Crisis Intervention Theory in Maternal-Infant Nursing SALLY F . BAIRD, R N , B S N
0
nursing roles Emotional Crisis and Maternal-
Child Nursing Two articles ofler daperent insights on the nurse and non-medical, or emotional, crisis in maternal-child health care. It is suggested that nurses should be prepared to recognize, understand, and intervene effectively and independently in such crisis situations as part of their role on the health care team. The second article offers a spec& model for crisis intervention.
Maternal-infant nurses are regularlyfaced with a multitude of crises. Whether they are able to effectively employ crisis intervention theory in these situations is dependent on their knowledge of the theory and its use in maternal-infant nursing. This article reviews aspects of crisis intervention theory, discusses its relevancyfor nursing, and explores the possible appropriate uses of the theory in maternal-infant nursing. An example of the nurse’s role in parenthood as a crisis illustrates the theory’s use in maternal-infant care. “The deeper that sorrow carves into your being, the more joy you can contain.”‘ During troubled times a person can mature, grow, and become better able to cope with future problems. Maternal-infant nurses are faced with a multitude of crises ranging from conception control to parenthood. Often the nurse is closer to these crises than any other professional person. Whether she is able to recognize the crises and intervene appropriately is often based on her knowledge of crisis intervention theory and its application in maternal-infant nursing.
Review of Theory Crisis is defined most simply as an upset in a steady state.2 This definition is based on the postulate that Man strives for homeostasis, i.e., physiologic steady state, by constantly using his coping mechanisms to maintain equilibrium. However, a “crisis is provoked when a person faces an obstacle to important life goals, that is, for a time, insurmountable through the utilization of customary methods of problem solving. A period of disorganization ensues, a period of upset, during which many different abortive attempts [at resolution] are made.”3 Eventually equilibrium is achieved, but it may or may not be for the better. A crisis can occur during an emotionally significant event, a threat, a disaster, a decisive moment, or a turning point. Change rather than stress may also serve as the precipi-
tating event. Examples are a change in body image, a change in environment, and a change in relevant social networks. An interesting point is that what constitutes a crisis for one individual and his family does not necessarily constitute a crisis for others. Three variables which generally determine a crisis situation are the event itself, the family’s resources in dealing with the crisis, and the meaning of the event for the family.‘ The outcome of a crisis depends on the above variables, but external intervention may counteract the forces already present. A person in crisis is totally involved in a subjective experience. He is psychologically vulnerable and open to outside assistance. This predictably more susceptible person in crisis may come through his experience in a healthy way, depending on the quality of help he receives during the crisis. Intervention can then be a decisive factor in the outcome. This is the rationale behind crisis intervention. A crisis is self-limiting, lasting from 4 to 6 weeks. During this time there are four characteristic phases, as identified by C a ~ l a n : ~
Phase I: There is an initial rise in tension as the impact of the stimulus calls forth habitual coping responses of homeostasis. Phase 2: Increasing tension results from lack of success of the responses and continuation of the stimulus. (Continued on page 37.) January/February 1976 JOGN Nursing
(Continued from page 30.)
Phase 3: The continued rise in tension proceeds past a third threshold where the tension acts as a powerful stimulus to mobilize internal and external resources. The person may redefine the stimulus or may become aware of new aspects of the problem. He may explore new coping mechanisms to use in handling the problem. As a result of this moblization of resources, the problem may be solved. This will usually result in an zlteration of the individual’s role vis-2-vis his group. Phase 4 : If the problem continues and cannot be solved, avoided, or distorted in such a way as to make it tolerable, the tension mounts beyond a last threshold and results in major disorganization of the person. Aguilera and Messick have outlined two approaches frequently used in crisis intervention, the generic and the individual.’ In both cases the goal is resolution of the immediate crisis, with the intervener attempting to reduce the impact of the event and to capitalize on the example of this experience for use during subsequent events. These two approaches are complementary. The generic approach focuses on a particular kind of crisis rather than on the psychodynamics of the the individual in crisis. Specific situational and maturational events occurring to significant population groups have been identified as following characteristic behavior patterns. An example of a situational event is an unwanted pregnancy in a member of the adolescent population group. Intervention is oriented to the crisis related to the specific event. This approach is recommended for use by non-mental health professionals because in-depth psychiatric knowledge is not required. The individual approach focuses on the interpersonal and intrapsychic processes of an individual in crisis. Intervention is planned to meet the unique needs of this person and his family. This approach is recommended only for mental health professionals. The steps used in crisis intervention will be discussed in depth January/February 1976 JOGN Nursing
later in this article. As described by Aguilera and Messick,‘ they consist of assessment, intervention planning, intervention, resolution, and anticipatory planning.
