Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. Living Through Sickness In Pregnancy A thesis presented in partial fulfilment of the requirements for the degree of Master of Arts in Nursing at Massey University Joyce Wenmoth 1997 ABSTRACT This thesis presents a study of the lived experiences of ten women who encountered symptoms of nausea, vomiting and I or retching during their pregnancies. These distressing and debilitating symptoms affect the quality of life of 50-75% of all pregnant women (Rhodes 1990). The thesis provides both a description and a beginning interpretation of the phenomenon of sickness in pregnancy. The four main lifeworld existentials of corporeality (the lived body), relationality (the lived other), spatiality (lived space) and temporality (lived time), as described by van Manen (1990), are used as a guide to reflect on the women's experiences. Disruptive symptoms such as nausea and vomiting seriously affect a woman's experience of the functioning of her body - in particular, it can no longer be taken for granted. The women coped by maintaining control over those aspects of the experience that they could. All women felt that they had been changed by the experience. New meanings had been incorporated in their 'being in the world' not just for the present but for the future. An inability on the part of health professionals to understand the significance of sickness in pregnancy and to comprehend the concerns of these women can result in ineffective care and support. The study offers recommendations for more effective professional care for these women. II ACKNOWLEDGEMENTS Although many people have encouraged and supported me in various way throughout the years I have been involved in this study, for which I am very grateful, I wish to express my thanks in particular to the following people whose input has been very significant: Dr Irena Madjar who introduced me to the variety of nursing research methodologies, in particular to phenomenology and the importance for nurses to understand the lived experience of illness and symptoms from the patient's perspective. The women who participated in this study which would not have been possible without their participation. They gave their time and openly shared with me their experience of nausea vomiting and retching associated with their pregnancies. I felt privileged to be afforded this glimpse into what was for most of them a very personal experience. Dr James Hefford for his assistance in contacting suitable participants and his interest in the project. Ee-Kheng Birks and Dr Beverley O'Brien for their encouraging research into nausea and vomiting associated with pregnancy and for the time these researchers gave to talk with me when I embarked upon this study. 111 My supervisors Dr Jo Walton, Dr Jan Rodgers and Professor Julie Boddy who have each at varying times guided this study. A special thanks to Professor Julie Boddy for her support is seeing this project to completion. My friends Erena De Grey and Alan Carson whose input and support throughout was invaluable. My husband Bryan for his encouragement, tolerance and helpful comments throughout this study, but above all for his belief in my ability to complete my MA. And lastly to our children, Elizabeth, Peter, John, Paul and Rosanne who have borne with me when I have had to get work done. Who have at times looked after one another, helped with household duties, and have been encouraging in their own way. TABLE OF CONTENTS ABSTRACT ACKNOWLEDGEMENTS PART ONE- BACKGROUND TO THE STUDY CHAPTER ONE: INTRODUCTION AND OVERVIEW Introduction Background to the study Significance of the study Purpose of the study Overview of the thesis CHAPTER TWO: LITERATURE REVIEW Introduction Symptoms of nausea vomiting and retching History of sickness in pregnancy Epidemiology of sickness in pregnancy Aetiology of sickness in pregnancy Physiological factors Psychological factors Genetic and cultural factors Management of sickness in pregnancy Pharmacological interventions Nonpharmacological interventions Developing an understanding of the lived experience Summary IV 11 iii 1 2 2 3 5 6 7 9 9 9 13 15 17 17 19 20 20 21 22 26 28 CHAPTER THREE: TIIBNATUREOFPHENOMENOLOGY Introduction Research paradigms utilised in nursing research Historical perspective on phenomenological enquiry Phenomenology and nursing Researching lived experience using hermeneutic phenomenology Assumptions of phenomenological research Methodology for hermeneutic phenomenological research The lifeworld as the world of lived experience Summary CHAPTER FOUR: STUDY DESIGN AND METHODS Introduction Orienting to the phenomenon Formulating the phenomenological question Explicating assumptions and pre-understandings Study design Identifying participants for the study Description of the study participants Ethical considerations for the study Data collection Data analysis Presenting the study findings Methodological issues pertaining to the study Key to presentation of findings Summary v 29 29 29 32 35 37 39 40 41 42 44 44 44 44 45 46 47 48 49 51 53 55 57 58 59 vi PART TWO- THE STUDY ACCOUNT 60 CHAPTER FIVE: CORPOREALITY - 1HE LIVED BODY 61 Introduction 61 Becoming aware of being pregnant 62 Expecting 'morning' sickness 63 A heightened awareness of the body 64 Experiencing nausea and vomiting in pregnancy 65 Becoming focused on aspects of the body 68 A loss of control 72 Feeling tired 7 4 Balancing sickness with the body's requirement for food 79 Changing moods 81 The individuality of the experience 85 Summary 88 CHAPTER SIX: RELA TIONALITY - RELATING TO OTHERS 89 Introduction 89 Reserved sharing of the experience 89 Needing support in pregnancy 91 Relating to the developing baby 91 Relating to family members 96 Interacting with others when working 100 Sharing with others 103 Limiting social contact 105 Relating to health professionals 107 Summary 111 CHAPTER SEVEN: TEMPORALITY AND SPATIALITY Introduction Temporality How temporality is affected by previous experience The women's outlook on life Spatiality The security of private space The unease of public space Summary CHAPTER EIGHT: BEING IN THE WORLD - COPING Introduction Coming to terms with the experience The normality of sickness in pregnancy Developing coping strategies Managing the experience The importance of rest Identifying and avoiding triggers The use of food in coping Changing daily routines in order to manage the effects Coping at work The importance of support and reassurance Psychological strategies in coping Summary CHAPTER NINE: DISCUSSION AND CONCLUSION Introduction Living through sickness in pregnancy vii 112 112 113 115 117 119 120 122 124 126 126 127 128 130 132 133 135 136 138 140 141 143 145 147 147 147 The women's relationship with health professionals Limitations of the study Areas for further research Implications for practice Conclusion REFERENCES APPENDICES Appendix 1 Information sheet for participants Appendix 2 Consent form. viii 151 153 155 157 158 160 177 177 179 1 Part One Background To The Study 2 Chapter One INTRODUCTION AND OVERVIEW Introduction This thesis presents a study of the lived experiences of ten women who encountered symptoms of nausea, vomiting and/or retching during their pregnancies. It provides both a description and a beginning interpretation of the phenomenon of sickness in pregnancy. Although not regarded as life threatening, except in extreme forms, sickness in pregnancy remains a cause of much discomfort and concern both to the women experiencing the symptoms of this phenomenon and to their families. The phenomenon of sickness in pregnancy is commonly referred to as 'morning sickness', however as detailed in chapter two, pregnant women experience symptoms of nausea, vomiting and retching over a wider time frame than that suggested by its common nomenclature. In this study, therefore, the term sickness in pregnancy is used to describe the overall phenomenon. As a nurse I have come to realise that we (health professionals) can never fully understand how another individual is affected by their experience of symptoms and, from the recipient's perspective, the care we provide is often ineffectual. The examination of the lifeworld of the women who participated in this study provides rich descriptive data to broaden nurses' and other health professionals' knowledge of this lived experience and thereby provides guidance for the provision of more effective care. 3 Background to the study Through my studies I have been introduced to the phenomenological work of Benner and Wrubel (1989), who stress the importance of nurses developing an understanding of lived experiences in order that they can care more effectively; and also the work of van Manen (1990), in turning to the nature of lived experience and researching experience as it is lived. The work of these authors have helped shape this study. Phenomenology provides a scientific method of exploration which is compatible with the humanistic concept that has been incorporated into the practice of nursing and midwifery. It enables the researcher to "uncover meanings in everyday practice in such a way that they are not destroyed, distorted, decontextualised, trivialised or sentimentalised" (Benner 1989, p. 6). As well as being a research method Kestenbaum (1982) indicates that phenomenology is a style of thought that; [A]dvances not only our knowledge of human nature but also our understanding of the awareness that a health professional needs if his or her practice is to convey more than simply an adequate technical comprehension of bodies and persons. To grasp the meaning of illness for humanity, the patient, and the humanity of the patient is more than simply to "identify" with the patient or to feel compassion. It is to appropriate at least one of the conditions necessary for professional judgement inspired by human wisdom (p. viii). Human wisdom is more than problem solving and rational calculations, it includes what it is to be human, and what is significant to anyone at any particular time. Lived experience is according to van Manen (1990) the beginning point and end point of phenomenological research. He sees that the aim of phenomenology is [T]o transform lived experience into a textual expression of its essence - in such a way that the effect of the text is at once a reflexive re-living and a reflective appropriation of something meaningful: a notion by which a reader is powerfully animated in his or her own lived experience (p. 36). 