Postpartum psychosisNurses View and care through a Disabling Illness

By Inger M. Engqvist

Design for Major paper submitted to the faculty of the Graduate Program of the University of Rhode Island College of Nursing in partial fulfillment of the Requirements for the degree

Master of Science, Nursing 2003

Table of Contents Page Introduction Literature Review

History Definition of postpartum psychosis Incidence Postpartum psychosis a reactive psychosis Cause Treatment Prognosis Family network Psychiatric Nursing Nursing in relation to Postpartum Psychosis Knowledge utilization in Nursing 5 7 7 8 8 9 10 11 11 11 11 13 14 15 15 15 16

Statement of Purpose
Aim of the Study Research Questions

Method
Procedures for the protection of human Subjects Ethical considerations

16 17

Creditability, Dependability, Confirmability and Transferability Sample/setting Data collection Data Analysis 18 19 20 21 24

Results
Theme 1. Signs that precede intervention from the nurse Theme 2. Nurses actions Theme 3. Nurses communication of focus Theme 4. Nurses reactions Theme 5. Knowledge development

24 25 28 32 34 36 36 37 37 37 38 38 38 39 39 36 40

Discussion
Knowledge Utilization in Nursing Relationship with the woman Communication To do good to the woman Improving the mother-child bonding The nurses reaction Additional education Interest in research Work satisfaction Implications Limitations

Future Research

40 42 46 46 47 48 49 50

References Appendices
1. Letter to nurses 2. Letter to nurses union 3. Letter to chief psychiatrist 4. Letter to head nurses 5. Interview questions

5 The conventional thought about new motherhood as expressed in commercial advertising suggests that the weeks and months following childbirth are filled with happiness, contentment and satisfaction, only generally disturbed in the early weeks by inadequate sleep. For new mothers this is typically not the case, but for women, who remain mentally healthy, this is a time characterized by both positive and negative feelings. While the majority of new mothers experience contentment and satisfaction, for a minority the picture is complicated by psychiatric illness. My interest for mothers that has been afflicted by postpartum psychosis (PPP) was piqued during my clinical studies in psychiatric nursing. For a long time I have worked as a midwife. When working in the psychiatric ward, I met a woman who had delivered only a few days earlier and was interested in her condition. This woman was confused, suffered hallucinations and had delusions. She did not believe she had delivered her baby but thought she was still pregnant. She refused her newborn baby and thought that it belonged to someone else. The woman did not sleep much, she was restless,and she went around the ward carrying a small teddy bear. There was constant risk of her hurting herself, and she repeatedly mentioned that she wanted to die.According to Knops (1993) 5 per cent of mothers with PPP commit suicide and 4 per cent infanticide. Sometimes she was deeply depressed and just stared absentmindedly without answering when she was spoken to She was clearly suffering greatly and seemed not to function both as a human being and mother.During the five weeks I was in contact with her I did not see any change for the better in her condition. This woman described with PPP is consistent with the description OHara (1987) gives of this illness. OHara describes PPP as a psychosis that is different to other psychoses. OHaras opinion is that this psychosis gives higher levels of euforia and activity, lack of functioning in daily life, and a higher degree of confusion than nonpuerperal psychoses. Postpartum psychosis is a relatively uncommon but serious disease that afflicts women at a time when significant demands are already being made on their ability to cope. Some women are deeply depressed and anxious. Risk of suicide as well as risk of infanticide is not to be ignored.Prompt intervention can prevent the tragedy of child abuse and infanticide that sometimes occur. When indications of a woman with such behavior who

6 recently delivered a baby, there is a need for the woman to be hospitalized as soon as possible. Sometimes it is possible to treat a woman with postpartum psychosis in her own home but with intensive outpatient care. Postpartum psychosis is a serious and disabling disorder, affecting the woman, the infant, her older children and her partner (Gaskell, 1999; OHara, 1987; Ugarriza, 1992). In contact with this woman the question was raised: How can I as a midwife/nurse diminish her suffering and improve her difficult situation? What kind of research has been done? What do psychiatric nurses know about the illness? Would it be possible to improve the nursing for these patients in asking psychiatric nurses about the nursing they give?

Literature review
In this part is a description of the early history of postpartum psychosis, a definition of the illness and a review of the literature and research done. Included is a description of the illness where incidence, cause, symptoms, treatment and prognosis are presented. Psychiatric nursing is described and, finally, knowledge that is utilized in nursing. History Interest in postpartum depressions and psychosis is not new. More than 2000 years ago Hippocrates described such a condition and theorized that the breast-milk went to the head of the woman (Cox, 1986). He also had another theory and suggested that the blood after the delivery took the path from uterus to the womans head and caused agitation, delirium and mania. These hypotheses were generally accepted for more than 2000 years (Dalton, 1980). In the Middle Ages mentally sick mothers were regarded as witches and were thought to eat their own children (Hwang, 1993). The French physician Marc (Puranen, 1994) was the first one in medicine to take an interest in womens psychological reactions at childbirth and the first to describe the psychosis in detail. In 1858 Marc did his doctoral dissertation on the psychotic conditions of new mothers. Later Marc society was founded which is an international association of researchers interested in psychological disorders at the time of childbirth. This association exists to this day and mainly do research in prevention and treatment (Puranen, 1994). In the literature from 1928 Bumke used the term tokophobia (theories about birth) which is a condition where the woman has deep fears regarding the delivery (Brudal, 1985). According to Johannisson (1994) anxiety around the delivery was a condition many women had and every delivery was considered a fundamental risk of death. Even after the child was born there were many dangers such as lengthy and complicated deliveries, bad technique with sepsis, uterus atonia with bleeding, and toxemia with convulsions and infections. And afterwards the woman could get the great fatigue, which was postpartum psychosis or depression. According to Johannisson (1994) psychiatric disorders in connection with deliveries were noticeable in mental health statistics at the end of the nineteenth century. Pregnancies were thought to be a great risk to bring forth hidden illnesses and making worse present conditions. For

8 women admitted to Swedish mental hospitals in the year of 1900, pregnancy, childbirth and breastfeeding were the second most common reason for a psychiatric diagnosis (Johannisson, 1994). Until 1939 there was a British law (Dalton, 1980) indicating that a mother could not be condemned guilty of murder of her own child during the first twelve months after her delivery. The reason for this was that it was believed that her psychological condition was not stabilized before this time had passed (Dalton, 1980). Definition of postpartum psychosis The words postpartum and puerperal are synonymous and mean, what belongs to childbirth. This refers to the six to eight weeks after delivery when the changes being developed in the female genital organs from pregnancy disappear. According to the Swedish Medical Dictionary (1997) psychosis is a combination of the word psyche meaning soul and senses, and the word osis which means illness. Puerperal psychosis includes every serious psychological disturbance or illness during pregnancy or after delivery (Lindskog & Zetterberg, 1997). In this study the word postpartum psychosis abbreviated as PPP will be used. The Diagnostic and Statistical Manual of Mental Dis-orders (DSM-IV) (American Psychiatric Association [APA], 1994) tells us that the onset should be within four weeks after childbirth. Symptoms are common in postpartum-onset episode with fluctuations and increased intensity in mood and preoccupation with the infants well being which may range from exaggerated concern to delusions. The presence of delusional thoughts about the infant is associated with a significantly increased risk of harm to the infant. It may present with or without psychotic attributes. Maternal attitudes toward the infant are highly variable but may include disinterest, fearfulness of being alone with the infant, or over-intrusiveness that inhibits adequate rest for the infant. Infanticide is most often associated with psychotic episodes that are characterized by command hallucinations directing to kill the infant or delusions that the infant is possessed (APA, 1994). Incidence According to Kumar (1990) childbirth is a time when women are at the most risk of becoming severely mentally ill. The incidence of PPP is 1-2 per 1000 new mothers. According to Balcombe (1996) the risk is as high as 50 percent of getting this illness for a subsequent

9 childbirth. Additionally, a family history of psychopathology has been found to be related to higher incidence of postpartum psychosis. In studies the incidence is as high as 57 per cent (Craddock & Jones 2001; OHara, 1987; Terp, Engholm, Moller & Mortensen, 1999). Knowledge of this connection is important to educate women who are planning to become pregnant and to discuss with them whether she should postpartum be prophylactic treated (Craddock & Jones, 2001). While pregnancy is a time of lowered risk for psychosis, the first month postpartum is a time of greatly elevated risk. Primiparous women are most vulnerable to PPP and this risk is considered to be twice the risk as for multiparous, especially if she is unmarried (Bewley, 1999; Brennan, 1991; Buist, 1997). Postpartum psychosis a reactive psychosis Postpartum psychosis is classified as a reactive psychosis. According to Gaskell (1999) there are three types: Manic, Depressive and Psychotic. These may overlap or follow simultaneously. Women experiencing PPP are grossly impaired in their ability to function, usually because of hallucinations or delusions. In other cases, a severely depressed mood or confusion may disturb women with this condition (OHara, 1987). According to Bgedahl-Stridlund and Rupert (1998) a reactive psychosis consists of acute, often reversible psychosis, triggered by a stressed life situation, sometimes in combination of physical exhaustion or illness. Single mothers with unplanned pregnancies and women with poor relationships with their own mothers may be the ones to develop PPP. It has been estimated that one in five postpartum disorders may require admission to a psychiatric hospital(Jones and Venis, 2001). Observable indications for this condition might be that the woman is more worried, tense, and suspicious but markedly exhilarated during her pregnancy compared other women (Balcombe, 1996). PPP occur in close proximity to time of childbirth (mainly within the first 2-4 weeks after delivery) but the first appearance is seldom within the first hours after the delivery. Usually two to three days will pass before the psychosis will occur. The onset usually occurs unexpectedly and abruptly without other warning signs except sleeping disturbances lasting a few nights (Ugarriza, 1992).