Relevancy of Theory for Nursing Does crisis intervention theory have a place in nursing care? People are the center of nursing’s purpose, and crises occur to all people at some time. The question appears to be whether nurses are able to incorporate the theory into their practice. Caplan3 states that nurses have a role in crisis intervention which is not open to any other specialist. The chief characteristic of this role is closeness. The nurse is closer in space and time to the patient than any other professional. She goes to the patient’s home and remains at his bedside. Her contact with the patient is constant and continuous. The nurse is also close in a social sense because many patients see her more as a “wise sister” than a parent figure. Contributing to the social closeness may also be the fact that nurses represent more varied cultural and socioeconomic groups, as contrasted with professional people in other disciplines. As a result, the nurse can more often relate to the patient on his level. Linked with this sociologic closeness, is the psychologic closeness that the nurse can develop. She is able to involve herself freely and less formally than are most other professionals. What this closeness means with regard to crisis intervention is that the nurse is in a better position than any other professional to detect and intervene in crisis. The nurse has other characteristics which make her suitable for using crisis intervention theory. 1. The public health nurse’s role as community problem solver and mobilizer of resources is applicable to crisis intervention. 2. Nursing education’s emphasis on care giving, supportive techniques, and appropriate social behavior are essential in crisis management. 3. Traditional medical areas, where many crisis programs are focused,
more easily accept nurses. 4. Aside from the psychiatrist, the nurse has a greater familiarity with pathophysiologic disorders and psychopharmacologic agents then her mental health colleagues. 5 . The nursing profession has been and is now working on the expansion of the nurse’s role throughout the health care delivery system. If nurses are in such a prime position to employ crisis intervention, why aren’t more nurses using it? Perhaps part of the reason stems from nursing education. The clinical psychiatric training of a nurse often lacks a solid base in crisis intervention theory and practice. Without this base, the nurse is unable to be completely effective in crisis intervention. Another problem is that many nurses are not willing or ready to take over the independent function required in crisis intervention. Numerous nurses have been trained to be only care givers, not independent practitioners. They do not see this expanded role as being within their realm of practice. It is unfortunate that crisis intervention is not used more widely, as nurses could make significant changes for the better in people’s lives during crises with it.
Use of Theory In Maternal-Infant Nursing It has already been proposed that nurses are in a prime position to use crisis intervention theory. The application of this theory to maternal-infant care begins with the identification of potential crises in this speciality. More obvious crisis-provoking areas include unwanted pregnancy, high-risk pregnancy, abortion, stillborn delivery, and the birth of a defective and/or premature infant. Other areas thought less likely to produce a crisis situation can still often cause severe problems for the family. These include the decision to use birth control, the “normal” pregnancy, and parenthood. As in the case of any crisis, it is the perception of the family involved that determines whether a crisis state exists; however, it is important for the nurse to recognize potential crisis areas so that she can be prepared to intervene. 37
Parenthood as a crisis has been the theme of two relativelv recent studi e ~ .In~ both . ~ studies, (he addition to the family of a first child was determined to constitute a crisis for both parents. Some of the factors that contributed to the crisis included the loss of sleep, the creation of new responsibilities, the loss of a second income, the decrease in social activity, and the role changes brought about by the existence of the infant. In both studies, it was also found that if the couple had anticipated the changes an infant would cause, the crisis was slight. Once the nurse becomes aware of the possible crisis state, she follows the steps of crisis intervention. Assessment may show that the family is not in crisis and that anticipatory guidance is all that is needed. In other cases, assessment will lead to planned intervention, intervention, resolution, and anticipatory planning. A closer look at a hypothetical crisis may clarify the application of this theory.