4 When studying the lived experience of others no researcher can ignore their own experience of the phenomenon under study. Van Manen (1990, p. 57) states "To be aware of the structure of one's own experience of a phenomenon may provide the researcher with clues for orienting oneself to the phenomenon and thus to all the other stages of phenomenological research". The research study presented in this thesis follows van Manen's approach and recognises that the researcher's own experiences of the phenomenon under study "are the possible experiences of others and that the experiences of others are the possible experiences of oneself." ~an Manen , 1990, p. 58). I experienced symptoms of nausea and vomiting during each of my own four pregnancies (my children range in age from four to thirteen years ' ). Each of these pregnancies differed in the amount and length of time the sickness was experienced, as well the significance it had in relation to my life at the time. Although I had come into contact with women experiencing sickness in pregnancy during my nursing, it was not until my own experience of this phenomenon that I understood what it was like. My own experiences have given me valuable insights into the experiential accounts provided by the participants of this research study and have helped in the identification of the common themes and structures of the participants' experiences. As an earlier part of my post graduate studies I undertook a preliminary fieldwork study on nausea and vomiting associated with pregnancy which involved single interviews with six pregnant women. This increased my knowledge relating to the impact of this phenomenon for other women. Although each woman's experience was uniquely her own there were many commonalities in their stories which demonstrated the distressing nature of the phenomenon for these women and their families. This present study sought to 5 confirm and to build on those preliminary findings exploring in more detail what it means to experience sickness in pregnancy. The respondents in this research do not include any of the women who were interviewed in the preliminary fieldwork exercise. Significance of the study Rhodes ( 1990) indicates that nausea, vomiting and retching are distressing and debilitating symptoms which affect the quality of life of 50-7 5% of all pregnant women. Diiorio and van Lier (1989) note that while it is well accepted that the symptoms of nausea and vomiting are commonly experienced by women in the first trimester of pregnancy, few studies have actually explored this phenomenon. The lack of nursing and midwifery research in this area is also raised by Cotanch (1989), Jenkins and Shelton (1989), Rhodes (1990) and Birks (1993). It is through the body an individual assesses and experiences the world. One is normally not aware of one's body, however, in the presence of disruptive symptoms like nausea, vomiting and retching an individual becomes acutely aware of the functioning of the body. Madjar (1991, p.114) in a phenomenological study examining pain as an embodied experience discusses the change from a situation where one's body is taken for granted to "becoming aware of a body which is the source of unpleasant and worrying sensations, which does not behave in predictable ways". She stresses that the communication of such experiences can deepen our understanding of human life and our ability to cope with various situations, and advocates that phenomenological research has a major contribution to make to nursing with "descriptions, exemplars and paradigm cases that depict the reality of human 6 experience and nursing practice in a way that statistical manipulation of values assigned to operationally defined variables cannot do" (p. 66). The need for nurses to develop an understanding of lived experiences in order that they can care more effectively is also stressed by Benner and Wrubel (1989) who state: Because personal concerns determine what is at stake for the person in any situation, the challenge for the health care provider is to interpret those concerns that influence the person's understanding of his or her own illness (p.88). Toombs (1987), in examining her own relationship as a patient with her physician, reported that rather than there being a 'shared reality' of illness there were in fact two distinct realities. Her perspective on experiencing being ill was significantly and qualitatively different in meaning to that of her physician. This is equally relevant to nurse-patient relationships. Benner and Wrubel (1989) discuss the difference nurses can make by being able to presence themselves in order to help others. "This ability to presence oneself, to be with a patient in a way that acknowledges your shared humanity, is the base of much of nursing"(p. 13). Presencing acknowledges a person's experience and involves making oneself available and accessible to another person in a way that they feel understood and supported. This requires an open mind and the use of one's knowledge surrounding various lived experiences. Purpose of the study The overall purpose of this study was To examine the lived experience ·of sickness m pregnancy and, its significance in the lives of women who are affected. 7 Overview of the thesis This thesis is presented in two parts. Part One (Chapters One to Four) introduces and presents material pertaining to the background of the study, the research methodology and the procedure used in this study. Part Two (Chapters Five to Nine) presents the findings of the research study and discusses the implications of the study for health care professionals. Chapter One has provided an introduction to the study topic and the background to this study. The lack of research into the lived experience of sickness in pregnancy is acknowledged. The significance for nurses and other health care professionals of developing an understanding of lived experiences has been outlined. Chapter Two presents an overview of the literature pertaining to the symptoms of nausea, vomiting and retching associated with pregnancy. There is little New Zealand literature on this topic, and the published research from overseas is not prolific. The lack of a conclusive aetiology for sickness in pregnancy and the predominance of quantitative studies focused on symptomatology is demonstrated. The limited literature focusing on the lived experience of sickness in pregnancy is identified. In Chapter Three the selection of a phenomenological method for this study is justified. Emphasis is given to hermeneutical phenomenology and the work of van Manen (1990) in researching lived experience as this is the approach that has been utilised in this research study. 8 The study design and methodology are outlined in Chapter Four. Ethical considerations of this study are discussed including the measures taken to protect the anonymity of the research participants. Chapters Five, Six and Seven use the existential lifeworld themes of corporeality (lived body), relationality (lived other), temporality (lived time) and spatiality (lived space) to describe and reflect on the study participants' experiences of living through sickness in pregnancy. Chapter Five examines how the body is affected by the presence of the disruptive symptoms of nausea, vomiting, retching and fatigue. The impact of the women's lived experiences on their relationships with others is examined in Chapter Six. In Chapter Seven the impact of the phenomenon of sickness in pregnancy on the women's lived time and lived space is examined. Chapter Eight integrates the study findings in a discussion of how the study participants have coped with the phenomenon. It tells of their 'being in the world'. Chapter Nine discusses the study's limitations and presents a summary of the thesis findings. The implications -~J this study for health care professionals are addressed. 9 Chapter Two LITERATURE REVIEW Introduction This chapter will provide a review of the literature relating to the phenomenon of sickness in pregnancy. While little has been published in New Zealand there is an increasing number of studies on this topic being carried out internationally; however, the literature to date has focused predominantly on the symptoms of nausea and vomiting. Key nursing and medical literature will be reviewed to discuss these symptoms, including the terminology currently used, a brief outline of the history surrounding sickness in pregnancy, and a consideration of the epidemiology, aetiology and management of this phenomenon. The limited literature relating to the lived experience of sickness in pregnancy is reviewed and its relevance for effective care is outlined. Symptoms of nausea, vomiting and retching Symptoms of nausea, vomiting and retching associated with pregnancy have been considered as either a discomfort, or a disease depending on whether or not specific interventions are required. The first category, discomfort, includes mild to moderate symptoms and is referred to as 'morning sickness' or more recently has been termed 'pregnancy sickness'. The second category, disease, includes more severe symptoms that mandate medical intervention and is referred to as 'hyperemesis gravidarium'. The need for hospitalisation is also a criterion frequently used for diagnosing hyperemesis gravidarium (O'Brien 1990, Gadsby 1994). Symptoms that are not serious enough to meet the diagnostic 10 criteria for hyperemesis gravidarium can still severely disrupt a pregnant woman's life (Dilorio 1988). An examination of hyperemesis gravidarium is beyond the scope of this study. This study is concerned with women's experiences of the ordinary symptoms of nausea, vomiting and retching that have classically been known as 'morning sickness'. Throughout nursing and medical literature the terms nausea, vomiting and retching, although they are separate concepts, are often used interchangeably (Rhodes 1990, Jablonski 1993). Rhodes (1990, p. 887) indicates that "this practice leads to confusion and inadequate understanding for practice, research and education." Clarity of the meaning of symptoms is stated to be essential for accurate assessment so nurses can plan patient care (Rhodes 1990, Hogan 1990). Nausea is defined as the subjective unpleasant feeling of the need to vomit without actually making any expulsive effort to do so (Jablonski 1993). It is recognised as being largely an unobservable symptom which consists of an unpleasant sensation experienced in the back of the throat and in the abdomen that may, or may not, culminate in the autonomic nervous system response of vomiting. Nausea is often described as feeling 'sick', having 'the birdies', 'the collywobbles', 'the weewaws', 'the heaves', and 'feeling squeamish' (Norris 1982, Rhodes 1990). Signs of nausea include vasomotor changes with feelings of hot or cold, increased perspiration, and pallor. The pulse usually increases then decreases. Increased salivation is frequently present accompanied by increased swallowing. Nausea associated with pregnancy often persists for hours. 11 Nausea usually precedes vomiting and if one vomits the nausea may pass. However, when associated with pregnancy the nausea frequently persists after vomiting (Norris 1982). While nausea may not be a very visible symptom it can be very disconcerting and may be life threatening if ignored. Jablonski (1993, p. 65) stresses it "is a symptom of and by itself". Retrospective studies including those by Brands (1967), Fairweather (1968), Jarnfelt-Samsioe, Samsioe and Velinder (1983) and Klebanoff, Koslowe, Kaslow and Rhodes (1985) confirm 50 - 80% of all pregnant woman suffer from nausea or vomiting during pregnancy. A more recent prospective study involving 363 pregnant women carried out by Gadsby, Barnie-Adshead and Jagger ( 1993) found 80% were affected by nausea. Their study indicated that 28% of women experienced nausea alone and 52% experienced nausea and vomiting. No one in their study experienced vomiting on its own. Vomiting can be defined as "the forceful expulsion of the contents of the stomach, duodenum, or jejeunum through the oral cavity" (Rhodes 1990, p. 888). The act of vomiting is reflexive and involves the coordinated activity of both voluntary and involuntary muscles. The intrinsic neurophysiological mechanisms of vomiting are well documented (Le Witt 1986, Rhodes 1990, and Jablonski 1993). Rhodes ( 1990) warns that the pathogenesis of nausea, vomiting and retching associated with pregnancy may differ from the current understanding of the physiological mechanisms of these symptoms which has arisen from research into the drug induced nausea and vomiting associated with chemotherapy. Language used to describe vomiting includes to 'puke', 'upchuck', 'spew' or phrases such as 'throwing up' or 'feeding the fishes' (Norris 1982, Rhodes 1990). 