Mothers overcoming remorse to care for self and baby: An emerging concept

Heather Lynn Coddington

a West Virginia University School of Nursing,Keyser,WV,USA

b UPMC Western Maryland Health System in Special Care Nursery,USA

Keywords:Emotions Infant Mothers Remorse Trust Uncertainty Substance-related disorders

ABSTRACT Objectives: Mothers with substance use disorder (SUD) experience a range of emotions such as feeling ostracized,diminished,and distressed while watching their baby experience withdrawal from substances.Being fully present in the now moment is to trust self to do what is best by moving beyond perceived boundaries to care for self and baby.The process of concept building arose from nursing practice encounters in a special care nursery (SCN) for babies who experienced withdrawal from substances.Method: Liehr and Smith’s 10-phase concept building approach was used to guide the development of this concept.Concept building began with a practice story.The emerging concept was named,core qualities identified,and supported through a literature review.The middle range theory of uncertainty in illness was chosen to serve as theoretical support for the concept.A model was created to provide clarity on the relationships within the concept.Result:A mini-saga was gathered from a mother in the SCN whose newborn had experienced withdrawal from substances.The minisaga follows:Due to the baby’s discomfort and judging eyes of the staff,she was unable to mother her baby.As the baby recovered,she asked for help,comforted her baby,and gained confidence to move beyond perceived boundaries to become the mother she envisioned.Overcoming perceived boundaries to attend to self and baby is trusting oneself to do what is best in spite of feeling ostracized,diminished,and distressed while watching baby withdraw from substances.Conclusion:This concept provides the perspective of mothers with SUD through intermodernism from experiences in nursing practice.The Uncertainty in Illness theory further allows practitioners to gain an understanding of the role uncertainty plays in this unique situation.

What is known?

· Mothers often conveyed feelings of judgment,guilt,shame,and distress while watching their baby experience the symptoms of withdrawal.

· Caring can be interpreted differently depending on the perspective in which one is viewing the experience.There are more ways that caring can be expressed,but it is important to identify the unique needs of each patient to help them cope.

What is new?

· An unbiased perspective on overcoming remorse to care for self and baby from the special care nursery nurse was formed using the 10-phase concept building approach.Overcoming boundaries in research/practice is being fully presented.

· The emerging concept of overcoming remorse to care for self and baby is grounded in theory,practice,and philosophy.This concept was viewed through the perspective of intermodernism as a philosophical perspective.

1.Introduction

The concept of overcoming remorse to care for self and baby was developed through a 10-phase process that included experiential,theoretical,and philosophical elements to describe the experiences of mothers with substance use disorder as they witness their newborns go through withdrawal from substances after birth.The purpose of this paper is to introduce the emerging concept of overcoming remorse to care for self and baby using Liehr and Smith’s 10-phase concept building approach [1].Intermodernism will be discussed as the philosophical perspective serving as a guide in the concept building process.This emerging concept is rooted in practice and was better understood through story gathering in a special care nursery (SCN) setting by a clinical staff nurse.A discussion of the development process and the theoretical background used for this emerging concept is provided.The concept of overcoming remorse to care for self and baby emerged as the 10-phase process was utilized.The process included 1) Writing a practice story;2) Identifying a phenomenon of interest;3) Choosing a theoretical lens to view the phenomenon of interest;4) Literature review to derive core qualities;5) Writing a reconstructed story from story-gathering;6) Developing a mini-saga;7) Refining and defining the core qualities;8)Defining the concept;9)Developing a model;and 10) Developing a mini-synthesis to pull together the concept building process [1].

The concept of overcoming remorse to care for self and baby emerged through a practice story that was written from a clinical staff nurse in the SCN in a rural hospital in Appalachia.The core qualities were observed throughout the practice story.A literature review assisted in gaining further insight into the phenomenon and presence of these qualities in the population of interest.This story was one example of what is observed in practice by the staff nurse telling the practice story,but similarities in other stories of mothers with substance use disorder (SUD) while watching their newborn go through withdrawal after birth have been noted.