10 PPP is characterized by bizarre behavior. For example, the woman might have a great fear of caring for her baby and may voice religious ideas that she usually does not. She might also have strange thoughts such as fear of kitchen utensils, food, water or medicine combined with a constant intense feeling of not wanting her baby (Semprevivo, Comitz, & Comitz, 1990). The mood may vacillate between agitation and despair sometimes within minutes. Aggressive fits with delusions about her child or her own body and hallucinations are often present (Jones & Venis, 2001). Cause Childbirth is known to be followed by an increase in psychiatric illness. Stillbirth or perinatal death, increasing maternal age, short gestation, and difficult labor were all related to increased risk for PPP. A womans history of multiple abortions, pregnancy complications and fewer visits to the antenatal care clinic were correlated with psychiatric illness related to the delivery (Bgedahl-Stridlund, 1986). Most researchers agree that postpartum psychosis is often due to biological, hereditary, and hormonal factors (Kumar, 1990). Some refer to the rapid decrease in the estrogen hormones level after the delivery as a cause for postpartum psychosis (Wieck, Kumar & Hirst, 1991). According to Robinson (1998) suicide kill more mothers than hypertensive disease, especially those who do not recover from psychiatric illness after giving birth. A long-term follow-up study in Sweden (Bgedahl-Stridlund & Ruppert, 1998) among women with PPP points to the suicide rate being 6 per cent, which includes deaths due to alcohol and drug abuse. The mortality rate among these women was five times higher than expected in a general Swedish female population with women of the same age and during the same period. Treatment The treatment must be adjusted to the type and severity of the psychosis (Jones & Venis, 2001). Some women will recover spontaneously in their homes with the support of relatives and with outpatient care services. Others may need admission to a psychiatric hospital and, if possible, together with her newborn child. ften medication is used, generally administering small doses so breastfeeding may be continued. The care objective must be to have as little disturbance as possible in the initial mother-child bonding period (Jones & Venis, 2001)). If the psychosis gets more serious, electric convulsive therapy (ECT) might be considered, especially if the woman is suicidal.

11 Usually one will see a distinct and drastic change in the woman after using ECT (Buist, 1997). Gaskell (1999) and Kumar (1990) claim that women who are cared for together with their child during their time of illness will recover faster. The woman will feel less guilt if she is not separated from her child. At the same time it is necessary to consider the security risk for the child if the mother and child are cared for together. Prognosis According to Balcombe (1996), Bewley (1999), Terp et.al. (1999) the prognosis for the woman is good and most women recover completely in a matter of two to six weeks, but some may develop chronic schizophrenia. If there is early onset of the psychosis (within the first month after the delivery), the woman typically regains her health more quickly. Women, who have had a history of earlier postpartum psychosis, psychiatric problems or heredity of mental disturbances, seem to have an increased risk of developing a postpartum psychosis. Family network The disease effects the whole family (Kumar, 1990). The relationship with the partner as well as with the older children will often become strained. Mostly it affects the newborn child, whose cognition and emotions can be delayed and disturbed.The woman may already during her pregnancy have feelings of hopelessness and depression (Jones & Venis, 2001). According to Bgedahl-Stridlund and Ruppert (1998) postpartum mental illness must be looked at as a potentially severe disease with possible long-term effects on the womans health and her social functioning, as well as possible adverse long-term effects on the infant and the whole family. Psychiatric nursing The most common symptom in psychiatric diseases is anxiety. Anxiety is defined as a diffuse worry, the feeling of uncertainty and helplessness. Anxiety is also a sign of a lack of balance in the person changing her behavior (Lindstrm, 1994). Psychiatric disease can influence a persons desire and ability to take good care of herself physically, emotionally, intellectually, socio-culturally and spiritually.She may also feel a lack of self-confidence and trust. She may not be able to express longings and

12 whishes or to be able to feel respect for herself or to express her own will (Lindstrm, 1994). The target groups for psychiatric nursing are people with one or more psychiatric health problems. When a person is not able to solve a problem by himself or in conjunction with a persons social network or medical expertise, we will then call it a psychiatric health problem (Lkensgard, 1997). According to Peplau (1952) the interaction between the nurse and the patient is very important. Peplaus theories are strongly oriented to the individual. Quality nursing care assumes a safe and supportive relation with the patient. This presumes that both partners can communicate and understand each others thoughts and feelings. Peplau identified four phases of interpersonal relations, such as orientation, identification, exploitation and resolution. Within these four phases, nurses take the role as teacher, resource counselor, leader, technical expert, and surrogate according to the need the patient has during the interpersonal process (Peplau, 1952). For Peplau (1988) nursing should be a maturing force and an instrument for education as well as a therapeutic process in the interpersonal relationship between patient and nurse. Her objective for nursing care is that the patient is eventually able to solve many of her daily problems without the aid of professionals. To try to keep intact the patients dignity it is necessary to let her take responsibility for herself according to her capacity and to let her participate in decisions concerning herself. When necessary, it can happen that the nurse is to take responsibility for the patient, when the patient or her relatives are not able to do so. This is also to keep dignity (Ltzn & Nordin, 1993). To confirm and support the patient is to illustrate responsibility in the context of I see you. One sees, confirms and responds to another persons sorrows, worries or happiness. The nurse sees the patient and confirms her as a human being. The confirmation is expressed through nursing activities highlighting responsibility, listening, understanding and recognition (Lavender & Walkingshaw, 1998; Ugarriza, 1992). A patient with psychiatric illness needs to have a nursing style characterized by trust in the patients own capacity to develop and confidence in her ability to change. For

13 the nurse to ignore the patient and not to give her necessary space would constitute an insult to the patient and cause her unnecessary pain. Nursing should reflect feelings of acceptance, respect and for her to be seen (Peplau, 1997). Nursing in relation to Postpartum Psychosis By actively listening to the woman and showing acceptance of her thoughts and feelings, the nurse gives her the support she needs. To give her the space to speak freely and openly about her worries and anxiety shows the patient that the nurse is interested in her. The nurse must be calm and supportive and, by doing so, lets the woman understand that she is deserving help and support (Ugarriza, 1992). A woman showing problems in her ability to take care of her baby is at greater risk of psychiatric problems after her delivery. A nurse can educate the woman on the basics of how to care for a newborn baby and give her good support in doing so. It is also important for the nurse to show support of the partners role and make sure that this partner participates in the care of the baby (Kendall-Tacket, 1993; Marmion, 2000). A good relationship between the nurse and the mother is of great importance. The nurse needs to be sensitive and supportive and to have a personal relationship with her patients. Women have to be able to feel comfortable enough to talk and the nurse has to be willing to listen. This may reduce the negative psychological impact of some birth experiences. Also, the nurse needs to realize that childbirth is not just a momentary occurrence but a major life event for her. The nurse needs to acquire as much knowledge about the disease as possible in order to understand what the woman tells her. She needs to be understanding, patient and caring, and to have a holistic view of the patient. That means to see the whole woman with body, mind, and spirit (Semprevivo et al., 1990). Prenatal education about postpartum illness should improve the couples ability to detect a psychiatric problem early and for them to seek appropriate help. That would reduce the fear and confusion the couple may feel given any lack of information regarding this. When PPP is present, counseling may reduce the blame, guilt and isolation that normally accompany the knowledge that they have this illness. A mourning process might take place, and the counseling might help to reduce the sadness that the knowledge of this knowledge of this illness can impart in unfulfilled expectations, and shattered visions the couple had about the first year of parenthood would be like for them (Stewart & Henshaw, 2002).

14

Knowledge utilization in nursing According to Kim (1999) nursing is a human practice discipline and knowledge of nursing must be the foundation from which the nurse is working. When the focus is on people, this knowledge must be used to try to understand and explain phenomena that are of interest to the nurse, such as phenomena about patients and nursing practice and to provide a basis for nursing practice. The highest and most mature nursing knowledge must be knowledge that is possible to use in practice, and can only be validated in practical work. Kim (1999) thinks that nursing knowledge consists of four foci. The first is general knowledge, which is generalized knowledge about human beings relevant to nursing. Next is situated hermeneutic sphere that means knowledge of clarifying, understanding, illumination, and appreciation concerning human experiences. For the nurse, this is the type of knowledge that is developed in clinical scripts, exemplars, and case narratives. The third is critical hermeneutic knowledge, which refers to knowledge of interpretation, critique, and emancipation. This knowledge the nurse gets from living together with others the focus of which is on coordinated living between people (which also includes patients and nurses). This knowledge gives nurses a basis to coordinate the work of practice, getting well, and living together. Finally there is ethical/aesthetic knowledge. This knowledge requires the nurse to determine what is desired, normatively expected, and aspired in nursing practice and is the base for ethical, aesthetic practice and for the nurse to know what is known and what must be desirable in nursing practice. According to Kim (1999) nurses need knowledge to frame their practice, come to conclusions and to be able to make references to both understand a specific situation and to be able to transform the situation of practice in order to get a better understanding. This means that the ultimate synthesizer and knowledge initiator is the nurse in practice. Conclusions are carried out by nurses in practice by their own personal experience, by drawing situation-specific knowledge and, sometimes, by using public knowledge. This does not necessarily mean that nurses do this consciously, systematically or programmatically. This is more often done unconsciously. While in daily life we do this, in nursing our actions must be based on specialized knowledge and should be goaldirected.