Example: Parenthood as a Crisis A maternal-infant nurse receives a call from a concerned mother who is now 1 week postpartum. The woman says that ever since the baby arrived, she and her husband have been tired and argumentative. Several times during the call, the mother questions her ability to be a good mother for her child and asks for any suggestions the nurse has to offer. The nurse says that she will make a home visit that day. Based on the above information, the nurse should be aware of a potential crisis situation following the birth of a first child. She should realize that the resultant change in the family structure can be both anxiety provoking and growth provoking and that as a nurse, her goal in this crisis situation of parenthood is to promote the growth potential and joys of parenthood while minimizing the disruptive effects it can have. The first step toward this goal is assessment, The initial step in assessment is to determine the couple’s perception of parenthood. LeMasters found that most parents “romanticized” parent38
hood and were unprepared for the realities of a b a b ~ CouDles .~ were prepared to be husbands and wives but were rarely prepared to be parents. Answers to questions such as: What does being a parent mean to you? Did you believe the infant would change your life style? Do you anticipate your life changing over the next year? will give the nurse a clearer idea of how this couple views their new role. Assessment of the couple’s situational supports is the next step. Typical questions include: Do you have anyone to help you care for the baby? Do you have someone you can rely on when you have baby-care questions? Do you have a baby-sitter in mind for when you wish to go out as a couple? Whom would you most trust for help in the baby’s care? The greater the number of trusted people who can be brought into the situation, the more support the couple will receive. A third assessment area is the history of past coping mechanisms used by the couple. This history may include answers to such questions as: Have you ever had to adjust to someone living with the two of you for a time? How did you cope with this arrangement? What do you usually do when you feel depressed, anxious, tired, e t c . ? What relieves these symptoms? The couple may remember methods of coping that they haven’t used for years. They may also discuss methods that worked before, but that wouldn’t work in this situation. Because adaptive skills are so individual, the nurse must work with the couple to determine what will restore equilibrium for them. Once the couple identifies the birth of the child as having caused some disequilibirum, planned intervention can occur. A determination is first made on how much of a disruption the addition of the baby is causing. The nurse needs to know if the mother is able to care for the baby adequately, to what degree normal household activities are being altered, and how the disruption is affecting the husband and other family members. The couple, with the nurse’s help, then examines the alternatives open to them for restoring equilibrium and chooses
those that seem feasible or that have worked well for them in the Dast. For example, it may be proposed that the child’s care be shared by both the mother and the father, that rather than forego their social activities, the parents can leave the child with a baby-sitter occasionally, or that child-care services will be used if the mother wishes to resume working. These alternatives are explored in the light of why the child is causing a crisis and what will best restore equilibriu m . After the options are explored, intervention is initiated. “Action is taken with the expectation that if (planned action) is taken, the (expected result) will occur.”’ The nurse defines the problem of bringing a new infant into the house and reflects it back to the couple. This clarifies the problem and encourages the couple to focus directly on the problems causing disequilibrium in the family. Alternatives which were explored in the planning stage are tried and evaluated. For example, if the husband finds he is unable to help his wife with the care of the infant, a new approach may be to have a grandparent assist with the care for 1 to 2 weeks. The goals of the intervention phase are to help the couple gain an intellectual understanding of why they are in crisis, bring into the open feelings which may have been suppressed about the new role, explore new ways of coping with this new experience, and restore family equilibrium. If the couple realistically examines why the child caused disequilibrium, if they have adequate help from family, friends, and health workers, and if they are able to develop new ways of coping with parenthood, the crisis should be resolved 4 to 6 weeks after delivery. The nurse can evaluate at this time whether the couple has returned to their usual level or a higher level of equilibrium because of the crisis. It is hoped that the arrival of the child was a growth promoting event for all concerned. Anticipatory planning is done after resolution. The nurse reinforces the couple’s new coping mechanisms in their adjustment to parenthood. She reviews why the family was thrown into crisis and explores the January/February 1976 JOCN Nursing
ways in which subsequent children may cause disequilibrium. Again the family will feel the loss of sleep, readjustment to new responsibilities, and the shift from a three-person home to a four-person home. The nurse and the family can discuss ways of coping should more children enter the family. As LeMasters pointed out, the more prepared a couple is for parenthood, the smaller the crisis.’ Because of this nursing intervention and the experience of already having one child, the couple should not undergo severe disequilibrium with subsequent children. They will have grown because of this crisis. Anticipatory planning can also be done by the nurse. After working with the problems new parenthood brings, she can more fully realize the value of preparation. More preconceptual and prenatal classes taught by maternal-infant nurses could decrease the severity of parenthood as a crisis. After delivery, the accessibility of the nurse, plus her collaboration with other health agencies could increase the amount of help available to new parents. One example of this is to include the telephone numbers of the postpartum unit, the public health department, and the community mental health clinic in the discharge information given to the new parents. Keys the nurse can use to help families avoid parenthood as a crisis can be summarized as: 1 ) preparation, 2 ) accessibility, and 3) collaboration.
