even an attempt to distance herself from the stroke itself.

Regardless, the omission of the word and description of it as a problem signifies that the turning point has a lot of emotion tied to it. During Jane’s interview, she cried multiple times, most notably when she talked about the birth of her second child and the support she has received from her family throughout her transition. She spoke of how she thought the stroke and birth could have resulted in “a very different outcome” for them, referring to possible illness, injury, or death. Jane’s emotional response to her stroke and birth signifies how turning points and transitions are particularly vulnerable points in human life.

Jane described the nurses that took care of her as amazing, sweet, kind, and gentle. She said it felt “heartwarming” because the nurses extended support to her constantly and would laugh, cry, sing, and joke with her. Jane described the interview as “cathartic,” and she would like to speak to someone about her experience again in the future. Jane’s identification of situations where emotional support was extended toward her emphasizes the importance of mental and emotional support during transitions.

Importance of Nurses in Her Recovery

Of the nurses Jane remembered from her hospitalization, she described most of them as

“amazing”. She said the nurses were sweet, kind, gentle, and it was heartwarming and an honor

to be around them. Jane felt many of her family members and friends would brag about how

wonderful the doctors were, but she felt the nurses were the ones who did most of the leg work.

She said the nurses, “were there for the dirty parts of things, the great parts of things, they were there, I just cannot say enough about the nurses.” During her hospital stay, Jane said sitting in bed all day could become depressing and she felt stuck. She asked the nurses if she could get up and walk, so they assisted her in ambulating and got her out of her room, which she was excited about. This shows how important the nurses role was in assisting Jane out of a depressed mood while in the hospital. As a result of her stroke, Jane experienced Broca’s aphasia and had difficulty finding the right words to describe her thoughts. She said the nurses assisted her in finding the right words by asking her to close her eyes and describe what it looked like, smelled like, or felt like, which was different from simply “Tell me what it’s like.” Jane said this

approach was very helpful to get her words out. The nurses seem to have shown Jane a plentiful amount of emotional support, for which Jane displayed large amounts of gratitude and

appreciation towards:

I loved that the nurses laughed with me cried with me, everything. It was just really, it was great to see them as people too, not just you know, a nurse and they’re there for a reason, and to check vitals and do this and do that. And it was, I loved them, I really, it was very nice because everyone will always talk about the doctors and how great the doctors are and, “oh the doctors saved my life,” and yes they did, but um, I think the nurses did a lot of the legwork of it, and, and more than that, so they were amazing people.

In contrast, Jane did remember one nurse who she said was “horrendous.” Jane called her

Nurse Ratched because of how harsh she was physically and emotionally. She said the nurse did

not have patience with her when she had trouble finding her words and would say, “Well, what’s

the problem? What’s the problem?” Being treated this way did not help Jane to find her words as easily or comfortably as the way the other nurses would address her aphasia. Jane’s difficult experience with this nurse came up several times throughout the interview, and she even said,

“Isn’t that terrible that that sticks out so vividly.” This is important for nurses to note that even though Jane had just experienced a stroke and could not remember words, and her short term memory was impaired, a physically and emotionally unsupportive experience with a nurse stayed with her so vividly.

Implications for Practice

Nurses encounter patients at times of high vulnerability. Hospitalization presents an unknown territory full of uncertainty for many patients. Hospitalization often is associated with transitions such as health to illness, or transitions into parenthood, or losing a family member.

Meleis and Trangenstein categorized transitions nurses assist with as individual developmental transitions, family developmental transitions, situational transitions, health/illness transitions, and organizational transitions (1994). Transitions are known to be times of increased

vulnerability for all persons. Illness such as a stroke during the pregnancy trajectory is an example of an exceptionally difficult transition where Jane was already transitioning into

motherhood for her second child, but she also had to face a transition from health to illness. This overlay of stroke within pregnancy made her particularly vulnerable.

Throughout her interview, Jane noted how important the support from nurses was

towards her recovery. She emphasized how the emotional support from the nurses made them

amazing, wonderful people compared to the doctors who were not with her as often. She was still

thankful for what the doctors did for her, but it was unmatched by the invaluable emotional

support from the nurses. Her family was also mentioned as an important piece within her

recovery. The emotional support from her husband and sister were particularly noted as factors that assisted in her transition because they helped her physically, but also loved her and joked with her, and cried with her. Even the interview I conducted with Jane served as a form of emotional support, because she expressed such gratitude towards being able to talk about her experience, and expressed an interest in talking with others in the future, such as support groups.

Meleis and Trangenstein found similar results in their 1994 study where three indicators of successful transitions were drawn from articles they reviewed; emotional well-being, mastery, and well-being of relationships. In parent transitions, enabling parents to discuss their feelings, mood swings, anxiety, and loss of self-confidence are important strategies for health

professionals to use when interacting with new parents (Barimani et al., 2017). The importance

of emotional presence can also be seen in Swanson’s theory of caring which includes “being

with” patients emotionally to cultivate healing (Swanson, 1993, p. 355). Turning points can

occur at any time, and excellent professional nursing care can mediate the vulnerability inherent

in times of change, as seen through Jane’s case study.

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