15 In the view of Flaming (2001) he suggests that nurses use knowledge from sources other than science. He recommends that nurses emphasize deliberation and ethical thinking which, by so doing, gives freedom to use intuition, experience, and ethical thinking when necessary. This thinking does not exclude research, but can raise it to a new level. Flaming (2001) still believes in the necessity of continuing research. Utilization of this knowledge is not a singular process but nurses use multiple ways to obtain, select and decide how to implement new knowledge in clinical use (Asselin, 2001). Nurses actively seek and obtain knowledge through many informal sources at the ward. Personal experience is one way to obtain new knowledge. Not much research is done in psychiatric nursing concerning women with postpartum psychosis and it is therefore essential to study how psychiatric nurses use their knowledge in caring for women with PPP. In the beginning of this paper the question was how I as a nurse/midwife can ease the suffering and improve a difficult situation for women with PPP. Would it be possible to improve nursing by asking psychiatric nurses about nursing? To get answers to these questions raised it was decided to do a study interviewing psychiatric nurses about how they deal with women with postpartum psychosis.

Statement of purpose
Aim of the study The aim of the study was to describe the utilization of knowledge in psychiatric nursing among nurses working with women with postpartum psychosis. Research questions What characterize psychiatric nursing for women with postpartum psychosis? What development of knowledge is necessary for psychiatric nurses in order to develop their nursing skills related to women with postpartum psychosis?

16

Method
In order to answer these research questions, the researcher decided to do a study using a qualitative approach and by interviewing nurses about their use of nursing knowledge concerning women with postpartum psychosis. A qualitative approach was chosen because it is a good way of describing and interpreting the life-world of the one being interviewed. By using this approach the researcher hoped to get the qualities, experiences and the contents of the nurses speech in a thorough and broad way. This is according to Kvale (2001). A qualitative method is generally used when little is known about the topic to be studied, when the researcher wants to seek a deeper understanding or when the researcher is looking for specific and unique attributes (Morse & Field, 1998). This method is also used when the investigator suspects that present knowledge or theories might be biased, or when the investigator wants to understand or describe something that is unknown. The method is particularly useful when describing a topic from the natives point of view. In nursing research this is useful to describe the topic from the perspective of patients, nurses or relatives. The qualitative approach to understand, explain and develop theory is inductive. This means that theories are derived from the data while the data collection is still in process and after the data collection is completed. The process of qualitative research process tends to be time consuming both during the data collection and analysis. The researcher seeks and selects participants who are willing to talk and share their unique knowledge in a trusted relationship (Morse & Field, 1998). For qualitative data collection the researcher must have an extensive knowledge about the topic and the complexity of the context (Kvale, 2001). Through reduction (which means refraining from making judgments or interpreting the subjects descriptions based on scientific concepts, theories and preconceptions), the essence of the topic can be discovered (Husserl, 1989; Polit & Hungler, 1999). Procedures for the protection of human subjects The principles of ethics in research approved by the Medical Research Council (MFR, 2000) and Sjukskterskors Samarbete i Norden (SSN, 1983) (Nurses Co-Operation in the Nordic countries) guided the implementation of this

17 research. Ethical considerations followed the ethical principles of clinical research: the principles of respect for autonomy, beneficence, and respect for human dignity and justice (Beauchamp & Childress, 1994). The principle of respect for autonomy involves the right to autonomy, participation and integrity and also the power to independently decide to participate in the study. The principle of beneficence involves freedom from harm and exploitation as well as benefits from research. The researcher has to carefully weigh the risks and benefits to the participants against the potential benefits to society. The principle of respect for human dignity involves the right to self-determination, full disclosure and respect. The informants have the freedom to control their own activities, including their voluntary participation. The principle of justice involves the right to fair treatment and privacy that can be maintained via formal confidentiality procedures (Beauchamp & Childress, 1994). These ethical criteria were fulfilled so that all participants were personally asked to participate, regardless of nationality, race, color, age, sex, political views and social status. If the informants were not willing to participate in a specific part of the study they were free to decline. The informants were repeatedly informed about their right to discontinue their participation and could inquire and get answers about the purpose and aim of the study. The right to privacy is a difficult matter in qualitative studies due to the nature of qualitative in-depth interviews. The researcher therefore tried to ensure that the research was not more intrusive than was needed (Polit & Hungler, 1999). The principle of beneficence (Polit & Hungler, 1999) encompasses freedom from harm and freedom from exploitation and this principle was followed.

Ethical considerations The recommended ethical considerations for qualitative research have been considered and addressed in this study. Legally, culturally and historically nurses have typically attempted and were required to protect the health and welfare of their patients. The fundamental ethical demands for the individuals such as informed consent, confidentiality, and right use of the findings has been followed. Approval for this research was obtained from the University of Gothenburgs Ethical Committee (No. . 155-

18 03). When the nurses were contacted, the research was explained verbally and all questions were answered to the participants satisfaction. Written information about the study was sent to each participant (appendix 1). Each participant had the possibility to withdraw from the study or terminate the interview at any time and to have any part of the interview deleted. Confidentiality was honored by coding each tape and transcription and keeping all data locked during the time the study was going on. The final research project contains only anonymous data from the original transcripts, and would only recognizable by the original participants themselves. Creditability, Dependability, Confirmability, and Transferability In all research studies it is difficult enough to describe and interpret reality but even more so in qualitative research studies. It is difficult to measure the truth in what a person interviewed tells the researcher and for the researcher to interpret what is truth in a narrated interview. One method of validation is to go back to the informants and ask them to make comments on the researchers interpretations (Polit & Hungler, 1999). Credibility of the study This researcher met this criterion by bracketing prior to each interview and during data analysis. Readers were provided with quotations from the transcriptions. Data analyses were followed the whole time by the supervisor. Credibility measures how sincere and faithful the description of the theme is. One way to establish it is a long engagement with the matter. Another one is that the informants should recognize the findings (Streubert & Carpenter, 1999). Dependability of the study Dependability is a criterion of how much one can depend on the findings. There can be no dependability without credibility (Streubert & Carpenter, 1999). Confirmability of the study This researcher met this demand by the fact that the interviews were tape-recorded and transcribed verbatim. Detailed descriptions of data collection and analysis methods were provided. Theme development was described and followed from the participants formulated meanings. The entire process was followed and verified by the supervisor.

19 According to Streuber and Carpenter (1999) another researcher should be able to follow the decision or audit trail from data collection to analysis. Transferability in the study This has been used in this study by this researcher making sure that the informants and their responses were typical for the topic studied. The researcher made sure that the data was representative for the topic investigated. The researcher chose participants who were experienced and knew the topic well. Data was analyzed objectively trying not to make the findings seem more meaningful than they were. Every effort was made to assure that the result fit the data from which it was collected. Transferability is that what is said and its meaning in the study will have similar meaning to others in a similar situation (Streubert & Carpenter, 1999). This also means relevance. To determine whether the findings have this relevance is up to the potential analysis of others of these findings. Sample/setting Ethical permission for the study was requested and given at the Ethical Committee of the University of Gothenburg. ( 155-03) The nurses unions in the hospitals were contacted by a letter of introduction and explained the aim of the study (Appendix 2). The participants/nurses in this study were recruited from psychiatric departments in three hospitals in the Southwest of Sweden. The chief psychiatrists were primarily contacted by telephone and by letter of introduction (Appendix 3), and subsequently given permission for the study. Following this permission being granted by the chief psychiatrists, the head-nurses in different departments were contacted by a letter of introduction and thereby informed of the nature and aim of the study (Appendix 4). This letter also explained the methodology of the study which would include audio-taped interviews to later be transcribed verbatim and studied. The researcher contacted these head-nurses in several different departments within a week period and asked for the nurses participation in the study. Each nurse was sent some information that explained the nature and aim of the study. The nurses interested in

20 participating were contacted by telephone and an interview time was decided upon. The sample group in this study was ten nurses all of whom were trained psychiatric nurses from three different hospitals in the Southwest of Sweden. They were chosen because of their professional experience, their length of service and their former experience caring for women with PPP. The criteria for choosing the individual nurses was that they needed to be trained psychiatric nurses with at least 5 years of experience. These nurses had between 8 and 28 years of experience (average of 14.6 years). Their ages varied between 39-60 years (mean age 54 years). There were nine female nurses and one male nurse interviewed. Their basic nursing education was general nursing training (5) with 5 semesters, and followed by psychiatric nurse training as a specialty with one-year training. The others (5) had nurse training with 4 semesters including psychiatric nursing training with earlier training consisting of four semesters with assistant nurse training as high school education. They had all worked in several different psychiatric nursing settings. Data collection was done at the nurses own place of employment during normal work hours and in a quiet place without disturbance. The interviews lasted for about one hour. Data Collection As mentioned, the informants were contacted in person by telephone and asked for the interest in participation. Participants were told that at the interview, the researcher would ask them to talk about the way they used their knowledge in nursing for women with PPP, but also to talk about feelings, thoughts and perceptions they had experienced when caring for women with PPP. The researcher then answered any questions that were asked and finally an interview time was agreed on. The researcher and the nurses did not know each other and had never met before. Before the beginning of each interview, the researcher restated the aim of the research. The participants were told that the interview could stop at any time, in order for them to gather their thoughts. The researcher had some questions written down as well as additional spontaneous questioning was used as the interview continued (Appendix 5). At the participants signal the interview began and they were allowed to terminate the recording at any time during the interview.