Summary Although the above crisis is hypothetical, it demonstrates the use of crisis intervention in one situation
likely to be encountered by the maternal-infant nurse. Crises in this speciality occur daily. If through appropriate intervention, nurses are able to help the families in their care grow and mature during troubled times, crisis intervention theory has its place in maternal-infant nursing.
References
v e n t i o n : S e l e c t e d Readings, edited by H. Parad, New York, Family Service Association of America, 1965, pp 312-323 9. LeMasters, E. E.: “Parenthood as Crisis.” In Crisis Intervention: Selected Readings, edited by H. Parad, New York, Family Service Association of America, 1965, pp 11 1-1 17
1 . Gibran, K.: T h e Prophet, New York, Alfred Knopf, 1923, p 28 2 . Rapoport, L.: “ T h e State of Crisis: Some Theoretical Considerations.” In Crisis Intervention: Selected Readings, edited by H. Parad, New York, Family Service Association of America, 1965, pp 22-31 3. Caplan, G . : A n Approach to Community Mental Health, New York, Grune and Stratton, 1961, p 18 4. Tudor, M.: “Family Habilitation: A Child With a Birth Defect.” In Family Health Care, edited by D. Hymovich and M . Barnard, New York, McGraw-Hill Book Company, 1973, pp 284-300 5. Caplan, G.: Principles of Preventive Psychiatry, New York, Basic Books, 1964 6 . Aguilera, D. and J. Messick:
Address reprint requests to Sally F. Baird, RN, c/o Felgenhauer, 10803 East 25th, Spokane, WA 99206.
Crisis Intervention: Theory and Methodology, St. Louis, C.V. Mosby Co., 1974
Sally F . Baird, AN, BSN, is working toward a master’s degree in maternal-child health at the University of Texas School of Nursing at San Antonio. In 1972 she received a baccalaureate degree in nursing f r o m t h e University of W a s h i n g t o n , Seattle, and was subsequently employed as a public health nurse in San Antonio. She is a member of the Texas Public Health Association and Sigma Theta Tau.
7. Schmidt, L.J. and D. Evans: “The Crisis Intervention Nurse in Community Mental Health.” In Family-Centered C o m m u n i t y Nursing, edited by A. Reinhardt and M. Quinn, St. Louis, C.V. Mosby CO., 1973, pp 291-298 8. Dyer, E.: “Parenthood as Crisis; A - Re-Study.” In Crisis Inter-
WORKSHOP ON FETAL MONITORING The School of Medicine of the University of California at San Francisco is sponsoring a workshop in Intrapartum Fetal Monitoring on April 2 and 3, 1976. Workshop Chairman is Julian T. Parer, MD, PhD, Assistant Professor of Obstetrics and Gynecology. Fees will be $35 for nurses, $120 for physicians, and a half-fee rate for non-University of California house staff and postdoctoral students (with letter of verification). Site: University of California at San Francisco. For information write to Extended Programs in Medical Education, Room 569 U, University of California, San Francisco, CA 94143, or call (415)666-4251.