12 Retching is defined as a failed attempt to vomit - the body undergoes the same physiological actions as vomiting but without expelling any gastric contents. It may be referred to as having the 'dry heaves', to 'gag' or to 'keck' (Rhodes 1990). Retching is often felt to be the worst of these three symptoms as many people report relief once their stomach contents are emptied after they vomit. Various studies indicate that the experience of sickness in pregnancy is not limited to the morning as one would suppose from the commonly used terminology of 'morning sickness' (Jarnfelt-Samsioe et al 1983, Vellacott et al 1988, Jenkins & Shelton 1989, and Dilorio & van Lier 1989). Jarnfelt-Samsioe et al (1983) found that 50% of women experience peak symptoms of nausea in the morning and 36% felt sick throughout the day. Other studies have given similar results (Vellacott et al 1988, Jenkins & Shelton 1989). Dilorio and van Lier (1989) reported that the peak period (period of greatest intensity of nausea and vomiting) was identified by some women in the morning, others in the afternoon or evening and in some cases symptoms persisted throughout the day. Birks (1993) reported that 7% of the 248 New Zealand women sufferers in her survey had vomiting only in the morning, 10% vomited only in the afternoon but 78% vomited throughout the day. Gadsby et al (1993) suggest a more appropriate description would be "episodic day-time pregnancy sickness" (p. 248). In some of the more recent literature the term 'pregnancy sickness' is being used rather than 'morning sickness' (Billett 1992, Anderson 1994, and Gadsby 1994). Many studies carried out in America such as those by Dilorio and van Lier (1989), Jenkins and Shelton (1989) and O'Brien (1992) use the term nausea and vomiting of pregnancy, which is abbreviated to NVP. Deuchar (1995, p. 6) indicates that the American nomenclature of NVP "is bland but holds several advantages: it is unbiased 13 towards any putative cause, it allows for a spectrum of severity, and it differentiates between the subjective symptom of nausea and the objective sign of vomiting". As previously stated, this study uses the terminology sickness in pregnancy when discussing this phenomenon. History of sickness in pregnancy Symptoms of nausea and vomiting have been associated with early pregnancy throughout the history of the civilised world. In Egypt a description of these symptoms was recorded on a papyrus dated 2000 B.C. and in the fourth century B.C. Hippocrates referred to nausea and vomiting induced by pregnancy as 'maux de coeur' or illness of the heart (Fairweather 1968). Aristotle (384-322 B.C.) noted that most pregnant woman experienced a syndrome that included nausea, headaches, feelings of 'heaviness' in all parts of the body, sensations of darkness before the eyes, superfluous swellings, rapid mood changes and longings. He recorded that the symptoms were present as early as the tenth day and he associated the symptoms with the suppression of menses due to pregnancy. Aristotle observed that many experienced relief when menstruation did not occur and blood was channelled towards the breasts where it became milk (O'Brien 1990). Soranus of Ephesus (98-138 A.D.), a Greek physician specialising in women's and children's illness, included nausea and vomiting of pregnancy in his definition of a condition called 'pica' which occurred in most pregnant women. This began around the fortieth day and lasted four months but could last the entire pregnancy. He viewed this as normal but not healthful, noting that "many inconveniences beset the pregnant woman who is heavily burdened and suffers 14 from pica" (Temkin 1956, p. 41). Temkin also details Soranus's description of women experiencing pica as follows; [T]hose with this condition are affected with the following: a stomach which is upset, indeed full of fluid, nausea and want of appetite sometimes for all, sometimes for certain foods; appetite for things not customary like earth, charcoal, tendrils of the vine, unripe and acid fruit; excessive flow of saliva, malaise, acid erucation, slowness of digestion, and a rapid decomposition of food . Some women are affected with vomiting at intervals or at each meal, with a feeling of heaviness, dizziness, headache, discomfort together with an abundance of raw pallor, the appearance of undernourishment, constipation; some also have gastric distension, or pain in the thorax" (p. 41). Soranus' definition is still considered accurate and much of his suggested management (which included a day's fast in order to rest the stomach) is still regarded as appropriate (O'Brien 1990). Comprehensive reviews of the history of nausea and vomiting associated with pregnancy and the debates that have occurred in relation to this throughout history are detailed by Fairweather (1968) and O'Brien and Newton (1991). During the early part of the 20th century researchers focused on seeking a cause and a cure for those most severely affected, those with hyperemesis gravidarium. Vellacott et al (1988) indicate that this is probably because these women are more easily identifiable and are also the group most accessible to hospital researchers. They warn that "extrapolation of the results from these patients to those with ordinary 'morning sickness' [is] highly questionable" (p. 58). Only in the last ten years has the more typical form of sickness in pregnancy become an area of interest. Dilorio and van Lier (1989) suggest that the historical lack of interest may be traced to the fact that women and health care professionals have "viewed these symptoms as mild and so short lived as not to be of any great importance for 15 study" (p.259). Cotanch (1989) indicates that until recently the sensation of nausea was frequently dismissed because it is self limiting in that it passes with time; is never life-threatening in itself; is considered psychogenic to some degree; and, being subjective, is very difficult to measure. This attitude has now been eroded by a changing society and women's changing expectations in relation to health care (Diiorio & van Lier, 1989). More pregnant women now work outside the home and demands for work and home duties leave little time for illness. These women seek some means to reduce their distress and discomfort and to cope with the changes in their lives at this time. Jarnfelt-Samsioe et al (1983) calculated that 12% of women suffering nausea and vomiting found ordinary work during pregnancy impossible. In the study by Vellacott et al (1988) 243 out of 500 women were employed. Of these 75% complained of symptoms and 47% felt their job efficiency was reduced with one in four requiring time off work. Gadsby et al (1993) found a strong positive association between the time lost to both paid employment and housework and the severity of pregnancy sickness symptoms in that the more severe the symptoms, the greater the time lost. Epidemiology of sickness in pregnancy Although it is commonly accepted that a large proportion of pregnant women experience sickness in pregnancy (70-80%) no one has identified why certain women experience it or why some multiparious women experience it in some pregnancies and not in others. One of the largest studies looking at the epidemiology was reported by Klebanoff et al (1985). This was a prospective study carried out between 1959 and 1966 by the National Institute of Health (USA). A sample of 9098 healthy 16 pregnant women with no predisposing factors was investigated. Vomiting was found to be more common among primigravidas, teenagers, women of less than 12 years education, non-smokers and women weighing 77.1 kg or more. Several factors that had previously been considered important such as a twin pregnancy, being 'black', smoking, known intolerance to oral contraceptives, degree of weight gain and unplanned or planned pregnancy were found to be of no significance. Gadsby et al (1993) could not determine why some women experience nausea and vomiting while others did not. In their study, for 72% of the women symptoms started between 29-49 days from the last menstrual period and for 80% of the women all symptoms ceased by the 99th day. Their results showed that a third of women will have different symptoms in successive pregnancies. A surprising finding in their study was a sudden cessation of symptoms in 39% of women. This cessation of symptoms occurred at approximately the same day from the last menstrual period whether symptoms began early or late or if the symptoms were severe or mild (Day 84 was the mean). O'Brien and Zhou (1995), in a study of 126 women, noted that "independent variables contributed little to predicting or explaining the presence and severity of nausea and vomiting during pregnancy" (p. 99). Their study supported some of the associations found in other studies including that older women experience less severe symptoms than younger women, primagravidas experience more vomiting than multiparious women, and smokers experience less nausea than non-smokers. 17 Aetiology of sickness in pregnancy The aetiology remains unclear despite many theories being proposed over the last several hundred years. One early theory suggested that vomiting resulted from pressure of engorged blood vessels on the diaphragm. Other early suggestions included displacement, distension or inflammation of the uterus, cervical erosions, constipation and neurosis (Fairweather 1968). Further studies need to be conducted to provide a clearer picture of the aetiology. At present there are several competing hypotheses which can be separated into those implicating 1. physiological, 2. psychological, and 3. genetic and cultural factors. 1. Physiological factors a) Vitamin B deficiency: A study by Schuster, Baily, Dimperio and Mahan ( 1985) did not support the theory of vitamin B deficiency in women who experience nausea and vomiting in pregnancy, however during the 1940 s several uncontrolled studies suggested efficacy from the use of vitamin B and vitamin B6 (Willis, Winn, Morris, Newsom and Massey 1942, Weinstein, Mitchell and Sustendal 1943, and Dorsey 1949). These studies were challenged when the American Medical Association (1979) stated that there was no solid evidence that Vitamin B6 was effective. A randomised, double-blind placebo- controlled study by Sahakian, Rouse, Sipes, Rose and Niebyl (1991) found that the use of oral vitamin B6 at a dosage of 25 mg every eight hours had an effect on reducing nausea for some women but did significantly reduce' vomiting for \ all women. b) Gastric function: Diiorio ( 1988) indicates that pregnancy significantly affects the functioning of the stomach and intestinal tract resulting in gastric 18 hypofunction. Experimental research by Riezzo, Pezzolla, Darconza and Giorgio (1992) in this area has shown various alterations in gastric motility in pregnant women, such as the reduction of lower oesophageal sphincter pressure, with an increased prevalence of gastroesophageal reflux and delayed gastrointestinal transit. Their study indicated that "there is a persistent chronic alteration in gastric electrical activity correlated to early pregnancy" (p. 706), but little difference between those who experience nausea and vomiting and those that do not. These researchers advocate further studies in this area. c) Biochemical: Yoda and Randall (1982) suggested that nausea and vomiting in pregnancy may be associated with changes in the biochemical milieu of the body. According to their model during the first trimester of pregnancy total body water increases, expanding plasma volume, lowering sodium concentrations and decreasing serum osmolality from a normal level of 290m0sm/kg to 280m0sm/kg. Since it takes several weeks for the osmoreceptors to reset to the lower value women may experience symptoms associated with hyponatremia which include nausea, vomiting and fatigue. d) Endocrine: The most popular theories proposed are those that involve an endocrine aetiology. Nausea and vomiting were commonly thought to occur in the first trimester of pregnancy due to elevated progesterone levels and elevated levels of human chorionic gonadotrophin (hCG). hCG rises rapidly in the first trimester and peaks at 12 weeks. However controlled studies testing this relationship have also yielded conflicting findings. Soules, Hughes, Garcia, Livengood, Prystowsky and Alexander ( 1980) could not find any evidence of a relationship between the levels of these hormones and the incidence or severity of nausea and I or vomiting in women. A study by Mori, Amino, Tamaki, Miyai and Tanizawa (1988) indicated that there is a relationship and in addition they 19 found a high correlation between hCG and free thyroxine in early pregnancy. It has been hypothesized that elevations in hCG may promote nausea and vomiting by stimulating secretion of thyroid hormone, however de Swiet (1989) regards this to be unproven and controversial. e) Allergenic: Fairweather (1968) noted that Hoffbauer in 1926 contended that some women had nausea and vomiting due to 'histamine poisoning' but this has not been substantiated. Jarnfelt-Samsioe et al (1983) found that women with gastritis, gall bladder and allergy problems tend to have more frequent and intense nausea and vomiting in pregnancy. The only proven physiological factors that have been identified are associated with hCG levels and those that affect the gastrointestinal tract. Medical research continues to be carried out in these areas. 