21 Each interview lasted about one hour. Before the interview the researcher tried to bracket her own perceptions and thoughts in order to reduce biases (Morse & Field, 1998). Also, an attempt was made neither to interrupt nor to ask leading questions. The researcher tried to refocus the interview if it began not to be centered on issues of women with PPP. When the participants had nothing else to add, or wished to stop, the interview was stopped. The tapes were then transcribed verbatim by the researcher. The interviews were identified by codes, known only to the researcher. Data Analysis Initially the tapes were listened to and the text was written down verbatim. Then the text was read as a whole and the meaning of the content identified. The second phase, structural analysis, included several readings of the text with additional content with meaning units identified in the data. Following is a sequence of an interview, translated from Swedish into English by the researcher. What is interpreted as important content meaning is put in Italic prints:
Yes, in caring for the woman it is important to be calm, and try to do everyday things together, maybe to look for baby clothes in a paper together, and I say `thats nice. To be natural, maybe listened to music together to have a relaxed atmosphere. I can sit and hum baby songs, and I may rock a little. To make the situation natural, and even though I might be afraid that she would drop the baby, not to show nervousness. Not say: You dont through the baby away, will you?, but to be calm and show her that you are comfortable.

Content analysis is a way to analyse by topic, and each interview is divided by these topics into a theme (Morse & Field, 1998). An interview category may consist of a few lines or might be longer than a paragraph. The question being asked is how. When performing the analysis the researcher reads the entire interview and in doing so identifies several important topics in the interview. These topics then become the primary categories. The categories are initially broad, so a large amount of data can be sorted into a few groups. When the categories are complete, the researcher may select to further categorise the data into subcategories. The researcher then starts to look for relationships between the categories. These relationships might be concurrence, antecedents or consequences of an initial category (Morse & Field, 1998). According to Polit and Hungler (1999) qualitative researchers read their narrative data repeatedly in search of meaning and deeper understanding. It was a process of

22 fitting the data together and making the invisible obvious. The content meaning gave the data a special pattern, and from this pattern appeared preliminary themes from the data. Some statements were, from the beginning, found in several themes because the data could be understood from different perspectives. Examples of preliminary themes were:
Signs that precede intervention by the nurse, nursing in post partum psychosis, nursing communication with the woman and her relatives, nursing reactions in connection to women with postpartum psychosis, and educational issues in connection with postpartum psychosis.

Every preliminary theme was then carefully analysed individually through repeated readings of the data. Gradually the specific and unique stood out with the variation of the facts in the theme and a content description could be done. Finally the quotations were chosen from the data to clarify the descriptions from the respondents. The following describes the different individuals quotations. A rough outline from the procedure of the analyse is shown in figure 1. Structure of the analyses of the interviews
Reading the interviews in the whole Identifying the meaning of the contents Patterns, outstanding in the interview materials Subjects, outstanding, preliminary themes Themes Descriptions of the contents Choosing the quotations

Figure 1. Structure of the analyses of the interviews

Gradually five themes emerged: Theme 1. Signs that precede intervention Introverted behavior Extroverted behavior

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Theme 2. Nurses actions Satisfaction of basic needs Being present Links to continuity Creating security Working alliance with the woman

Theme 3. Nurses focus of communication On the perception of reality On hope On confirmation On knowledge of PPP On other professionals in the care of the woman Theme 4. Nurses reactions Positive reactions Negative reactions Theme 5. Knowledge development Renew knowledge Using research

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RESULTS
This chapter describes the utilization of knowledge in nursing as it is described by the respondents. A description is given of what it is like to notice and respond to the signs that precede an intervention by the nurse. In the following section, introverted, extroverted and aggressive behavior is addressed. Later there is a nurses description of her experience which refers to her addressing basic needs of the patient, the importance of her being present and staying close to the patient and of being the person to provide continuity. It also consists of how the nurse creates a secure environment and establishes a working alliance with the woman, thereby expanding the possibilities for participation with the woman in addressing her problems. Later there is a description of contact between the nurse, the patient and her relatives, and between the nurse and other professionals who cooperate in the care for the woman and her child. Finally there is a description of the respondents reactions and what she does in nursing the women with PPP and their children. Theme 1. Signs that precede intervention. When the woman in the initial phase of the illness comes to the ward, there are some significant indications that precede a nurses intervention. These signs that a woman with PPP shows are one or more of the following: introverted, extroverted, aggressive or chaotic behavior. Introverted behavior The women the nurses meet who have an introverted behavior are quiet and often appear isolated and withdrawn. They appear not to be in the same reality as experienced by the nurse. Several nights with disturbed sleep is commonplace. The womans usual personality is often altered showing very little or no interest in the newborn child, as one would expect a new mother to inhibit. There is no interest in seeing the baby or of having the baby close or a desire to touch it. Some of them show signs of having a psychotic depression such as being very quiet, showing little response, being apathetic and experiencing delusions, especially regarding the baby.
She gave so little contact, and she was not interested in the child. Yes, really, she was neither interested in her child nor in us..//..she didnt say very much, she was almost apathetic.. //..and her behavior was like one with psychotic depression. (6)

Extroverted behavior The nurses also deal with these women showing extroverted behavior. These women are in chaos, anxious with having

25 strong psychomotor activity. They might be aggressive, fearful, and appear horrified. They may try to escape. Disturbed sleep for the last nights before the first appearance of the onset of PPP is common. They might be confused with a sense of being persecuted and followed, and are not in normal reality. Sometimes the women are very aggressive and may want to hurt both the ward staff and her partner. These women are often aggressive to themselves, throwing things around and it is typically difficult to leave them alone. They might totally reject the baby with a constant strong desire of not wanting the baby and not wanting to touch or cuddle the baby. They are not aware of their roll as mothers but appear to deny what is expected of them as new mothers. Infanticid as well as suicide has been reported by the respondents.
She was aggressive, she was frightened because she was attac-king us often..//..this fear and fright and confusion..//..she wanted to leave us the whole time, she was close to attacking, when we were near her..//..but there was a fear from her, a fear for something we could not understand..//..as a mother she did not care for her child..//..there wasnt any happiness in the woman, no, I couldnt see any. (3)

Conclusions Either the woman has an introverted or an extroverted behavior and the nurse knows by experience the best way to help the woman. The nurse sees and hears the signs that the woman gives and she acts in accordance with them. How to give nursing for the woman and her child is stated in the next part. Theme 2. Nurses actions This part describes how nurses use their knowledge in nursing. This consists of taking care of the basic needs of the woman, the importance of being present, and to be the person that provides continuity. A secure environment is described, and how the nurse makes an effort in trying to better the relationship between the mother and child. Finally, there is a description of how to establish a working alliance with the woman. The nurse uses her knowledge in nursing in all aspects of the daily activities for the woman. Satisfaction of basic needs The nurse is also taking part in the care of the womans basic needs. The nurse assists in extracting excess milk from the womans breasts, helps with hygiene, and makes sure that the woman looks presentable. The nurse is responsible for the womans meals and brings it to the woman in her room. In the beginning of the illness, the woman has difficulties in taking care of her basic needs

26 and needs extra support. Later there is a need to be outside and to do shopping, both in which the nurse is involved. The more the woman recovers, the less the nurse needs to support these basic needs.
Yes, in the beginning we helped her to take showers, to wash her hair and we made sure she looked nice, we helped her to extract the breast milk because she didnt do this herself.. //..and we helped with her food, and then she had to eat in her room and we sat with her, the whole time. Sometimes - nothing is functioning..//..they dont manage to dress, they dont manage to take a shower, and these are women who have been well functioning before..//.. sometimes they are not able even to make a sandwich. Then we have to help them with everything. Later we made sure that she had fresh air and took walks. But the whole time, almost, we made sure to look after her. (4)

Being present One of the most important things for the nurse to do is to be present. The nurse is physically present and close to the woman, sits beside her and touches and puts her arms around her so the woman can see and feel the presence of the nurse. Psychological presence is to give the woman her complete interest and her full attention, even through silent periods. The nurse is at hand when the woman needs her. She remains with the woman when she is chaotic, calms her down by being there, sits down and engages in communication with her, or stays there calmly and quietly. The nurse stays there even though the situation around the woman may be chaotic. It is this kind of nursing the nurses think is important.
..and I try to be close, and as you feel that they are secure if you are close, and are touching them and so, as I have been. Not to abandon, but make them safe..//..not to abandon the woman when she comes to the hospital, but to be close as much as possible, you need not talk or inquire too much, but only to be there..//..they just dont have any strength, they are just there. (5) Yes, she was in total chaos and wouldnt accept her child..// ..she just ran around naked..//..had forgotten that she had just delivered and wanted to go back to the delivery department and deliver again..//..I couldnt talk to her, but it ended so that we had to put her in a restraining belt..//..we had to sit down with her and calm her down..//..mostly it was to talk, to be a friend to her..//..we sat there with her the whole time. (10)

Links to continuity Nursing care for the woman also consists of being the person that stands for continuity. This same nurse, who comes with food and drinks, is also administrating the medication. In conference with the doctor, the nurse is present but also speaks privately with the woman. At planning meetings the nurse is present, and the woman will have a sense of continuity by the nurse always being

27 present. In a chaotic situation the nurses presence symbolizes continuity for the woman.
..and what we did there was to be continuously present - just there..//..and I have to be sure where I stand myself, so I have the strength to remain, where I am. And the more experi-enced I become, the more stability I can give. (5)