Intermodernism is the philosophical perspective that was chosen as a foundation for the development of this emerging concept.Reed [2] describes practice as a perspective that informs theory development and a context of theory validation and how it may be applied.Practice as Reed explains,guides theory development as observations and phenomena are observed.One can see through practice how different practices,behaviors,and care can influence the human experience.The focus of the discipline of nursing discussed by Newman,Sime,and Corcoran-Perry [3] is caring in the human health experience.Caring can be interpreted differently depending on the perspective in which one is viewing the experience.Caring may be listening and taking the time to hear a person’s story.Caring may also be providing physical care and providing education that will benefit the patient.There are more ways that caring can be expressed,but it is important to identify the unique needs of each patient to help them cope.Intermodernism according to Reed [2] has three philosophical components related to the nursing theory which are ontological,epistemological,and semantic components.Ontological components are beliefs about reality,in this case,the beliefs about how mothers with SUD feel about watching their baby go through withdrawal.This may not be the reality of how they feel once stories are gathered.The epistemology of this concept is what we know,found through practice,story gathering,and literature review as evidence.Lastly,the semantic component can potentially give accurate descriptions and representations of aspects of the world [2].

Ethical Considerations.This process included a practice story from the author’s perspective and thus did not require Institutional Review Board (IRB) approval.Empathy was shown in the practice story and the reconstructed story as the author displayed appreciation for the unique situation and point of view of the mothers.An unbiased perspective from the SCN nurse was formed using the 10-phase process.

2.Process for concept building

2.1.Practice story

The practice story was gathered from the perspective of a SCN nurse while caring for a mother/baby dyad in the days after delivery as the baby experienced symptoms of withdrawal from opioids.The mother began with feelings of uncertainty as she was unsure of what to expect while her daughter was hospitalized,followed by anger and fear as she watched her daughter’s symptoms escalate.She expressed feelings of shame and guilt due to her daughter’s withdrawal.She also stated that she felt little support from healthcare professionals caring for herself and her newborn.She reported differing information from staff as her newborn continued to experience withdrawal.Her anxiety grew as she realized the need for medication-assisted treatment due to the severity of withdrawal symptoms shown by her newborn.As she saw improvements in her daughters’symptoms and realized the role that she could take in caring for her newborn during this process she began to trust herself and her parenting skills.Her anxiety decreased and she became more involved in her newborn’s care.The symptoms of withdrawal improved and she was able to take her newborn home feeling competent in her parenting skills.

2.2.Emerging concept and definition

The emerging concept from the practice story as the practice story was read and analyzed for aspects depicted in the experiences of the mother during the treatment of her daughter for withdrawal in the SCN became: Guilt of watching the baby go through withdrawal,judgment,inadequacy as parent,empowerment and overcoming,and a realization of her own abilities as a mother to do what was best.This is the second step in the 10-phase process in which the phenomenon is identified and subsequently defined.This phenomenon then had to be named as a human health experience.The name given to the phenomenon based on the qualities pulled from the story was:Overcoming remorse to care for self and baby.Next,the concept was defined using these newly refined core qualities as Overcoming remorse to care for self and baby is trusting oneself to do what is best in spite of feeling ostracized,diminished,and distressed while watching the baby withdraw.

2.3.Definition of core qualities

Preliminary core qualities were identified from the practice story to aid in a literature search.The literature search was performed through the university library database along with google scholar.Keywords used were neonatal abstinence syndrome,overcoming guilt,remorse,opportunities for bonding,self-blame,empowering,experiencing stress of child,stigma and bias,and mothering.Recurring qualities found within these articles were:distress as the baby withdraws,opportunities to overcome,fulfillment of maternal role,helpless,ostracized,diminished,doing what is best,trusting relationships,and unpredictability.From those,four core qualities were established as distress watching baby withdraw,feeling ostracized and diminished,and trusting oneself to do what is best.