2. Psychological factors Dilorio (1985) indicates that hypotheses relating to psychological factors include Higgin's assertion in 1887 that nausea and vomiting was a response to the pregnant woman's aversion to sexual intercourse, and Deutsch arguing in 1945 that vomiting and craving for food during pregnancy are expressions of conflicting wishes - vomiting is an unconscious wish to expel the child whereas craving food is an unconscious wish to keep and nourish the baby. An experimental study carried out by Uddenberg, Nilsson and Almbren (1971) found that women without nausea and vomiting were generally more prone to psychological difficulties during pregnancy and had more difficulties with adjustment in the postpartum period. Wolkind and Zajicek (1978) carried out a follow up study but this did not support Uddenberg et al's findings. However they did find that the women who experienced nausea and vomiting reported 20 feeling closer to their own mothers and closer to their husbands after the pregnancy began. Psychological factors such as unwanted pregnancy, unresolved conflict, and identification with the female role have also been implicated as possible causes for the symptoms of nausea and vomiting (Dilorio 1985), however research is inconclusive. 3. Genetic and cultural factors Studies by Walker, Walker, Jones, Verardi and Walker (1985) and Diiorio (1985) indicate that the incidence of nausea and vomiting is lower in groups of 'black' people compared to their 'white' counterparts. Such studies suggest that there may be a genetic aetiology. Mini tum and Weiher ( 1984) in a cross cultural study involving thirty-one societies found that those societies whose women did not experience nausea and vomiting in pregnancy included more green vegetables, higher levels of fat intake and a substantial amount of maize in their diets. Such results may indicate dietary considerations for nausea and vomiting of pregnancy rather than a cultural aetiology. Although several studies have been carried out over the last two decades to determine the aetiological factors it is consistently reported that many of the results have been inconclusive and the underlying mechanisms are not understood (de Swiet 1989, Rhodes 1990, Anderson 1994). Currently no specific aetiology is confirmed. Management of sickness in pregnancy To date, despite the increase in the number of studies being undertaken, there are still insufficient conclusions to lead to any commonly accepted simple, and 21 effective treatments. Management has revolved around pharmacological or non­ pharmacological measures to relieve symptoms. Pharmacological interventions Early studies investigating the relief of the symptoms of nausea and vomiting in pregnancy indicated a fairly high use of medication which was prescribed without research on the effectiveness as well as the side effects of the medications (Dilorio 1988). Diggory and Tomkinson (1962) reported 83% of subjects used medication to relieve the symptoms. The main medications which have been used are thalidomide, bendectin, and pyrodoxine. In 1962 thalidomide, a widely prescribed sedative and anti-nausea medication, was implicated in the birth of infants without limbs and was subsequently withdrawn from the market. Subsequent studies by Biggs (1975) reported 50% utilising medication, and the study by Vellacott et al (1988) showed only 10% using medication. Dilorio and van Lier (1989) reported only one person from their research sample utilising medication to control nausea. The decreasing percentages reporting the use of pharmacological means since 1962 may be largely due to the increasing awareness of the potentially harmful side effects of medication on the foetus. Le Witt (1986) indicated that until the early 1980:; 10% to 25% of pregnant women in the United States were prescribed bendectin, a combination of the antihistamine doxylamine succinate and pyridoxine, for the relief of nausea and vomiting. It was formulated as a delayed release tablet so that when taken at bedtime the active ingredients would be utilised early in the morning before the onset of morning sickness. Although the occurrence of birth defects after the use of bendectin was rare, it led to a number of litigations in 1983 causing it to 22 be withdrawn from the market by the manufacturers. There is some debate that the birth defects leading to these lawsuits were in fact coincidental and not directly related to Bendectin (LeWitt 1986, de Swiet 1989, Newman, Fullerton & Anderson 1993). Pyridoxine has been indicated in the treatment in nausea and vomiting of pregnancy. The antihistamine component of pyridoxine has been shown to have a direct effect on the emetic centre (Diiorio 1988). Although historically controversial, the recent study by Sahakian et al (1991) indicates that pyridoxine (Vitamin B6) is beneficial for those women who experience severe nausea and for all women who experience vomiting. De Swiet (1989) stresses that the majority of cases can be managed without recourse to drug therapy because of the concern over the safety of anti-emetics. Birks (1993) notes that some women have tried various homeopathic medications, such as Cocculus 30, Kreosote 30 and Verat Alb 30 with varying success. No formal research studies on these preparations were identified. Non-pharmacological interventions Professional and lay literature suggests many non-pharmacological remedies for 'morning sickness'. Traditionally these have been limited to psychological support and dietary modification. Suggestions in relation to diet include: fasting, avoidance of specific foods, a bland diet, eating low-fat protein foods and easily digested carbohydrates, eating crackers and toast, and having small frequent weals. A common intervention suggested to women has been to have a cup of tea and a piece of toast prior to rising in the morning. The drinking of herbal teas such as spearmint, raspberry leaf, peppermint, chamomile and ginger root have also been advocated (Newman et al 1993). Only limited research has been 23 done to assess the effectiveness of such interventions (Yoda & Randall 1982, Diiorio 1985, and Birks 1993). The effectiveness of self-care actions in reducing 'morning sickness' was the subject of a retrospective survey of 55 pregnant women undertaken by Jenkins and Shelton (1989). In this study self- care actions fell into three broad categories: manipulating diet, adjusting behaviour and seeking emotional support. The most effective self care actions are listed in ranked order in table 1. Table 1 Effective Self-Care Actions to Reduce Morning Sickness (Jenkins & Shelton 1989, p. 270) RANK SELF-CARE ACTIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23 24. 25. 26. 27. 28. 29. Getting more rest Several small meals rather than three big ones A voiding bad smells A voiding greasy or fried foods A voiding cooking Receiving extra attention from partner A voiding spicy foods Eating whenever I felt nauseous Keeping myself busy Sharing experiences with another mother Eating bland foods Eating dry toast or crackers before getting out of bed Cutting down on drinks with caffeine Getting more exercise Cutting down on alcoholic drinks Eating a midnight snack Taking a prescribed medication Having someone tell me that the morning sickness was normal and would go away soon Eating hard candy A voiding certain other foods Drinking herbal tea Taking vitamins at bedtime Cutting down on smoking A voiding riding in the car Taking extra B vitamins Eating more acid foods A voiding vitamins with iron Avoiding liquids with meals Taking 'over the counter' medication 24 Over 50 % of the women in the Jenkins and Shelton study reported trial and error as the way they found successful remedies to relieve their symptoms. They reported that other sources of advice for dealing with these symptoms included the woman's mother or an experienced friend (13.5%); doctor (10%); nurse practitioner (8%); nurse (5.5%); and midwife (3%). Although this study was carried out in USA, it is significant that nurses and midwives are so poorly represented, and leads one to question their educative role in relation to a woman's symptom experience. Newman et al (1993) reported that "emotional support and patient education often are the only nursing interventions necessary for the nausea and vomiting of early pregnancy" (p. 484). The studies by Diiorio and van Lier (1989) and Jenkins and Shelton (1989), indicated that nurses and midwives can assist women to adopt self-care behaviours that enable them to cope more effectively with the distressing symptoms of nausea, vomiting and retching associated with pregnancy. In her book 'Coping with Morning Sickness' Birks (1993) presents many suggestions based on a combination of anecdotal evidence and research which may help women to manage their symptoms. She stresses the need for emotional as well as physical support. A newer therapeutic approach being investigated is the use of sensory afferent stimulation (SAS). Evans, Samuels, Marshall and Bertolucci (1993), following on from the use of SAS for the treatment of nausea and vomiting associated with cancer chemotherapy, investigated the use of SAS for the suppression of pregnancy related nausea and vomiting. In a randomised, cross-over study comparing an active SAS device with an inactive placebo device, the results 25 indicated an 87% improvement in symptoms with the SAS device and a 43% improvement with the placebo device. More recently alternative health approaches such as acupuncture and acupressure have been suggested as being beneficial (Newman et al 1993). Stainton and Neff (1994) identified an acupressure wristband known as 'SeaBands' 1 to be effective for 50% of the women in their study for the control of nausea and vomiting in pregnancy. 'SeaBands' were found to be more effective if applied early in the symptom experience but less effective if applied late. The authors commented that the 'SeaBands' have a high potential for "enabling and restoring a sense of control and alliance with the body during pregnancy" (p. 574). The effectiveness of digital accupressure was evaluated by Belluomini, Litt, Lee and Katz (1994) in a study involving 60 women. Women were assigned using a randomised block design to one of two accupressure groups: a control group using an accupressure point (PC-6) 2 and a sham control group using a placebo point. The results indicated that accupressure at PC-6 is effective in reducing symptoms of nausea but not the frequency of vomiting. "Accupressure is convenient to use, does not cause discomfort, avoids the cost of wristbands and can be easily taught to patients" (Belluomini et al 1994, p. 247). Such interventions are looked forward to by both sufferers and health care professionals alike. Finding reliable ways to provide relief from nausea and vomiting in pregnancy will remain a challenge for health professionals into the future. The literature indicates that therapies controlled, at least partly by the 1 2 SeaBands are elasticised circular bands with a plastic button incorporated in them which are worn around the wrists. When worn on the wrists the plastic button exerts even pressure on the Neiguan (P6) pressure point on the anterior surface of the forearm proximal to the wrist crease. SeaBands were originally developed to control nausea and vomiting associated with seasickness. PC-6 is the accupressure point specifically designated in traditional Chinese medicine for the treatment of nausea and vomiting. 