Creating security An important part of nursing is to create a secure environment for the woman. The nurses plan is for the woman to have a single room, the surroundings of which should be calm and quiet in a secluded area of the ward. The nurse restricts the woman to only a few stimuli meaning that she is alone, has few contacts with other patients and only with as few of the nursing staff as possible. Other restrictions that will make the woman feel secure will be to stay in her room, to have her eat there, and have all activities during the day at her room in isolation. This is done to protect the woman from a behavior, which she might later recall as shameful. To create a secure environment also means for the nurse to give time to the woman which might just mean to be with the woman and to sit silently with her.
..to create a secure surrounding..//..it has to be calm around, rather quiet with few stimuli..//..a single room..//..to give her time and to stay with her..//..maybe not always through a lot talk, but through being with her. (8) ..we isolated in a nice way room. She had made sure not restrict her. her from the other patients, we just had to do that without offending her..//..the isolation was in her to stay there and she had her meals there too..//..we too many people took care of her; this was to (4)

Working alliance with the woman To have better nursing result and willing cooperation with the woman there is a need of a working alliance. The woman then is participating in the planned care and treatment and given a treatment plan. Here includes decisions about privileges the woman might have, as whether the woman may take walks alone when she feels well but has notifying the nurse when she is not feeling well so the nurse may step in and give comfort and help.
Today the patients participate in treatment, and care. Every patient has her own treatment plan which is done with the patient, the doctor and nurse. `This is good for you, this you can get help with, and this is done together, a working alliance..// ..then she gets a working alliance to take walks by herself, she has to tell us if she feels well, and if she doesnt feel well she is supposed to tell the nurse so we can help her. (2)

28 Another agreement is that the nurse finds it her responsibility to have the woman create a relationship between her and her child. While the woman suffering from PPP may initially be disinterested in her child, through taking part in the care of the baby and with the nurses help, the woman to get a better relationship with her child. The nurse changes the baby, holds the baby, talks with the baby and in this way becomes a model of how to care for the baby. When the nurse is together with the woman and her child, talking and giving supporting, the woman will feel more secure in caring for her child. The nurse improves the relationship through talking to the woman about her child and by doing this shows how much the baby is in need of her mother. The nurse also makes sure that the mother and her child may stay as long as possible together. Commonly, the child is cared for at the maternity or childcare unit, while the mother is cared for in the psychiatric unit. If there is a possibility for the mother and the baby to be cared for together, both the nurse and the midwife at the maternity unit hold the responsibility for the babys care until such period as the mother can manage by herself.
Yes, it is about talking a lot about the baby. And also to make sure the mother and the baby are together, as much as you can and as much as possible, both for the child and the mother. (8) ..in the beginning I dont say so much about the baby, but I wait until she says something first..//..the husband has been here with the child, so I say..//..oh, how sweet he is or what a fine little boy, and by so doing I try to encourage this type of contact. (10)

Conclusions The nurse acts according to the womans needs that may vary. In the beginning of the illness (which might be very chaotic and dramatic) there is a necessity to take care of the basic needs such as food, drinks, hygiene and to express the womans breast-milk. The nurse is to be available for her and to remain with the woman offering stability in a chaotic situation. It is important to create as secure an environment as possible and to restrict the woman in her movement around the ward. During the womans illness the nurse is aware of the importance of her influence on creating a better relationship between the mother and her child. Theme 3. Nurses focus of communication This chapter describes the nurses communication with the woman, her partner and significant others, and also describes the nurses communication with other participants who cooperate in the care of the woman and

29 her child. A great deal of nursing consists of conversations with the woman often concentrated on attempting to bring her back to reality. The nurse speaks with the woman to give her hope, both for the time of illness and beyond. The nurse confirms the woman by talking with her. Communication is an important part of nursing and of establishing a network of co-workers in different aspects of the care that the woman may need. On the perception of reality The nurse repeatedly speaks with the woman, and tries to reconnect her to reality. To get the woman to understand and see that what is going on here and now is bringing her back to reality. The nurse may suggest to the woman that her experiences and delusions may be due to recent sleep disturbances. She may give the explanation that these experiences may be temporary and only correlated with her illness and that others see reality different from the way she does in her present state.
..when they are not in reality..//..in talking about what is real..//..maybe I say that this is the way you experience it now, but I dont see it that way..//..I try to neutralize it a bit, not to talk about what is right or wrong, such that the patient is wrong, but to try in another way to explain to her, that this is not the way we see it. But this is the way you see it now when you are not feeling well. Or because you have not slept for three nights, then you can have experiences like this. (8)

On hope The nurses care also consists of communication such as conversations that give hope to the woman. Through these discussions, the nurse gives hope of recovery to the woman and her partner as well as to significant others. This is because the nurse knows from her own experience that this sickness has an end.
..yes, my thoughts as a nurse is of course that I know this illness will end, this I have with me the whole time, and then I will try to infuse hope in her, both to the woman, her husband end her relatives. (4)

On confirmation A great deal of time for the nurse is spent in communication with the woman. When communication, the nurse confirms the womans experience as a woman, mother and human being. The nurse reminds and confirms the woman repeatedly that she is the mother and this is her child and she is the best one to care for her child. The nurse also reminds the woman about her older children and how important and absolutely necessary she is for her family. By doing this, the nurse gives the woman new courage and confirmation of how important she is.

30

Yes, we confirmed the woman the whole time, not only as a mother, but also as a woman and a human being. You can not put another burden on somebody, who already carries a heavy load..//..and we confirmed her as a mother to the older child as well. (3)

On knowledge of PPP One important aspect of communication is imparting information to the patient and relatives. When the woman is transferred or admitted to the psychiatric outpatient care, the nurse generally gives information about the illness to the womans partner. This information is given in order to reduce the fear that accompanies this illness to the husband and significant others. The nurse paints a picture of the illness, the causes, symptoms, treatment and prognosis, and puts emphasis on the fact that when the woman is recovered she will be back to normal again. The nurse gives information initially and later during the illness to the woman and her partner. This may include advice both before the woman is given a short leave from the hospital and before the woman is discharged. This guidance might consist of recommendations to let the woman be in charge of her babys care at home, or information about not being overprotection of the woman on her stay at home, and that means to reduce the fear that the husband might have.
That is what we explain to the husband..//..he gets, so to speak, information about psychosis. And how this illness starts, and what symptoms there are..//..if relatives want information as well, then they get it, BUT I always ask the husband first. I never talk over their heads. Yes, if the patient can.. Of course we always do that. So they get the same information as her husband gets, about the illness. Yes, information..//..its about so much, this to lessen the fear. I always put an effort on to inform so the mother wouldnt be too overprotected when she returns to her home. Yes, when the psychosis is over the person is normal, and that is important to see, and not be so afraid that the psychosis may return, and overprotect, but to give her the responsibility. (2)

On other professionals in the care of the woman In the care of the woman the nurse has to cooperate with several of the participants in the treatment. In the beginning of the illness there is a cooperation between the nurse and the midwife and other staff on the maternity ward. These different professionals stay active in the womans care as co-workers during breastfeeding, and during the time the baby is cared for. As the psychiatric nurse realizes that breast-feeding and baby care is not her specialty she turns to the midwife. In this way, the nurse and the midwife exhibit close cooperation for the sake of the mother and baby.

31
Rather immediately we started a collaboration with the delivery ward, which was situated just across us..//..so the doctors talked to each other and we with the midwives..//..and the best was, I think that it is possible to cooperate around a patients sake with all the different staff and the varied areas of expertise..//..they could give us a call so we could support them, when they cared for the baby..//..the woman was admitted to the maternity ward, they had a room outside the wars itself, so you didnt enter the ward. (5)

In the end of the illness the nurse is in contact with several people such as those in the psychiatric outpatient care in order for the woman to get a contact there as well as the pediatric district nurse. To both these professionals the nurse gives very thorough descriptions about the conditions of the woman and her child and discusses how to help and support the woman after being discharged. If the woman is in need of social welfare such as a domestic aide, the nurse will then make contact with the social worker in charge to discuss help and support. The nurse may also take initiative for continued care for the woman and her child by suggesting treatment in a mother-and-child home or a psychiatric rehabilitation center after discussing with the doctor. The nurse builds up a network of support and help for the woman and her family.
..yes, so it was, this new modern what is it called, yes, the come-and-go team, yes, that is when they are discharged from the maternity ward. Yes, and then it is the district nurse, she is in charged of new mothers today.. and then we referred to them with close contact between us. And we kept in contact with this staff, so that they knew exact what to do..//..the district nurse, so she could be admitted again straight away if necessary. (2) We have a team at the outpatient care only for patients with psychoses, and she got in contact with this team..//..there she was assigned a nurse to take care of her, and she could coordinate if there was a need for communal help, and so..//..and that becomes a personal contact for her. (3)

Conclusions Major parts of nursing consist of communication, which means to give the women hope, confirmation and by trying to bring them back to reality. It also consists of giving information to the partner and other relatives. At the same time there is also communication and collaboration with other professionals who take part in the care of the woman and her child and the psychiatric nurse coordinating their care. Communication and co-operation is there to give the woman and her child good nursing care in the hospital, as well as after their discharge to give support and help by doctors and nurses in the psychiatric outpatient care and by the pediatric district nurse and by