The first core quality was trusting oneself to do what is best.A review of the literature revealed a desire to be present and to be affectionate with the baby.Wanting to do what is best and have a meaningful role in newborn care was evident[4].A determination to have a good relationship with the baby [5].Challenges include stigma and bias experienced by mothers from healthcare providers and families that contribute to mothers feeling incompetent in their ability to make good decisions [6].

The second core quality drawn from the literature search was feeling ostracized while watching the baby go through withdrawal.Feeling ostracized in the literature search was described as a feeling of exclusion in the healthcare setting[6].Mothers described feeling shamed and not included in the care and treatment process [5].Challenges include a lack of understanding of communication approaches for mothers suffering from SUD and the need to include mothers in the treatment regime[7].

The next core quality is feeling diminished.Feeling diminished while the baby is receiving treatment for withdrawal in the SCN gave recurrent descriptors such as feeling shame,feeling like a bad mother,feeling worthless,and being judged [6].A lack of understanding from society and healthcare providers can compound these feelings and cause a withdrawal of parenting and decreased self-esteem and trust in parenting abilities.Praise and support during an already stressful time may assist with a reduction in these feelings [8].

Lastly,the core quality of feeling distressed while watching the baby withdraw was identified as the emotional process of watching the baby experience withdrawal [8].An inconsistency,unpredictability,and uncertainty that often accompanies the withdrawal process make this quality more complex[9].Empowering mothers and preparing with education on the withdrawal process with techniques and ways to participate in treatment may help to decrease distress during this time.Support for mothers with SUD during the time of treatment of the newborn is essential to decrease anxiety and promote bonding within the mother/baby dyad to sustain long-lasting family relationships.

2.4.Theoretical lens

Once the concept was named and identified a theoretical lens was sought.The lens that was identified to be most fitting for this phenomenon was the theory of uncertainty in illness developed by Merle Mishel in 1988 and reconceptualized as the reconceptualized uncertainty in illness theory (RUIT) in 1990 [10].Mishel described uncertainty as existing in illness situations which are ambiguous,complex,and unpredictable [10].She also viewed uncertainty as a cognitive state rather than as an emotional response.The concepts of uncertainty in illness theory included antecedents of uncertainty which is the stimulus for uncertainty or the event that causes uncertainty.The second is the appraisal of uncertainty or how the individual places value on the event or situation and is unique to everyone based on life experiences and personal perspective of experience and knowledge in uncertain situations.The third is how one copes with uncertainty and includes danger,opportunity,coping and adaptation.The RUIT adds in the concepts of selforganization and probabilistic thinking.Self-organization gives the person a new order or a new value system based on the experiences had during those uncertain situations.Probabilistic thinking abandons the idea of predictability and accepts the idea of uncertainty in illness as a new normal as a life perspective[10].The model helps to describe the phenomenon as the progression of withdrawal is an uncertain process for parents and cannot be predicted by parents or providers.Abandoning the idea of what should or will happen and learning to address things as they do happen to form a value system of how to become part of the team and a valuable member of the care process is the goal and is what was portrayed in this practice story.

2.5.Related literature

A review of the literature using CINAHL,PubMed,and Science-Direct helped to give a better understanding of the concept of overcoming remorse to care for self and baby and the core qualities that were identified.Keywords for this search included stigma,bias,mothers,neonatal abstinence syndrome,substance use disorder,and opioid use disorder.A qualitative study performed by Rockefeller and colleagues [4] revealed an overarching theme of trying to do what is best by mothers that were interviewed during this time of treatment.Although mothers reported facing barriers such as guilt,bias,stigma,and feelings of being judged;mothers continued to express their need to be included in the treatment and care process [4].Mothers often conveyed feelings of judgment,guilt,shame,and distress while watching their baby experience the symptoms of withdrawal[5,6,8].Feeling ostracized and diminished was also communicated throughout the literature and described as exclusion from communication during treatment,lack of opportunity to care for and spend time with baby while in the SCN for mothers,and feelings of marginalization as a person with a substance use disorder [4,6,9].One study included in this search reported that mothers felt respected and included by healthcare providers at times and that this improved feelings of guilt,shame,and increased bonding between mother and newborn [4].Studies providing the maternal perspective during treatment of the newborn for withdrawal were few as this is an area that needs further research and support.