26 women are the most effective for managing the nausea and vomiting associated with pregnancy. Developing an understanding of the lived experience Although several research studies have considered various aspects of sickness in pregnancy only a few have looked at what the symptoms mean to those women experiencing them. One such study (Diiorio & van Lier 1989) acknowledged the distressing nature of nausea and its multidimensional impact on the woments life styles. It was noteworthy that most women in their first pregnancy indicated that the experience of nausea was worse than they had anticipated but those who had been pregnant before were divided in opinion. A range of lifestyle changes for many women were necessary due to their nausea and I or vomiting. These included "changing eating habits, reducing physical and outside activities, sleeping more, avoiding food or shopping, changing work schedules, and being less productive" (Diiorio & van Lier 1989, p. 265). The need for nurses to develop an understanding of lived experience in order that they will care more effectively is stressed by Gadow (1985) and Benner and Wrubel (1989). Gadow (1985), in examining the caring relationship between a nurse and a patient, notes how patients are often removed from the centre of their experience. In health care the body is often viewed as a machine which Gadow indicates occurs because [R]egard for the body exclusively as a scientific object negates the validity of subjective meanings of the person's experience. Those meanings are categorically nonexistent in the scientific object. Thus clinical decisions are based upon external interpretations, not upon the meanings and coherence of the body as constituted by the patient. (p. 36) Zanter (1985), in examining what it is to be a patient and what it is to be ill, stresses the need to "reconsider this business of being ill from the patient's actual 27 perspective, not from that of the health care provider's .. .// ... To attain this perspective, there is nothing to do but consult patients themselves" (p. 83) According to Morse and Johnson (1991, p. 341) health professionals are beginning to "listen more attentively and to give credence to the patient's perspective". In examining the client~ perspective of 'morning sickness' Alley (1984) stressed that the "nurse must listen when the client describes how the problem is affecting her and what the client thinks helps or hinders the nausea. Only · then can the nurse offer counsel and guidance"(p. 188). It is this perspective that is the focus of the phenomenological study reported in this thesis. The phenomenological approach is concerned to show "not simply that the patient's experience should be taken into account as a subjective accounting of an abstract 'objective' reality, but that the patient's experiencing must be taken into account because such lived experience represents the reality of the patient's illness" (Toombs 1987, p. 236). According to Benner and Wrubel (1989): [T]he best nursing practitioners .. .// ... seek the patient's story in formal and informal nursing histories, because they know every illness has a story - plans are threatened or thwarted, relationships are disturbed, and symptoms become laden with meaning depending on what else is happening in the person's life. Understanding the meaning of the illness can facilitate treatment and cure. Even when no treatment is available and no cure is possible, understanding the meaning of the illness for the person and for that person's life is a form of healing, in that such understanding can overcome the sense of alienation, loss of self­ understanding, and loss of social integration that accompany illness (p. 9). O'Brien and Naber (1992, p. 138) stipulate that "Since pregnant women's qualitative experiences with nausea and vomiting have not been adequately . documented, health caregivers may be unable to advise and support them appropriately". This study examines the stories of the individual women who 28 agreed to participate and describes their experiences of living through the phenomenon of sickness in pregnancy. Summary The literature reviewed in this chapter is predominately of a quantitative nature and is focused on the symptoms rather than the overall experience of sickness in pregnancy. No clear understanding of aetiology currently exists. The lack of a conclusive aetiology continues to affect the management of sickness m pregnancy. The vast majority of literature reviewed is written from the perspective of the health professional. Little has been researched about what it is like to live with this phenomenon and its effect on women's lives. The importance of developing an understanding of the lived experience in order that nurses can give more effective care was identified. The following chapter identifies the selection of phenomenology as the most appropriate research methodology to examine lived experience. 29 Chapter Three PHENOMENOLOGICAL ENQUIRY Introduction This chapter focuses on the nature of phenomenological enquiry and its appropriateness to this study. The chapter begins by examining the three research paradigms utilised in nursing research in order to highlight the value of the interpretive paradigm for examining lived experience. This is followed by a more detailed consideration of phenomenological enquiry, including its historical development and the relationship between phenomenology and nursing. An examination of researching lived experience using hermeneutic phenomenology is given, including outlining the assumptions and methodology associated with this research approach. The chapter concludes by outlining the use of lifeworld existentials as constructs to reflect on lived experience. Research paradigms utilised in nursing research The three major paradigms utilised in nursing research are the positivist or empirico-analytical, the interpretive, and the critical theory approaches (Allen, Benner & Diekelrnann 1986). The empirico-analytical paradigm dominates research in the broader scientific community and assumes structure, universality and order. The world is seen as being structured by law-like regularities which can be identified and manipulated. This applies to the study of human behaviour as well as to that of objects. It is seen that there is a body of facts and principles that are universal 30 and therefore are not bound to any specific context, be it social, political, economic or historical. Research within this paradigm is often guided by hypothesis testing and a structured design that is imposed prior to data collection. By confirming or disproving hypotheses in which objects and events are manipulated as dependent or independent variables regularities are identified that give the researcher the ability to describe events of the world through explanation and prediction. Knowledge generated within this paradigm is seen as being factual, observable, verifiable and generalisable. (Munhall 1981; Allen, Benner & Diekelmann 1986). The major criticism of this paradigm is that there may be multiple subjective truths experienced by different individuals and that these may not necessarily be fully generalisable. Swanson and Chenitz (1982, p. 241) indicate that such research has limited meaning for nursing practice as "this approach, in which each variable is given a single dimension and isolated to give a direct relationship between phenomena, yields findings that belie what nurses know to be the exceedingly complex and diversified nature of their professional domain". This view is supported by Munhall (1981), Meleis (1985), Barnum Stevens (1990), Bartjes (1991) and Wilkes (1991). The interpretive paradigm developed due to dissatisfaction with the positivist approach in the study of humanism. It's philosophy has given rise to various qualitative research methodologies which include grounded theory, ethnography and phenomenology (Wilkes 1991). Wilkes states these research approaches are directed "towards providing 'interpretive' accounts of phenomena rather than law-like generalisations" (p. 231). The interpretive paradigm is concerned with studying individuals, their views and everyday experiences within their natural context (Cohen 1987). This approach has gained favour in recent years. 31 Meaning in the interpretive paradigm is viewed as being somewhere between within the individual and within the situation. Knowledge in this model is socially constructed with language, culture, life experiences, ideology, social, economic and political conditions shaping what is 'truth' and how we come to know the world in which we live. Research data is generated by direct contact with the participant using interviews and I or observation and is presented by description and interpretation of the phenomena or experience being researched rather than relying on explanation and analysis. Presentation of the research data is concerned with the entirety of the experience. Nursing is now seen as an applied discipline with nursing knowledge directed towards practice, many components of which are not amenable to the reductionistic techniques of empirico-analytic research (Barnum Stevens 1990). The techniques of the interpretive paradigm are appropriate for an examination of the lived experience of sickness in pregnancy, because they reflect the complex nature of the phenomenon through the interweaving of perceptions, values and beliefs that constitute an individual's lived experience. The critical theory approach goes beyond the interpretive and positivist approaches. "It seeks to identify and criticise disjunctions, incongruities, and contradictions in people's life experiences. It focuses on critical self-reflection coupled with action and change" (Wilkes 1991, p. 232). An assumption of this paradigm is that social life is structured by meanings, rules, conventions and habits to which individuals adhere. The central interest of critical social theory is in emancipating individuals "from conscious or unconscious constraints in the hope of making community life more rational" (Allen, Benner & Diekelmann 1986, p. 33). It is therefore political and is directed at personal and social transformation rather than scientific description (Wilkes 1991). 32 Wilkes ( 1991, p. 228) states "If nursing is considered holistic, caring, involving human beings experiencing and interacting, the interpretive approach to research will help nurses to grasp the totality of events, situations, and experiences and fit them together for themselves and others". Although she recognises that nursing can be seen from many perspectives and as such a variety of research methods should be utilised, she believes phenomenology is a 'window to the nursing world'. Wilkes (1991) notes that phenomenology: [P]rovides a baseline to provide ways of elevating nurses to new levels of understanding; for setting parameters for future research in the empirical paradigm; and especially in opening doors to the critical theory paradigm where critical self-awareness is coupled with action, and change. In order to instigate change through action the phenomena need to be understood and have meaning to the human involved in the experience (p. 244). Spiegelberg (1976) believes the phenomenological approach is best suited to examine lived experience, as this approach is an inductive, exploratory method that seeks to provide understandings of the meanings of a given lived experience. Historical perspective on phenomenological enquiry Phenomenology is not only a research method, it is a philosophy. It arose in Germany in the 19th century from a perceived need to understand that human science was different from natural science, and therefore required interpretation and understanding rather than external observation and explanation as used in natural science (Wilkes 1991 ). 