32 the social welfare worker for support and help in the home. Theme 4. Nurses reactions This section describes the nurses reaction related to woman with PPP. Reactions may consist of both positive and negative feelings. Positive reactions are described when the nurse is happy and thankful when the woman is discharged with her baby. The respondents have also described strong negative reactions in connection with women with PPP, reactions that might be related to the fact of the womans rejection of her baby and partner. The nurse knows these feelings might have a bad effect on the nursing given so the nurse tries to suppress these negative feelings. Even if the nurse has many negative feelings and reactions towards the woman however, she knows by her knowledge and experience that she is not to show these reactions to the woman. Instead she tries to create an environment for the woman that consists of sympathy and compassion. The nurse is also thankful and humble knowing that this illness has not afflicted her or her relatives. Positive reactions The nurse may react positively and feel happy and thankful when the woman begins to accept her baby and when the woman is happy for her family. The nurse may also be thankful and feel humble that neither she nor her relatives have been afflicted with this devastating illness.
But it gives me a great pleasure to see the family return home. Then I am happy as a nurse. And then it feels very, very good! Or when I see the mother, when she holds her baby the first time, and she cuddles her baby, and she doesnt treat the baby like a pillow or as something that is not there. (10) ..to work with women with PPP has given me an experience.. //..of the sickness. And a humility..//..for this could happen to me, my friends, yes, really whomever..//..I feel very humble that I was not afflicted by this illness. (8)

There are also reactions of tenderness and sympathy from the nurse toward the woman. She feels compassion and sympathy for the family, which have been suffering greatly. Maybe the couple had been waiting a long time for their baby, and after the childbirth everything became so difficult instead of fulfilling as they had hoped.
..so there are feelings of compassion in me. I feel compassion and sympathy for the family, and I have much empathy. And the thought, why should this happen, when things could be so much better. (3)

33 Negative reactions Postpartum psychosis is an illness that causes strong reactions and feelings among nurses. There is often some negativity in the mixed feelings of thoughts and inner experiences the nurse has. Several of the nurses have expressed anxiety and fear concerning their contact with the woman. This anxiety and fear may come when the woman will not accept her child and also the thought that they could have been afflicted personally.
But often the women have a very extroverted chaotic behavior, hard to work with, creating much anxiety in both me and others.. //..I think mostly that its the rejection of the child that is uncomfortable..//..I had a lot of mixed feelings for her this that were creating anxiety in me..//..I think that a woman with post partum psychosis is able to create a lot of anxiety..//..I have learned to work with my own anxiety. (4)

The nurse may feel uncomfortable, often in connection with compulsory institutional care or treatments with compulsion. This might consist of violence and compulsive behavior in the early stage of the illness, and the situation might become dramatic. This gives a feeling of uneasiness, but is still a necessary part of working with women with PPP. Experiences of earlier occurrences with patients have given the nurses knowledge how to handle these uncomfortable situations.
..injection by force..//..it was uncomfortable, yes, it was, but of course, I had worked for some years..//..but it was so dramatic, feelings of uneasiness..//..but I think that I would be as uneasy today, even though I am much more experienced today. (9)

The nurse typically feels sorrow in connection with the womens affliction of illness. There is sorrow in connection with the disaster that has afflicted the woman and her family and of the womans incapability to accept her child and to feel the happiness, contentment and satisfaction that normally follows childbirth. The nurse can experience sorrow when thinking of the child and the loss the child is deprived through this illness when he/she does not get his/her mothers concern and care early in life.
..sorrow..//..that is that I wish for this new family to feel well in its new parenthood as well as everybody else I see, those who feel well in becoming a new family. Yes, I want them to have and feel well, as everybody else. (3)

The nurse also feels a lack of power in connection with the woman and her familys future.
Maybe also a feeling of powerlessness, in a way, that this is how it became for them. This is life, the child has had an invitation

34
to life itself. And so there is nobody, who takes care of it, as you are suppose to be. Yes, there are thoughts of powerlessness..//..why did it become this way? And how can I possibly help her in the best way? To manage, and how is it on the outside, is there any competent person who can support these ones? Is there enough resources and money, and.. (5)

The nurse can experiences anger in the contact with the woman. This anger might come because of the womans rejection of the child, or if the woman has made attempts to harm her child.
..anger towards the patient too, thats how I felt, yes. And how is it possible to do so to her child..//..so we had much feelings against her, anger, and sorrow also. And we were also sad that we did not understand what was going on.. (11)

Conclusions To care for a woman with PPP gives the nurse mixed feelings and different reactions. The respondents have described reactions as pleasure, happiness, humility, thankfulness, tenderness, sympathy and compassion but also descriptions of anger, fear, sorrow, anxiety, powerlessness, discomfort, uneasiness and sorrow. Still if the nurse has many negative reactions and feelings, she tries to hide these feelings and uses her knowledge in nursing to create positive surroundings for the woman. Theme 5. Knowledge development All nurses except one were asked about their desire to receive further knowledge in PPP. Most of them think they need further knowledge, but pointed out that these women with PPP are rare in the wards. The nurses also know they can get new knowledge by themselves from studying research from the computer. Renew knowledge The nurses are interested in getting additional knowledge on PPP. Several of the nurses think they had very little teaching about PPP during their education. Women with PPP are not very common but still common enough to be included in teaching in the nursing education about the topic.
But to upgrade the knowledge..//..to get to know how they do in other places, experiences they have. To learn how to do in other ways. Yes, that I would like to know. (8)

The nurses want to have further education in this area through lectures from more experienced nurses. They want to know more about the sick woman and the specific signs and symptoms she has and to be able to try to understand a woman with this illness more competently.

35
Yes, if so what does it mean to be newly delivered and that part..//..but this, what roles and influences the woman after childbirth? Yes, what happens physically in the body. (9)

Using research The nurses want more teaching and guidance in understanding their own reactions and feelings concerning women with PPP. They know about the possibility of getting additional knowledge from studying new computer-based research. But few of them use this in actuality usually because of lack of knowledge about the computer or because of too little interest.
Yes, I would like to have more nursing education such as how to deal with a woman with PPP. How I should be, to be explained to about the illness, my own reactions, and the relatives reactions..//..what is this? Why do you get it?..//..there are so many areas that would be possible for further study. (4)

Conclusion The nurses were interested in acquiring additional knowledge. They thought they had too little teaching in this area during their initial education, and when these women are admitted to the ward some of them sometimes felt insecurity, because of this lack of specific education.

36

Discussion
The aim of this study was to describe the knowledge utilization in psychiatric nursing among nurses working with women with postpartum psychosis. The result of the study will now be discussed in relation to the research questions. The research questions were to describe what characterize psychiatric nursing for women with postpartum psychosis, and what developments of knowledge are necessary for psychiatric nurses to develop their professional competence. The method used was a qualitative approach in order to seek and find a deeper understanding of the topic. The instrument used to find how nurses use their knowledge use was through interviews. All the nurses who were asked to participate with one exception agreed to being interviewed. All of them were very easy to talk to, and all of them seemed to enjoy and appreciate the interview. Kvale (2001) indicates that a qualitative research interview might be a positive experience for the one being interviewed. It is not a common happening for somebody else to offer the time to sit down and listen for an hour even when the topic might be of interest for both persons. In this case even to show great interest, sensitivity and as far as possible understanding the other persons experiences and opinion. Knowledge utilization in nursing The utilization of knowledge in nursing by the nurses in psychiatric nursing has to see the woman and identify the her needs and to act according to the needs that the nurse recognizes. This is in agreement with Kim (1999) that a nurse needs knowledge to frame her practice and to be able to understand specific situations for nursing. The nurses have extensive experience from psychiatric nursing and much of their nursing knowledge is based on their experiences. The study has indicated that nursing knowledge is based on experience and complemented with medical knowledge. In asking the nurses whether or not they followed recent research in PPP, all except three gave a negative answer. These three were also interested in psychiatric research in general. This means that only thirty per cent of this group are interested in new research and make efforts in trying to obtain new research, which they get from different nursing magazines or from different databases. Seventy percent, however, of the nurses interviewed are not actively trying to acquire new knowledge from recent

37 scientific research even though they made indications about their need for additional knowledge and the ease of downloading from the computer. How is it possible to get psychiatric nurses interested in new research? Relationship with the woman When assessing the crucial knowledge for psychiatric nurses, caring for women with PPP appears to require a broad and deep general knowledge in psychiatry and an extensive knowledge based on experience. To create and maintain relationship with the woman is of great value for the nurses. This is in accordance with Peplau (1988) where she points to the importance of having a good relationship with the patient, which, for the patient, is a therapeutic force. Communication Communication with the woman is a big part of the nursing. This communication often consists of imparting information to the woman and her relatives as advising before the womans discharge from the hospital. The nurse might also give advice before the woman has a short leave from the hospital for a few days or so in order to see how she can manage at home with her baby and family. Here the nurse can use her extensive experience and practice in nursing. The nurse has knowledge that she can use in giving advice to the woman, of which she may receive benefit. It is important for the nurse to communicate with other participants cooperatively around the woman and her family. A big part of the nurses work time is used in communication around the woman and her child. The nurse communicates with co-workers at the ward to make plans for the woman while she is hospitalized and from the time the woman enters the ward, the nurse plans for the womans discharge. To have broad life experiences is required to be successful in psychiatric nursing, which would mean not being too young and immature when working in this field. To do good to the woman The nurses have deep and extensive connection with these women, their children and families, and they use their knowledge to try to meet the needs of the woman. This is in accordance with what Ltzn and Nordin (1993) are indicating as being important. First when the woman is hospitalized the nurses use their knowledge to make the time in the hospital as easy as possible for the woman. The nurses see to the basic needs, make an effort to start a good relationship with the woman and do good in every