January/February 1976 JOCN Nursing
39
0
nursing roles Emotional Crisis and Maternal-
Child Nursing Two articles ofler daperent insights on the nurse and non-medical, or emotional, crisis in maternal-child health care. It is suggested that nurses should be prepared to recognize, understand, and intervene effectively and independently in such crisis situations as part of their role on the health care team. The second article offers a spec& model for crisis intervention.
Maternal-infant nurses are regularlyfaced with a multitude of crises. Whether they are able to effectively employ crisis intervention theory in these situations is dependent on their knowledge of the theory and its use in maternal-infant nursing. This article reviews aspects of crisis intervention theory, discusses its relevancyfor nursing, and explores the possible appropriate uses of the theory in maternal-infant nursing. An example of the nurse’s role in parenthood as a crisis illustrates the theory’s use in maternal-infant care. “The deeper that sorrow carves into your being, the more joy you can contain.”‘ During troubled times a person can mature, grow, and become better able to cope with future problems. Maternal-infant nurses are faced with a multitude of crises ranging from conception control to parenthood. Often the nurse is closer to these crises than any other professional person. Whether she is able to recognize the crises and intervene appropriately is often based on her knowledge of crisis intervention theory and its application in maternal-infant nursing.
Review of Theory Crisis is defined most simply as an upset in a steady state.2 This definition is based on the postulate that Man strives for homeostasis, i.e., physiologic steady state, by constantly using his coping mechanisms to maintain equilibrium. However, a “crisis is provoked when a person faces an obstacle to important life goals, that is, for a time, insurmountable through the utilization of customary methods of problem solving. A period of disorganization ensues, a period of upset, during which many different abortive attempts [at resolution] are made.”3 Eventually equilibrium is achieved, but it may or may not be for the better. A crisis can occur during an emotionally significant event, a threat, a disaster, a decisive moment, or a turning point. Change rather than stress may also serve as the precipi-
tating event. Examples are a change in body image, a change in environment, and a change in relevant social networks. An interesting point is that what constitutes a crisis for one individual and his family does not necessarily constitute a crisis for others. Three variables which generally determine a crisis situation are the event itself, the family’s resources in dealing with the crisis, and the meaning of the event for the family.‘ The outcome of a crisis depends on the above variables, but external intervention may counteract the forces already present. A person in crisis is totally involved in a subjective experience. He is psychologically vulnerable and open to outside assistance. This predictably more susceptible person in crisis may come through his experience in a healthy way, depending on the quality of help he receives during the crisis. Intervention can then be a decisive factor in the outcome. This is the rationale behind crisis intervention. A crisis is self-limiting, lasting from 4 to 6 weeks. During this time there are four characteristic phases, as identified by C a ~ l a n : ~
Phase I: There is an initial rise in tension as the impact of the stimulus calls forth habitual coping responses of homeostasis. Phase 2: Increasing tension results from lack of success of the responses and continuation of the stimulus. (Continued on page 37.) January/February 1976 JOGN Nursing
(Continued from page 30.)
Phase 3: The continued rise in tension proceeds past a third threshold where the tension acts as a powerful stimulus to mobilize internal and external resources. The person may redefine the stimulus or may become aware of new aspects of the problem. He may explore new coping mechanisms to use in handling the problem. As a result of this moblization of resources, the problem may be solved. This will usually result in an zlteration of the individual’s role vis-2-vis his group. Phase 4 : If the problem continues and cannot be solved, avoided, or distorted in such a way as to make it tolerable, the tension mounts beyond a last threshold and results in major disorganization of the person. Aguilera and Messick have outlined two approaches frequently used in crisis intervention, the generic and the individual.’ In both cases the goal is resolution of the immediate crisis, with the intervener attempting to reduce the impact of the event and to capitalize on the example of this experience for use during subsequent events. These two approaches are complementary. The generic approach focuses on a particular kind of crisis rather than on the psychodynamics of the the individual in crisis. Specific situational and maturational events occurring to significant population groups have been identified as following characteristic behavior patterns. An example of a situational event is an unwanted pregnancy in a member of the adolescent population group. Intervention is oriented to the crisis related to the specific event. This approach is recommended for use by non-mental health professionals because in-depth psychiatric knowledge is not required. The individual approach focuses on the interpersonal and intrapsychic processes of an individual in crisis. Intervention is planned to meet the unique needs of this person and his family. This approach is recommended only for mental health professionals. The steps used in crisis intervention will be discussed in depth January/February 1976 JOGN Nursing
later in this article. As described by Aguilera and Messick,‘ they consist of assessment, intervention planning, intervention, resolution, and anticipatory planning.