1 Immanual Kant (1724-1804) was the first philosopher to describe phenomenology as it is now understood. Historically there have been three phases in the development of contemporary phenomenology: the preparatory phase; the German phase; and the French 1 Human science concerned mental, social and historical perspectives whereas natural science was concerned with physical, chemical, behavioural, and animal studies. 33 phase. The discussion which follows relating to these three phases is based on the work of Spiegelberg (1969) and Cohen (1987). The preparatory phase involved the work of Franz Brentano (1838-1917) and one of his students, Carl Stumpf ( 1848-1936). Brentano's objective was to reform philosophy so that it could provide answers about humanity that religion could not provide. Brentano provided two ideas essential to later phenomenology: inner perception (the ability to be aware of one's own psychic phenomena); and intentionality (the inseparable connectedness of the human being to the world). Strumpf s contribution was to develop the scientific rigour of phenomenology. The German phase was dominated by Edmund Husserl (1859-1938), a former student of Brentano's, and Husserl's assistant Martin Heidegger (1889-1976). Husserl related phenomenology to the question of knowing. He favoured pure subjective consciousness as the condition for all experience and he placed emphasis on 'essences', which are also identified as the 'beginnings' or 'roots' of all knowledge. Husserl saw phenomenology as a discipline that endeavoured to describe how the world is constituted and experienced through conscious acts. Two other important concepts introduced by Husserl were those of 'intersubjectivity' and the 'lifeworld' (Lebenswelt) or the everyday world in which we live. Central to this is the view that one takes for granted so much of what is commonplace that one often fails to notice it. Heidegger was primarily concerned with 'Being' and 'Time' (Zein und Zeit). The phenomenological view of the person has its basis in Heidegger's work. He notes that a person does not come into the world predefined but becomes a self-interpreting being 'f that defines things for him/her selves in the course of living. A person is seen as "a creative, generating being, who lives embedded in a context of meaning, a 34 being whose actions and understandings form a comprehensive whole" (Benner and Wrubel 1989, p. 35). Heidegger believes that a person grasps a situation directly in terms of its meaning for the self. Existential phenomenology had a great influence on the French phase of phenomenology. Three prominent philosophers of this phase were: Maurice Merleau-Ponty (1908-1961), Gabriel Marcel (1889-1973) and Jean-Paul Sartre (1905-1980). Merleau-Ponty developed the case for the importance of considering an individual's experience. He is the most important figure from this group in the development of the phenomenological research as used in this study. Merleau-Ponty (1962, p. vii) speaks of phenomenology as "The study of essences" and "all problems amount to finding definitions of essences; the essence of perception, or the essence of consciousness for example". By this he meant that phenomenology does not merely report the event but seeks to define its essential nature or meaning. It asks the question: What characterises this phenomenon? Consciousness links the subjective experience of the person to the physical experience through bodily contact with the world around them. Merleau-Ponty called for a return to embodied experience, that is the pre­ reflective world in which people already live before they develop knowledge about it. Our bodies are in contact with the world around us and it is through sensation, language and speech that we create and store knowledge about the world. Marcel was concerned with phenomenology in the analysis of 'Being'. Sartre developed a philosophy to reconcile the object and subject which has become central to existential phenomenology. He believed that "a person's concrete behaviour (existence) preceded a person's character (essence)" (Cohen 1987, p. 33). Sartre reinforced Husserl's intentionality as the central feature of consciousness. 35 Van Manen's approach2 to phenomenological research utilises many of these traditional phenomenological understandings. For him phenomenological research is: 1. The study of lived experience (Husserl, Schutz and Luckman, and Dilthy); 2. The explication of phenomena as they present themselves to consciousness (Sartre); 3. The study of essences and essential relationships (Husserl and Merleau- Ponty); 4. The description of the experiential meanings we live as we live them (van Manen); 5. The human scientific study of phenomena (van Manen); 6. The attentive practice of thoughtfulness, a 'caring attunement' (Heidegger). Phenomenology and nursing The use of the phenomenological method in nursing research is advocated by many authors including Parse, Coyne and Smith (1985), Munhall and Oiler (1986), Anderson (1989), Benner and Wrubel (1989) and Wilkes (1991). These authors all point out that the traditional scientific method is inadequate as it fails to address lived experience. They acknowledge that phenomenology provides a scientific method of discovery which is compatible with the humanistic concept, central to the practice of nursing. Dreyfus (1994, p. x-xi) acknowledges that nursing draws on a mixture of natural and medical sciences, but he also believes 2 [T]hat in addition to the human sciences nurses need a way to criticise the Cartesian view of the person as a private subject standing up against an objective world. They need to be able to From conference presentation I attended by Max van Manen at Monash University, Gippsland campus, Victoria, Australia, January 1995: Researching Lived Experience using Phenomenology. describe and legitimise the person in relation with others for coherence in their own self understanding as nurses engaged in caring practices. Finally, studying Heideggerian phenomenology seems to enable them to understand human beings in their physical and cultural diversity and not only as private autonomous Cartesian selves. 36 Many nurse theorists have used phenomenology as a philosophical approach in their descriptions of the nursing world, or in the development of nursing theories (Wilkes 1991). The work of Watson (1979, 1985) in caring has an existential phenomenological perspective influenced by Heidegger. Parse (1981) uses the tenets of the existential phenomenologists (Sartre; Merleau-Ponty; and Heidegger) in building the assumptions of her Man-Living-Health model of nursing. In her investigations of what constitutes an expert nurse Benner (1984) uses Heidegger's approach extensively. Benner and Wrubel (1989) also use Heidegger's approach in their exploration of caring, stress and coping in health and illness. Wilkes (1991) stresses: "Only through an analysis and synthesis of the experiences of the nurse and the nursed will an understanding of nursing and caring evolve .. .// ... If nursing is holistic it should be explored and analysed by research methods that look at the lived experience and describe it" (p. 230). Phenomenology is an approach to viewing and researching lived experience within a subject's world. Phenomenology allows "participants to describe their everyday concerns and practical knowledge, thereby giving access to practical worlds" (Benner 1994, p. 112). Lawler (1991, p. v-vi) notes that "Nursing practice is essentially and fundamentally about people's experiences of embodied existence, particularly at those times when the body fails to function normally". A clearer understanding of the experiences and concerns of women who live with sickness in pregnancy 37 will improve the professional care that is offered to them. Bartjes (1991, p. 262) stresses that within the realm of nursing [P]henomenology offers a different research approach and meanings for use in understanding the healing experience of the individual within the context of his or her lived-experience. Phenomenology communicates the authentic meaning using a language that deepens the understanding of the lived experience of the person and this understanding of life and healing as it is lived is valuable to the development and growth of nursing knowledge. Bartjes (1991) is confidant that knowledge arising from phenomenological studies will strengthen the foundation for nursing practice and the development of nursing as a discipline. This view is supported by Swanson-Kauffman and Schonwald (1988, p. 97) who insist that "knowledge of lived experiences of health and healing are legitimate topics of nursing inquiry". Furthermore, the focus of phenomenology on the lived experience allows for the provision of nursing care in which patient-identified needs are paramount (Jasper 1994). Researching lived experience using hermeneutic phenomenology Van Manen's view of hermeneutic phenomenology goes further than Spiegelbergs (1976) view of seeking the meanings of understandings of a given lived experience. For him it is the study of our lived experience in order to "make some aspect of our lived world, of our experience, reflectively understandable and intelligible" (van Manen 1990, p. 126-127). His methodology involves a systematic reflection on lived experience of any human experience. It is a human science of lived experience and experiential meaning. Hermeneutic phenomenology does not aim ata certain truth (a danger of positivism) nor absolute essences (a danger of essentialism), but a plausible insight into situations in which we find ourselves. This insight is shaped by contexts such as culture, language, time, gender, and history. There is no 38 ultimate reality to be interpreted only experience and life-expressions. The perception of the individual is the truth for that individual at a particular time, which may change as the experience is lived over time. For the individual at that time it is absolute (van Manen 1995). Van Manen argues that as a 'critical philosophy of action' hermeneutic phenomenology is oriented toward understanding an aspect of a person's experience that is otherwise taken-for-granted or glossed over. The researcher or practitioner has a thoughtful involvement, a personal, practical engagement, in addressing the uniqueness both of the experience of another and of their own practice. It is thus a 'theory of the unique', since the researcher is interested in the uniqueness of the experience of persons and "what is essentially not replaceable" (van Manen 1990, p. 7). In 'borrowing', making sense of, and understanding other people's experiences, one seeks to better inform one's personal and professional way of acting in the context of the whole of human existence (van Manen 1984). This is very relevant for nurses and other health professionals. The research attempts to record the essential characteristics of the experience in such a way that it is comprehensible to others and to give it meaning. Van Manen (1990 p. 27) speaks of a 'validating circle of inquiry' in that a good phenomenological description "is collected by lived experience and recollects lived experience - is validated by lived experience and it validates lived experience". Consequently phenomenological research requires active involvement from the researcher, the participants in the study, and from those who read and evaluate the research report. The researcher aims to transform personal lived experience into consensually validated social knowledge. 