38 small detail. This is acting in the way Ltzn and Nordin (1993) value as important for nursing. Improving the mother-child bonding All nurses are aware of the importance in helping the woman to accept her child, to assist her in building a good relationship and creating a strong early bond with her child. This is in agreement with the findings Semprevivo and McGrath (1990) regarding mother-child bonding and the importance of reducing the time of forced separation between the mother and child. When the time comes for the womans discharge from the hospital, the nurse cooperates with different actors such as the outpatient care, the pediatric district nurse and social welfare worker. The nurse uses her knowledge and experience to support the woman, and she surrounds the woman and her family with a secure network of help and support. This network is of great importance for the woman in order for her to manage in her home. She might need help in her house almost daily in the beginning of her return from the hospital and the nurse knows this and makes sure that either a nurse or social welfare worker visits her often. Several of the respondents have pointed to the picture of an illness relapsing within a few weeks. This shows the importance of keeping a close eye on the woman and her baby. This is also according to the findings Bgedahl-Stridlund and Ruppert (1998) have found with severe negative long-term effects on the woman, her child and her whole family. The nurses reactions In caring for the women, the reactions of the nurses towards them were very significant and sometimes intense. Despite this the nurses point out the importance of not laying more burdens on the woman than necessary. Instead of showing anger, anxiety, and feeling of powerlessness that the nurses sometimes felt towards the women, they tried to create an environment about the woman full of hope, compassion, sympathy, and tenderness. This is good use of their nursing knowledge and shows that the nurse has matured in profession and as a human being. Peplau (1997) also single out the importance of not insulting or ignoring a patient, but to give care that demonstrate feelings of acceptance, respect and to be seen. Additional education Nearly all nurses in the study wanted more teaching and education in PPP. Their opinion is that they are missing out on nursing knowledge specified on the illness of PPP and suggest getting new knowledge from nurses who are more experienced in this kind of nursing. The nurses want more

39 knowledge about physical and hormonal changes in a womans body through childbirth. The nurses inquire about additional knowledge in order to understand their own feelings and strong reactions to the woman with PPP. All the nurses have supervision by trained psychiatric nurse supervisors, and they feel very strongly the need for this. Several of them also have daily reflection-time in the end of the working day. One nurse gives the comment that this reflection-time takes the load of work off her shoulders before she goes home from work. For the nurses to understand their negative feelings maybe there is a need for them to have supervision time alone, and to go deep into their emotions. Interest in research As mentioned before, all nurses know about the possibilities for acquiring additional knowledge from computer downloads and by searching scientific databases, but few of them take the advantage of this. The reason for this could either be lack of knowledge of computers or no interest in persue this. This lack of effort on their part might also be due to difficulties in understanding the English language given that most research is written in English. Almost all of them read the Swedish nurses magazine, and they read articles that are of interest to them in their work. The lack of interest in research needs to be taken seriously and much effort should be expended to increase their interest in research for nurses and students. Work satisfaction The nurses are well motivated in their work for those psychiatric nurses in the study. They have chosen this part of nursing because they are interested in this specialty and their life experiences and maturity have made psychiatric nursing attractive to them. The result shows contentment with this kind of work increasing as the years pass by. The nurse feels that she is on stable foundation through her long experience and this stability increases the contentment with her work. Implications This studys aim was to describe the knowledge utilized in psychiatric nursing among nurses working with women with PPP. The results show a pattern of the psychiatric nurse as the one who is placed in the middle of all the commotion. She is the one who needs to give stability to the woman and her family during their stay in the hospital and by providing a network of help and support when they are discharged from the hospital.

40 Limitations There were limitations to this study as the sample size was small and homogenous, and the study was done in a small area of Sweden. Variation of ages was small and there was no diversity in race or ethnic background. Only one male nurse was included. Why is there such a small diversity of ages? Is the reason that psychiatric nurses are older, and that young and newly educated nurses do not have the desire to work in the field of psychiatric nursing? If this is true, this implies that in ten to fifteen years time, when these nurses retire, there will be a great lack of trained psychiatric nurses in Sweden unless much effort is directed towards educating more nurses for the future now. Additionally, there appears to be a trend in Sweden today for nurses employers not to give leave of absence for a regular nurse to give her the possibility to gain specialist or further training in nursing. If continued, this can have marked negative effects in the future when few nurses are specialist trained and only regular nurses are available for working in places like psychiatric nursing, district or communal nursing, pediatric nursing where further education is crucial to the quality of care provided for the patient. Future research There are limitations to this study due to the small sample size and the equality both in age difference and long experience among the nurses studied. It would be interesting to compare this study with a subsequent study with younger nurses, with less experience and with an education from today. Interesting also would be to make a further investigation of the nurses reactions in caring for woman with PPP. All the nurses mentioned strong reactions and none of them were left unaffected by the experience with these sick women and their rejected children and partners. Another possibility would be to do an interview study from the partners perspective and to capture their reactions, thoughts and experiences during the time of their spouses illness. Such a study would certainly have much to add regarding the research of women with postpartum psychosis. Also interesting would be studying the effects on the children from women with PPP. What have become of them after some years, or after many years? How did the illness affect them? How did they manage afterwards and later in life?

41 Finally it would be interesting to interview midwives about their care of childbearing women. What they do and when do they notice the first signs of when the woman gets sick.

42

REFERENCES
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Bewley, C.(1999).Postnatal depression. Nursing Standard, 16, 49-56. Brennan, A.(1991).The enigma of puerperal psychosis. Nursing Standard, 6 (1) 33-36. Brudal, L. (1985). Fdandets psykologi Lrobok i frebyggande arbete.(The psychology of birthing Manual in preventive work) Vllingby. Buist, A. (1997). Postpartum Psychiatric Disorders: Guidelines for Management. CNS Drugs Aug. 8(2) 113123.

Bgedahl-Stridlund, M. (1986). Mentally ill mothers and their children: An epidemiological study of antenatal care consumption, obstetric conditions, and neonatal health. Acta Psychatrica Scandinavica, 74, 32-40.

Bgedahl-Stridlund, M., & Ruppert, S. (1998). Parapartum Mental Illness: A Long-Term Follow-up Study. Psychopathology, 31,250-259.

Cox, J. L. (1986).Postnatal depression: A guide for health professionals. Edinburgh:Churchill Livingstone.

43 Craddock, N., & Jones, J. (2001). Familiality of the Puerperal Trigger in Bipolar Disorder: Results of a Family Study. American Journal of Psychiatry, 158(6), 913-917. Dalton, K. (1980).Depression after childbirth. Oxford: Oxford University Press. Flaming, D. (2001). Using phronesis instead of researchbased practice as the guiding light for nursing practice. Nursing Philosophy, 2, 251-258.

Gaskell. C. (1999). A review of puerperal psychosis. British Journal of Midwifery. 7(3) 172-175. Hwang, P. (1993). Spdbarnets psykologi. (The psychology of the infant). Stockholm: Natur & Kultur. Husserl, E. 1989). Fenomenologins id (The idea of phenomenology). Gteborg: Diadalos. Johannisson, K. (1994). Den mrka kontinenten.(The dark continent) Stockholm: Norstedts. Jones, H., & Venis, J. (2001). Postpartum Psychiatric Disorders Journal of Psychosocial Nursing, vol. 39, 12, 23-30. Kendall-Tacket, A. (1993). Postpartum depression a comprehensive approach for nurses. Newbury Park: SAGE publications. Kim, H. S. (1999). Models of theory nursing (knowledge utilization presented at the International Conference, Edmonton, Alberta, practice linkage in in nursing). Paper Nursing Research Canada.

Knops, G. (1993). Postpartum Mood Disorders. Postgraduate Medicine, 93(3) 103-116. Kvale, S. (2001). Den kvalitativa forskningsintervjun (The qualitative research interview). Lund: Studentlitteratur. Kumar, R. (1990). An Overview of Postpartum Psychiatric Disorders. NAACOGs clinical issues in perinatal and womens health nursing I:3; 351-358.

44 Lavender, T., & Walkingshaw, S. (1998). Can Midwives Reduce Postpartum Psychological Morbidity? A Randomized Trial. Birth, 25(4) 215-219. Lindskog, B., & Zetterberg, B. (1997). Medicinsk terminologi lexikon. (The Medical Terminology Lexicon). Stockholm: Almqvist & Wiksell. Lindstrm, U.(1994).Psykiatrisk vrdlra (Psychiatric textbook). Stockholm: Liber. Ltzn, K., & Nordin, C. (1993). Benevolence, a central moral concept derived from a grounded theory study of nursing decision making in psychiatric settings. Journal of Advanced Nursing 18, 1106-1111. Lkensgard, I. (1997). Psykiatrisk vrd och specifik omvrdnad (Psychiatric care and specific nursing care). Lund: Studentlitteratur.

Marmion, S. 2000). Reflections on Emotional Disturbances after Childbirth. British Journal of Midwifery 8(9) 539-543. MFR, Medicinska Forskningsrdet.(2000). Riktlinjer fr etisk vrdering av medicinsk humanforskning. Forskningsetisk policy och organisation i Sverige (Rev. Uppl.).(Guidelines for ethical evaluation of medical research involving human subject. Research policies and organization in Sweden.). Stockholm: Medicinska Forskningsrdet. Morse, J. M., & Field, P. A. (1998). Nursing Research, The application of qualitative approaches. WestKey Limited, Falmouth, Cornwall. OHara, M. (1987). Postpartum blues, depression and psychosis: a review. Journal of Psychosomatic Obstetrics and Gynaecology, 7, 205-227. Peplau, H. (1952). Interpersonal Relation in Nursing. A Conceptual Frame of Reference for Psychodynamic Nursing. London: MacMillian Education. Peplau, H. (1988). The Art and Science of Nursing: similarities, differences and relations. Nursing Science Quartely, 1, 8-15. Peplau, H. (1997) Peplaus theory of interpersonal relations. Nursing Science Quartely 10(4):162-167.