Relevancy of Theory for Nursing Does crisis intervention theory have a place in nursing care? People are the center of nursing’s purpose, and crises occur to all people at some time. The question appears to be whether nurses are able to incorporate the theory into their practice. Caplan3 states that nurses have a role in crisis intervention which is not open to any other specialist. The chief characteristic of this role is closeness. The nurse is closer in space and time to the patient than any other professional. She goes to the patient’s home and remains at his bedside. Her contact with the patient is constant and continuous. The nurse is also close in a social sense because many patients see her more as a “wise sister” than a parent figure. Contributing to the social closeness may also be the fact that nurses represent more varied cultural and socioeconomic groups, as contrasted with professional people in other disciplines. As a result, the nurse can more often relate to the patient on his level. Linked with this sociologic closeness, is the psychologic closeness that the nurse can develop. She is able to involve herself freely and less formally than are most other professionals. What this closeness means with regard to crisis intervention is that the nurse is in a better position than any other professional to detect and intervene in crisis. The nurse has other characteristics which make her suitable for using crisis intervention theory. 1. The public health nurse’s role as community problem solver and mobilizer of resources is applicable to crisis intervention. 2. Nursing education’s emphasis on care giving, supportive techniques, and appropriate social behavior are essential in crisis management. 3. Traditional medical areas, where many crisis programs are focused,
more easily accept nurses. 4. Aside from the psychiatrist, the nurse has a greater familiarity with pathophysiologic disorders and psychopharmacologic agents then her mental health colleagues. 5 . The nursing profession has been and is now working on the expansion of the nurse’s role throughout the health care delivery system. If nurses are in such a prime position to employ crisis intervention, why aren’t more nurses using it? Perhaps part of the reason stems from nursing education. The clinical psychiatric training of a nurse often lacks a solid base in crisis intervention theory and practice. Without this base, the nurse is unable to be completely effective in crisis intervention. Another problem is that many nurses are not willing or ready to take over the independent function required in crisis intervention. Numerous nurses have been trained to be only care givers, not independent practitioners. They do not see this expanded role as being within their realm of practice. It is unfortunate that crisis intervention is not used more widely, as nurses could make significant changes for the better in people’s lives during crises with it.
Use of Theory In Maternal-Infant Nursing It has already been proposed that nurses are in a prime position to use crisis intervention theory. The application of this theory to maternal-infant care begins with the identification of potential crises in this speciality. More obvious crisis-provoking areas include unwanted pregnancy, high-risk pregnancy, abortion, stillborn delivery, and the birth of a defective and/or premature infant. Other areas thought less likely to produce a crisis situation can still often cause severe problems for the family. These include the decision to use birth control, the “normal” pregnancy, and parenthood. As in the case of any crisis, it is the perception of the family involved that determines whether a crisis state exists; however, it is important for the nurse to recognize potential crisis areas so that she can be prepared to intervene. 37
Parenthood as a crisis has been the theme of two relativelv recent studi e ~ .In~ both . ~ studies, (he addition to the family of a first child was determined to constitute a crisis for both parents. Some of the factors that contributed to the crisis included the loss of sleep, the creation of new responsibilities, the loss of a second income, the decrease in social activity, and the role changes brought about by the existence of the infant. In both studies, it was also found that if the couple had anticipated the changes an infant would cause, the crisis was slight. Once the nurse becomes aware of the possible crisis state, she follows the steps of crisis intervention. Assessment may show that the family is not in crisis and that anticipatory guidance is all that is needed. In other cases, assessment will lead to planned intervention, intervention, resolution, and anticipatory planning. A closer look at a hypothetical crisis may clarify the application of this theory.