39 The ultimate verification of any research using hermeneutic phenomenology lies in its resonance, or sense of congruence with one's lived or imagined experience so that one "can 'see' (know, feel, understand)" its previously silent, deeper significance (van Manen 1990, p. 130). It is something that we can acknowledge, recognising it as an experience that we have had or could have had in a similar situation. Overseas research studies by Banonis (1989), Santopinto (1989), Beck (1992) and Reid (1994) have used phenomenology to research various lived experiences. One of the earliest phenomenological studies conducted in New Zealand was by Madjar (1991) who researched the experience of clinically inflicted pain in adult patients. Her research examined pain as an embodied experience and her study has provided guidance to the use of phenomenology within this country. Van Manen's hermeneutic phenomenology also guided a study by Bland ( 1994) in examining the lived experience of chronic leg ulcers. Assumptions of phenomenological research The central assumption of phenomenological research is that knowledge of a phenomenon can be gleaned from understanding and making explicit the experience of those who live the experience (Munhall & Oiler 1986). This rests largely on the participants' ability and willingness to adequately communicate their experience to the researcher. It also depends on the interpretation, sensitivity and thoughtfulness of the researcher, as well as the researcher's scholarly tact and writing talent (van Manen 1990). A second assumption is that people are able to communicate their lived experience in an honest and trustworthy manner. It has to be accepted that the participants, because they have the direct experience of the phenomenon that the 40 researcher is investigating, are the 'experts' on the topic of inquiry (Swanson- Kauffman & Schonwald 1988, van Manen 1990). Methodology for hermeneutic phenomenological research According to van Manen (1990, p. 180) hermeneutic phenomenology: [T]ries to be attentive to both terms of its methodology: it is a descriptive ( phenomenological) methodology because it wants to be attentive to how things appear, it wants to let things speak for themselves; it is an interpretive (hermeneutic) methodology because it claims that there are no such things as uninterpreted phenomena. The implied contradiction may be resolved if one acknowledges that the (phenomenological) 'facts' of lived experience are always already meaningful (hermeneutically) experienced. There is no definitive set of steps for phenomenological research, which has led to criticism of the method as "often being ill defined and difficult to understand" (Wilkes 1991, p. 236). Wilkes indicates that the lack of distinctive steps causes many novice researchers considerable difficulty. Although the data collection varies, studies by Giorgi (1970) and Colaizzi (1978) have proposed a similar method for data analysis. The text is read to get a 'feel' for the material, themes are identified and joined together to form relationships, and then a description is written. Van Manen (1990) outlines six interrelated research activities that provide a for~ methodical structure1into lived experience and these are followed in this study: 1. Orienting or turning to the nature of lived experience; 2. Gathering the data - investigating the experience of the phenomena as it is lived rather than as it is conceptualised; 3. Reflecting on essential themes which provide a deepened understanding; 4. Describing the experience through the interpretive practice of writing; 5. Maintaining a strong involvement with the phenomenon; and 41 6. A hermeneutic interpretation - balancing the research context by considering parts and the whole. The lifeworld as the world of lived experience Lifeworld existentials are used in this study as a guide to examine the lived experience of sickness in pregnancy. The idea of the lifeworld, or Lebenswelt, as the world of lived experience is derived from the work of Husserl. He described the lifeworld as the 'world of immediate experience'. Van Manen (1990, p. 101) states: "Our lived experiences and the structures of meanings (themes) in terms of which these lived experiences can be described and interpreted constitute the immense complexity of the lifeworld". It is noteworthy that there are multiple lifeworlds that belong to different human existences. For example, the lifeworld of a nurse to that of a patient. People may be seen to inhabit different lifeworlds at different times of the day, a nurse has the lifeworld of the hospital as well as the lifeworld of home. The concept of the lifeworld is central to this study. The lifeworld of women experiencing sickness in pregnancy is very different to the lifeworld of pregnant women who do not experience this phenomenon. The four fundamental lifeworld themes which pervade all human lifeworlds regardless of their social, cultural or historical situation are: the lived body (corporeality); lived other (relationality or communality): lived space (spatiality); and lived time (temporality) (van Manen 1990). These are largely pre-verbal in that we do not ordinarily speak of them or reflect on them. Lived body (corporeality) refers to the fact that we are always bodily in the world or embodied. It is through our bodies that we experience the world about us and give meaning to that world (van Manen 1990). 42 Lived other (relationality or communality) refers to the lived relationship we have with others in the interpersonal space we share with them. Lived space (spatiality) refers to felt space. It explains why the spaces we find ourselves in affect how we feel. For example, our homes are generally a place where we can feel relaxed and 'be ourselves'. In order to understand the nature of a particular phenomenGflit is useful to inquire into the nature of the lived space that renders an experience its quality of meaning (van Manen 1990). Lived time (temporality) is subjective time rather than clock time. This is the time that appears to speed up when we are enjoying ourselves or slows down when we are bored. Lived time has past, present and future dimensions. Van Manen (1990, p. 104) indicates that: "The temporal dimensions of past, present and future constitute the horizons of a person's temporal landscape". The four lifeworld themes, or existentials, can be differentiated but can never be separated as they are all interrelated. As van Manen (1990) states: "In a research study we can temporarily study the existentials in their differentiated aspects, while realising that one existential always calls forth the other aspects" (p. 105). Summary This chapter began by outlining the three paradigms in the philosophy of science which guide all research in order to highlight the value of the interpretive paradigm to nursing research. This was followed with an examination of the contribution phenomenology has for nursing. The development of phenomenological enquiry was addressed to present the philosophical background of herrrieneutic phenomenology as it is used in researching lived experience. The methodological structure of van Manen's (1990) hermeneutic 43 phenomenological research, as used in this study was described and its appropriateness to this study determined. An examination of the four lifeworld existentials (lived body, lived other, lived space, and lived time) has shown these to be useful constructs to reflect on the lived experience. It is concluded that van Manen's hermeneutic phenomenology is an appropriate methodology to apply to this study. 44 Chapter Four STUDY DESIGN AND METHODS Introduction The previous chapter focused on the nature of phenomenological ~quiry and the reasons for using the hermeneutic phenomenological approach of van Manen in this study. This chapter describes the interrelated phenomenological research activities outlined by van Manen (1990, pp. 39-51) of orienting to the phenomenon, formulating the phenomenological question, and explicating assumptions and pre-understanding. This is followed by an explanation of the design, the methods and procedures involved in carrying out this study. Ethical considerations involved in the study are also addressed. Orienting to the phenomenon Orienting to the phenomenon involves focusing on the phenomenon of interest and concern to the researcher to clarify their approach to the problem. Chapters one and two report the process of orienting to the phenomenon of sickness in pregnancy as addressed in this study. Formulating the phenomenological question According to van Manen (1990, p. 42) "to do phenomenological research is to question something phenomenologically and, also to be addressed by the question of what something is 'really' like". The phenomenological question formulated for this study was: What is the nature of living with sickness in pregnancy? 45 By addressing the nature of the lived experience one attempts to discover what the associated embodied meanings and implications are for a particular group of people. The objective for this study was then redefined as: To understand more about the impact of sickness on the everyday life of pregnant women so that the realities of living with this phenomenon would be revealed. Explicating assumptions and pre-understandings Van Manen (1990) warns that a problem of phenomenological enquiry is that a researcher's pre-understandings, assumptions and existing knowledge often predispose them to interpret the nature of the phenomenon before they have "come to grips with the significance of the phenomenological question" (p. 46). Many phenomenological approaches require the researcher to 'bracket', or set aside assumptions and expectations about the phenomenon being investigated (Swanson-Kauffman & Schonwald 1988). Van Manen (1990, p. 47) considers that it is more appropriate to "make explicit our understandings, beliefs, biases, assumptions, presuppositions, and theories" in order to expose them and to avoid unwarranted implications or conclusions in the study. My own experience of nausea and vomiting during pregnancy, nursing experience, and familiarity with the relevant literature contributed to the following assumptions and expectations prior to the beginning of this study: 1. Experiencing sickness in pregnancy can be very distressing, disturbing the lives of those who experience this phenomenon. 2. Women will share their experience with the researcher in differing degrees. Some women may n:ot wish to fully communicate their experience of this phenomenon. 46 3. As a mother of four children who had experienced nausea and vomiting with each pregnancy I may be seen by the participants to be someone who was likely to empathise with their experience. This may affirm their willingness to share their experiences with me. 4. The experience of this phenomenon will differ with individuals, and with different pregnancies, but will exhibit some basic commonalities or 'essences'. Study design Investigating a phenomenon involves accessing the sources of 'lived-experience' descriptions in order to answer the question 'What is this experience like?' The participants in the context of a research study transform their private experience into actions and language and make these available to the researcher. A 'purposeful sample', where "the researcher selects a participant according to the needs of the study" (Morse 1991, p. 129) was required for this study. The design was to include women who had direct experience of the phenomenon under study. Because one can never enter or sense directly another's experience we rely on the information provided by the participants. This relies on the participants' ability to communicate the experience and the researcher's ability to assist the participants to reflect on their experience. To clarify the information provided by the participants it was important that the researcher continually reflected meanings and confirmed understandings of descriptions and explanations given throughout the study. The women were invited to share their lived experience of this phenomenon with me in conversational interviews and together we were to explore what this experience meant to them. Van Manen ( 1990, p. 66) refers to this as a "conversational" relationship. I then examined the transcripts of these 47 interviews, using hermeneutic