2.6.Reconstructed story from story gathering

For the reconstructed story,a mother of a 12-day-old boy provided further personal story support in the SCN who was to be discharged the next day.She spoke of the distress that she had while watching her son as he experienced withdrawal symptoms and times that she felt ostracized and diminished by healthcare providers and members of her social circle,but also spoke of how she found allies within the nursery and how she came to know how to care for her baby and trust herself to take care of him while trusting her instincts as a mother to provide the best support and comfort for him.The mother in the reconstructed story provided valuable insight into this phenomenon through her unique perspective without prompting that included many of the core qualities through her experiences as she witnessed her newborn experiencing withdrawal.

2.7.Model

The model contains the core qualities only and connects them in a way that visually creates the interrelatedness of the qualities so that the person viewing the model can see how they are related.The model for this emerging concept is watching baby experience withdrawal from substances in a center circle with feeling ostracized,feeling diminished,feeling distressed,and trusting oneself to do what is best in smaller circles surrounding that circle.This model provides the viewer the ability to easily see the relationships of the core qualities in relation to the mother as she watches her newborn experience withdrawal symptoms.The outside circle including the core qualities encloses the circle with the mother as she watches her newborn experience withdrawal symptoms as it is all happening simultaneously (Fig.1).

2.8.Mini-saga

The mini-saga was a 50-word story that took the essence of the emerging concept from the reconstructed story to provide the core qualities from the story with a beginning,middle,and end so that the reader could quickly get the idea of the concept.In this case,it was Watching her baby go through withdrawal,she experienced guilt.Due to the baby’s discomfort and judging eyes of the staff,she was unable to mother her baby.As the baby recovered,she asked for help,comforted her baby,and gained confidence to become the mother she envisioned.

Fig.1.Model for overcoming remorse to care for self and baby: Core qualities.

2.9.Mini synthesis

The mini synthesis is a three-sentence synthesis that pulls together the concept building process.The first sentence addresses the significance of the phenomenon and names the population:“Mothers with substance use disorder experience many challenges while caring for their child with neonatal abstinence syndrome.”The second sentence is the definition of the concept “Overcoming remorse to care for self and baby is trusting oneself to do what is best in spite of feeling ostracized,diminished,and distressed while watching baby withdraw.” And the third sentence suggests an approach for moving toward a research question: “A qualitative study to describe what it is like to mother a child experiencing withdraw is proposed.”

3.Implications for beginning a program of research

A qualitative study to describe the lived experience of mothering a child experiencing withdrawal would be beneficial to assist healthcare providers in understanding supports that can assist the mother/baby dyad.This study will feature qualitative interviews to develop a better understanding of the concept of overcoming remorse to care for self and baby.

4.Conclusions

The emerging concept of overcoming remorse to care for self and baby is grounded in theory,practice,and philosophy.This concept was viewed through the perspective of intermodernism as a philosophical perspective.The theory of uncertainty in illness provided a middle range theory to offer further foundational groundwork for the concept.The practice story and reconstructed story supplied experiential evidence.The literature review also gave further empirical proof to corroborate the story gathering process.The concept of overcoming remorse to care for self and baby is connected to the discipline of nursing and will advance the knowledge of the discipline to improve caring in the human health experience by assisting health care providers to better understand how to support the mother/baby dyad as newborn experiences withdrawal symptoms.

Declaration of competing interest

No sources of funding and no conflicts of interests.

Acknowledgments

I would like to thank Dr.Mary Jane Smith and Dr.Suzy Walter for providing mentorship utilizing the 10-step process by Liehr &Smith as this concept emerged.

Appendix A.Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2022.09.002.