Example: Parenthood as a Crisis A maternal-infant nurse receives a call from a concerned mother who is now 1 week postpartum. The woman says that ever since the baby arrived, she and her husband have been tired and argumentative. Several times during the call, the mother questions her ability to be a good mother for her child and asks for any suggestions the nurse has to offer. The nurse says that she will make a home visit that day. Based on the above information, the nurse should be aware of a potential crisis situation following the birth of a first child. She should realize that the resultant change in the family structure can be both anxiety provoking and growth provoking and that as a nurse, her goal in this crisis situation of parenthood is to promote the growth potential and joys of parenthood while minimizing the disruptive effects it can have. The first step toward this goal is assessment, The initial step in assessment is to determine the couple’s perception of parenthood. LeMasters found that most parents “romanticized” parent38
hood and were unprepared for the realities of a b a b ~ CouDles .~ were prepared to be husbands and wives but were rarely prepared to be parents. Answers to questions such as: What does being a parent mean to you? Did you believe the infant would change your life style? Do you anticipate your life changing over the next year? will give the nurse a clearer idea of how this couple views their new role. Assessment of the couple’s situational supports is the next step. Typical questions include: Do you have anyone to help you care for the baby? Do you have someone you can rely on when you have baby-care questions? Do you have a baby-sitter in mind for when you wish to go out as a couple? Whom would you most trust for help in the baby’s care? The greater the number of trusted people who can be brought into the situation, the more support the couple will receive. A third assessment area is the history of past coping mechanisms used by the couple. This history may include answers to such questions as: Have you ever had to adjust to someone living with the two of you for a time? How did you cope with this arrangement? What do you usually do when you feel depressed, anxious, tired, e t c . ? What relieves these symptoms? The couple may remember methods of coping that they haven’t used for years. They may also discuss methods that worked before, but that wouldn’t work in this situation. Because adaptive skills are so individual, the nurse must work with the couple to determine what will restore equilibrium for them. Once the couple identifies the birth of the child as having caused some disequilibirum, planned intervention can occur. A determination is first made on how much of a disruption the addition of the baby is causing. The nurse needs to know if the mother is able to care for the baby adequately, to what degree normal household activities are being altered, and how the disruption is affecting the husband and other family members. The couple, with the nurse’s help, then examines the alternatives open to them for restoring equilibrium and chooses
those that seem feasible or that have worked well for them in the Dast. For example, it may be proposed that the child’s care be shared by both the mother and the father, that rather than forego their social activities, the parents can leave the child with a baby-sitter occasionally, or that child-care services will be used if the mother wishes to resume working. These alternatives are explored in the light of why the child is causing a crisis and what will best restore equilibriu m . After the options are explored, intervention is initiated. “Action is taken with the expectation that if (planned action) is taken, the (expected result) will occur.”’ The nurse defines the problem of bringing a new infant into the house and reflects it back to the couple. This clarifies the problem and encourages the couple to focus directly on the problems causing disequilibrium in the family. Alternatives which were explored in the planning stage are tried and evaluated. For example, if the husband finds he is unable to help his wife with the care of the infant, a new approach may be to have a grandparent assist with the care for 1 to 2 weeks. The goals of the intervention phase are to help the couple gain an intellectual understanding of why they are in crisis, bring into the open feelings which may have been suppressed about the new role, explore new ways of coping with this new experience, and restore family equilibrium. If the couple realistically examines why the child caused disequilibrium, if they have adequate help from family, friends, and health workers, and if they are able to develop new ways of coping with parenthood, the crisis should be resolved 4 to 6 weeks after delivery. The nurse can evaluate at this time whether the couple has returned to their usual level or a higher level of equilibrium because of the crisis. It is hoped that the arrival of the child was a growth promoting event for all concerned. Anticipatory planning is done after resolution. The nurse reinforces the couple’s new coping mechanisms in their adjustment to parenthood. She reviews why the family was thrown into crisis and explores the January/February 1976 JOCN Nursing
ways in which subsequent children may cause disequilibrium. Again the family will feel the loss of sleep, readjustment to new responsibilities, and the shift from a three-person home to a four-person home. The nurse and the family can discuss ways of coping should more children enter the family. As LeMasters pointed out, the more prepared a couple is for parenthood, the smaller the crisis.’ Because of this nursing intervention and the experience of already having one child, the couple should not undergo severe disequilibrium with subsequent children. They will have grown because of this crisis. Anticipatory planning can also be done by the nurse. After working with the problems new parenthood brings, she can more fully realize the value of preparation. More preconceptual and prenatal classes taught by maternal-infant nurses could decrease the severity of parenthood as a crisis. After delivery, the accessibility of the nurse, plus her collaboration with other health agencies could increase the amount of help available to new parents. One example of this is to include the telephone numbers of the postpartum unit, the public health department, and the community mental health clinic in the discharge information given to the new parents. Keys the nurse can use to help families avoid parenthood as a crisis can be summarized as: 1 ) preparation, 2 ) accessibility, and 3) collaboration.