phenomenological reflection, to answer the research question. The following chapters of this thesis are the result of this process. Identifying participants for the study A local General Practitioner assisted me to contact participants for the study. The study was explained to the doctor in person and he was given a copy of the research proposal. Questions relating to the study were answered and any issues or concerns he had in identifying suitable participants were clarified . The criteria for inclusion in the study were that: 1. The woman was pregnant at the time of the study and was experiencing or had experienced sickness in her current pregnancy; 2. The woman was able to communicate clearly in English; 3. The woman had been born into or substantially adopted the values of Maori or Pakeha New Zealand culture. (Most studies that I had identified in relation to sickness in pregnancy were overseas ones. This study was to be based specifically on New Zealand cultural values). The doctor mentioned the study to likely participants. Those who showed interest in participating were given the information sheet (Appendix 1) which outlined the study and the degree of involvement required of participants. Potential participants made their own contact with me or indicated their willingness to be involved to the doctor by requesting that I contact them. Other pregnant womw who heard about the study offered themselves as participants. Where these volunteers met the criteria for inclusion in the study they were accepted. The possibility of this 'snowballing' effect had been planned for in the 48 research proposal as this had been experienced in an earlier fieldwork study (Wenmoth 1992). Contact was made with prospective participants to reaffirm their interest to be involved, and to seek their approval to visit them to discuss the study in more detail. Once participants had been identified there were no refusals to being involved in this study. Arrangements were made so that I could interview each participant at a time and place that was convenient to her. All but one of the women chose their own homes for the initial interview and the majority chose a time when they were the only adult present. The other participant chose to have her initial interview at her place of work in a private interview room. The study was further clarified in person prior to the first interview. Participants were given the opportunity to discuss the research and to consider whether they still wanted to participate. In all instances the offer was made to come back at another time so they could think about the study and decide their level of participation. This was not required. All participants appeared eager to share the stories of their experience. The ten women freely chrn~~ to participate in this study and their written consent was obtained. Description of the study participants The participants in this study came from a variety of backgrounds and social situations. All met the three predetermined criteria (as noted above). For some of the women the experience of symptoms had settled on entry to the study while for others it was continuing at the time of interview. This is acceptable for a study examining lived experience as "Reflection on lived experience is always recollective; it is reflection on experience that is already passed or lived through" (van Manen 1990, p. 10). As some of the women were in the latter stages of 49 their pregnancy on entering the study the second interview followed the birth of their baby. For five of the women this was their first pregnancy, for three it was their second pregnancy and for two it was their third pregnancy. Their ages varied from 20 to 45 years. Eight of the women were married and living with their spouses. The other two women were living with family members. The women illustrated variability in the symptoms they experienced as well as the duration they were present. This varied from experiencing nausea alone (three participants), nausea and vomiting (four participants), nausea and retching (two participants) and one participant who experienced nausea, retching and vomiting. All of the women reported that the nausea and I or vomiting began between the third and sixth week of their pregnancy. For four of the women it had disappeared by the twelfth or thirteenth week, for three of the women by the sixteenth week and for one at the twentieth week of her pregnancy. The remaining two women experienced symptoms throughout the term of their pregnancies. The pattern or time of the day when the experience of these symptoms peaked showed similar diversity. Two of the women experienced symptoms in the morning only, two experienced symptoms during the evening only and one participant experienced symptoms both in the morning and in the evening. Three of the women experienced symptoms all day, while for the other two participants there was no characteristic pattern and their experience varied from day to day (sometimes it was worst in the morning, sometimes in the evening and occasionally even all day). Ethical considerations for the study The study proposal was approved by the Human Ethics Committee of Massey University and all ethical considerations have been complied with. Protection of 50 the rights of the study participants was of paramount importance. The ten women chose freely to participate and understood that they were free to withdraw from the study at any time. Individual written consent forms were signed by each of the women participants and myself as the researcher (Appendix).). All interviews were recorded using a microcassette tape recorder. The interviews were transcribed onto computer and a printed transcript obtained. The printed transcripts were shared with the woman concerned for verification and correction. No one chose to delete any material. The tapes were stored in a secure place. It was intended that each woman, and any other persons identified in the transcripts, would be given pseudonyms for the final report. The use of pseudonyms was discussed with the participants and they had the opportunity to select their own. Only one participant chose to do so. Every attempt to preserve the participants' anonymity has been maintained. It was made clear to the participants, that although I am a registered nurse I would not be seeing them in this role. For the purposes of this study I was a post graduate student with the Department of Nursing at Massey University. Because I was aware that during visits I may be asked for my professional opinion I stressed my role as a researcher, not as a professional nurse. No conflicting situations arose during this study. Provided that I made every attempt to maintain anonymity and confidentiality there were no potential long-term disadvantages to subjects participating in this study. There was the possibility of the interviews being distressing to the 51 participants either because of the physical aspects of symptoms like nausea and vomiting, or in relation to emotional factors when reflecting on the extent to which sickness had impacted on their quality of life. It was made clear that should the interview appear to be distressing to the participants for any reason then the interview would be stopped. The need for this did not arise. Hutchinson, Wilson, and Skodol Wilson (1994) suggest that, while the risks associated with participation in qualitative studies for health research have received attention, little has been reported of the potential benefits that may be experienced. The benefits to the ten participants were not formally addressed in this study, however all of the women expressed their appreciation for the opportunity to share their stories and to assist me with this study. Data collection As indicated data for this study was collected by the use of interviews with women who had experience of the phenomenon. Van Manen (1990) states that the interview serves very specific purposes: ( 1) it may be used as a means for exploring and gathering experiential narrative material that may serve as a resource for developing a richer and deeper understanding of a human phenomenon, and (2) the interview may be used as a vehicle to develop a conversational relation with a partner (interviewee) about the meaning of an experience (p. 66). The interviews for this research addressed both of these purposes. Two interviews were held with each participant with each being approximately one hour in duration. The interviews were conducted over a six month period. At the first interview participants, in addition to sharing their experience of sickness in their current pregnancy, were asked to share some background information such as their age and number of previous pregnancies. The 52 participants were also invited to keep a record of their experience noting anything that occurred to them between interviews or that they had subsequently remembered about their experience. Most participants had difficulty with keeping a written record but some did raise issues later that were not raised in the first interview. Because sickness in pregnancy is personal and has often been perceived as a symptom of not coping with pregnancy (Birks 1993), it was important to create an atmosphere of trust and confidentiality so the participants would share their experiences fully. Swanson-Kauffman and Schonwald (1988, p. 101) stress that the success of gathering the data depends on "the researcher's ability to engage with the informants' reality" which requires empathy, intuition, and attentiveness. In-depth interviews provided the opportunity to develop a good rapport with each participant. The interview process began with an open question; "Thank you [participants name] for agreeing to share your experience with me. Could you tell me what the sickness has been like for you and what it has meant to you in your daily life?" The interview proceeded in a conversational manner with questions arising to probe the experience in greater depth or to seek clarification relating to issues surrounding their experience. The interviews used 'talk-turning', where probing questions developed out of the respondent's preceding replies and descriptions. As the rapport developed so did the flow and depth of the information given. Often the second interview gave a richer picture of the lived experience of the phenomenon. Between interviews I would read the previous transcript and note any points for clarification or elaboration at the second interview. Transcripts of the initial interview were returned to each participant before the second interview. In this way participants could both verify their transcript as correct and make any 53 necessary corrections. Only a few minor corrections were necessary. The transcripts enabled the participants to further reflect on their experience, confirm understandings, gave an opportunity to clarify or to enlarge upon details given and prompted new information for the second interview. The second interview involved verifying transcripts, expanding on issues identified by participants and myself and further examination of their lived experience. New questions arising from the transcripts were probed in terms of the meaning of experience to the participant. In this manner van Manen (1990) notes that the interview turns into "an interpretive conversation wherein both partners self-reflectively orient themselves to the interpersonal or collective ground that brings the significance of the phenomenological question into view" (p. 99). The transcripts of the second interview were similarly prepared for return to participants for verification. Some of the participants indicated that they did not want their second transcript returned and this wish was respected. Participants where possible were contacted following the conclusion of the study to share the major themes that emerged and to reflect on their participation in the study. Data analysis Analysis of data was continual from the first interview as e