45

Polit, D.F.,& Hungler, B. P.(1999). Nursing Research Principles and Methods. Philadelphia: J.B. Lippincott Company. Puranen, B.(1994). Att vara kvinna r ingen sjukdom. (To be a woman is not an illness). Stockholm: Norstedts. Robinson, J. 1998). Suicide: a major cause of maternal deaths. British Journal of Midwifery, 6(12) 767-768.

Semprevivo, D.M., Comitz, S., & Comitz, G. (1990). Postpartum Psychosis: A Familys Perspective. NAACOGs clinical issues in perinatal and womens health nursing, 1(3) 410-418. Semprevivo, M., & McGrath, J. (1990). A select Psychiatric Mother and Baby Unit in Britain: Implications for care in the United States. NAACOGs clinical issues in perinatal and womens health nursing 1:3, 402-409.

Sjukskterskors Samarbete i Norden (Nurses Co-Operation in the Nordic) (1983). Etiska riktlinjer fr omvrdnadsforskning i Norden (Ethical guiding principles for Nursing Science in the Nordic). Stewart, C., & Henshaw, C. 2002). Midwives and Perinatal Mental Health. British Journal of Midwifery, 10(2) 117-121.

Streubert, H., & Carpenter, D.(1999). Qualitative Research in Nursing. 2nd ed. Lippincott Company, USA. Terp, I., Engholm, G., Moeller, (1999). A follow-up study Prognosis and Risk factors Psychiatrica Scandinavica, H & Mortensen, P. of Postpartum Psychosis: for Readmission. Acta 100, 40-46.

Ugarriza, D.N. (1992). Postpartum Affective Disorders: Incidence and Treatment. Journal of Psychosocial Nursing, 30,(5), 29-32. Wieck, A., Kumar, R., Hirst, A.D. (1991). Increased Sensitivity of Dopamine Receptors and Recurrences of Affective Psychosis after Childbirth. British Medical Journal 303, 613-616.

46 Appendix 1

University of Skovde College of Nursing Dear Nurse Due to scientific studies the time of childbearing is a time when the woman is very sensitive and might be afflicted of psychiatric illness. Of one thousand newly delivered women one or two women will be afflicted with postpartum psychosis. Often the woman will be deeply depressed and the risk of suicide and infanticide is great. Most of the time these women are in need to be hospitalized. The signer of this letter is a psychiatric nurse and midwife and is studying at the University of Skovde, College of Nursing. During 2003 I will, in connection with studies in Master in Science of Nursing, carryout a scientific empirical investigation in the subject of psychiatric nursing. The study is focused on nursing for women with postpartum psychosis. There are few studies carried out on knowledge use in nursing among nurses who care for these women. To be able to carry out this study I need to interview at least ten experienced psychiatric nurses, this means that you will have to have practiced in psychiatric nursing for at least five years. Every interview will last for about one hour. The interviews will be tape-recorded and then verbatim transcribed and analyzed. The participation is voluntarily and you are allowed to leave the study at any point. Your narration will be analyzed with all the other nurses, and you will not be able to be identified as a person in the result. Collected data will be handled confidentially. The tapes are kept locked in a fireproofed locker in the University of Skovde. When the study is finished the tapes will be destroyed. Skovde 03-05-28

If you have any questions dont hesitate to call me. Supervisor: Agneta Nilsson, PhD, RN, Senior Lecturer The Academy of Sahlgrenska At the University of Gothenburg Department of Health Care Pedagogics Box 456 405 30 Gothenburg Phone: XXX-XXXXXXX

Inger Engqvist, RN, Mn, RM Phone XXXX-XXXXXX

47 Appendix 2 University of Skovde College of Nursing

To Nurses Union at

Skovde 03-05-28

The signer of this letter is a psychiatric nurse and midwife and is studying at the University of Skovde, College of Nursing. During 2003 I will, in connection with studies in Master in Science of Nursing, carry out a scientific empirical investigation in the subject of psychiatric nursing. The study is focused on nursing for women with postpartum psychosis. There are few scientific studies carried out on knowledge use in nursing among nurses who care for these women. To be able to carry through this study I will have to interview at least ten experienced psychiatric nurses, this means that the nurses will have to have practiced in psychiatric nursing for at least five years. Every interview will last for about one hour. The interview will be tape-recorded and verbatim transcribed and analyzed. The permission for the study has been given from the chief physician at the hospital. I will inform the Nurses Union about the study. If you have any question, I will be available on the phone.

Inger Engqvist RN, MN, RM Phone XXXX-XXXXXX

Supervisor: Agneta Nilsson, PhD RN, Senior Lecturer The Academy of Sahlgrenska at the University of Gothenburg Department of Health Care Pedagogics Box 456 405 30 Gothenburg Phone: XXX-XXXXXXX

48 Appendix 3 University of Skovde College of Nursing

To Chief Psychiatrist

Skovde 03-05-28

Due to scientific studies the time of childbearing is a time when the woman is very sensitive and might be afflicted of psychiatric illnesses. Of one thousand newly delivered women one to two women will be affected with post partum psychosis. Often the woman will be deeply depressed and the risk of suicide and infanticid is great. Most of the time these women are in need to be hospitalized. The signer of this letter is a mental nurse and midwife and is studying at the University of Skovde, College of Nursing. During 2003 I will, in connection with studies in Master in Science of Nursing, carry out a scientific empirical investigation in the subject of mental nursing. The study is focused on nursing for women with postpartum psychosis. There are few scientific studies carried out on knowledge use in nursing among nurses who care for these women. To be able to carry through this study I will have to interview at least ten experienced mental nurses, this means that the nurses will have to have practiced in mental nursing for at least five years. Every interview will last for about one hour. The interview will be tape-recorded. After the study the tapes will be destroyed. Collected data will be handled confidentially. The participation is voluntarily and it is allowed to leave the study at any point. I ask permission to interview nurses who have practiced for at least five years in hospital mental nursing. The requirements for the interviews are to be in a secluded place inside the working place and during the nurses own working times.

Inger Engqvist RN, MN, RM Phone XXXX-XXXXXX

Supervisor: Agneta Nilsson, RN, MN, PhD The Academy of Sahlgrenska at the University of Gothenburg College of Nursing Pedagogy Box 456 405 30 Gothenburg Phone: XXX-XXXXXXX

49 Appendix 4

University of Skovde College of Nursing

To Head Nurse

Skovde 03-05-28

Due to scientific studies the time of childbearing is a time when the woman is very sensitive and might be afflicted of psychiatric illnesses. Of one thousand newly delivered women one to two women will be affected with post partum psychosis. Often the woman will be deeply depressed and the risk of suicide and infanticid is great. Most of the time these women are in need to be hospitalized. The signer of this letter is a mental nurse and midwife and is studying at the University of Skovde, College of Nursing. During 2003 I will, in connection with studies in Master in Science of Nursing, carry out a scientific empirical investigation in the subject of mental nursing. The study is focused on nursing for women with postpartum psychosis. Few scientific studies are carried out on knowledge use in nursing among nurses who care for these women. To be able to carry through this study I will have to interview at least ten experienced mental nurses, this means that the nurses will have to have practiced in mental nursing for at least five years. Every interview will last for about one hour. The interviews will be tape-recorded and then verbatim transcribed and then analyzed. After the study the tapes will be destroyed. Collected data will be handled confidentially. The participation is voluntarily and it is allowed to leave the study at any point. The permission for the study is given from the chief physician at the hospital. I ask you to talk to the nurses on your ward and those who meet the criterion at least five years of practice as mental nurse and are interested in participating. Both men and women may participate. Any questions and you reach me at phone no XXXX-XXXXXX or mobile no XXXXXXXXXX Supervisor: Agneta Nilsson, RN, MN, PhD The Academy of Sahlgrenska at the University of Gothenburg College of Nursing Pedagogy Box 456 405 30 Gothenburg Phone: XXX-XXXXXXX

Inger Engqvist RN, MN, RM Phone XXXX-XXXXXX

50 Appendix 5 Interview guide Background Age? When did you finish your education to a nurse? How many years did you work as a regular nurse? Where have you worked as a regular nurse? When did you finish your education to a specialist nurse? How many years have you worked as a psychiatric nurse? How many years have you worked in psychiatric nursing? How nurses understand nursing of women with postpartum psychosis How would you describe in general a woman with PPP? Can you describe what you did in an incidence in which you cared for a woman with PPP? Why did you do what you did? What did you think was the most troublesome with this patient? What made you think this woman had PPP? Was it typical for PPP? What made you think this was typical for PPP? How did you handle this patient in relation to her relatives? How was her newborn child cared for? (How did you think at that time?) (Why did you do so?) (What made you do so?) (Are you following the researching?)

How was her partner cared for? How were siblings cared for? How were other relatives cared for?

Do you see any difference in nursing between a woman with PPP contra another psychosis in a woman who has not recently been pregnant? What further knowledge do you believe you need in order better to care for a woman with PPP? What have situations where you have cared for women with PPP taught you? What feelings come to you when caring for a woman with PPP? What thoughts come to you when caring for a woman with PPP?