Summary Although the above crisis is hypothetical, it demonstrates the use of crisis intervention in one situation
likely to be encountered by the maternal-infant nurse. Crises in this speciality occur daily. If through appropriate intervention, nurses are able to help the families in their care grow and mature during troubled times, crisis intervention theory has its place in maternal-infant nursing.
References
v e n t i o n : S e l e c t e d Readings, edited by H. Parad, New York, Family Service Association of America, 1965, pp 312-323 9. LeMasters, E. E.: “Parenthood as Crisis.” In Crisis Intervention: Selected Readings, edited by H. Parad, New York, Family Service Association of America, 1965, pp 11 1-1 17
1 . Gibran, K.: T h e Prophet, New York, Alfred Knopf, 1923, p 28 2 . Rapoport, L.: “ T h e State of Crisis: Some Theoretical Considerations.” In Crisis Intervention: Selected Readings, edited by H. Parad, New York, Family Service Association of America, 1965, pp 22-31 3. Caplan, G . : A n Approach to Community Mental Health, New York, Grune and Stratton, 1961, p 18 4. Tudor, M.: “Family Habilitation: A Child With a Birth Defect.” In Family Health Care, edited by D. Hymovich and M . Barnard, New York, McGraw-Hill Book Company, 1973, pp 284-300 5. Caplan, G.: Principles of Preventive Psychiatry, New York, Basic Books, 1964 6 . Aguilera, D. and J. Messick:
Address reprint requests to Sally F. Baird, RN, c/o Felgenhauer, 10803 East 25th, Spokane, WA 99206.
Crisis Intervention: Theory and Methodology, St. Louis, C.V. Mosby Co., 1974
Sally F . Baird, AN, BSN, is working toward a master’s degree in maternal-child health at the University of Texas School of Nursing at San Antonio. In 1972 she received a baccalaureate degree in nursing f r o m t h e University of W a s h i n g t o n , Seattle, and was subsequently employed as a public health nurse in San Antonio. She is a member of the Texas Public Health Association and Sigma Theta Tau.
7. Schmidt, L.J. and D. Evans: “The Crisis Intervention Nurse in Community Mental Health.” In Family-Centered C o m m u n i t y Nursing, edited by A. Reinhardt and M. Quinn, St. Louis, C.V. Mosby CO., 1973, pp 291-298 8. Dyer, E.: “Parenthood as Crisis; A - Re-Study.” In Crisis Inter-
WORKSHOP ON FETAL MONITORING The School of Medicine of the University of California at San Francisco is sponsoring a workshop in Intrapartum Fetal Monitoring on April 2 and 3, 1976. Workshop Chairman is Julian T. Parer, MD, PhD, Assistant Professor of Obstetrics and Gynecology. Fees will be $35 for nurses, $120 for physicians, and a half-fee rate for non-University of California house staff and postdoctoral students (with letter of verification). Site: University of California at San Francisco. For information write to Extended Programs in Medical Education, Room 569 U, University of California, San Francisco, CA 94143, or call (415)666-4251.
January/February 1976 JOCN Nursing
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