Abstract

In a more inductive or deductive way, several theorists have problematized about nursing care in which they seek to clarify nursing science focus of attention. The phenomenological perspective allows us to perceive the human lived experience and unveil their meaningful understanding as a person. Stemming from the question ‘What is the lived transition experience of the maternal role of women with problems of addiction to psychoactive substances, from pregnancy to the first year of the child’s life?’ This research distills the core principles of a qualitative research, with a phenomenological and interpretative design, with the objective of understanding the lived experience transition process of the maternal role of women with problems psychoactive substances addition. The research does not only reveal the contribution of phenomenological studies in the development of nursing science, but also enhances the living experience of women with addiction problems to psychoactive substances, during pregnancy, childbirth, postpartum and the first year of their children’s life, enabling nurses to develop specific interventions to dealt with this problematic issue under study.

Key words:
Phenomenology; Living experience; Nursing; Maternal role

Introduction

Knowing that a person is an individual human being, who is in permanent interaction with the world and in constant development through individual choices and interaction with others¹1 Paterson J, Zderad L. Humanistic Nursing. Copyright Status: The Project Gutenberg eBook; 2008. [cited 2018 Apr 12] Available at: http://www.gutenberg.org/ebooks/25020, nursing is an intentionally nourishing response focussed on the person’s well-being, purposefully directed in helping this person to become committed, more humane as possible, in her own particular situation¹1 Paterson J, Zderad L. Humanistic Nursing. Copyright Status: The Project Gutenberg eBook; 2008. [cited 2018 Apr 12] Available at: http://www.gutenberg.org/ebooks/25020. On the other hand, nursing care is an experience lived between humans, in an intersubjective relationship in which the process of nurturing occurs, involving a way of being and building relationships with others, in a certain timeframe and place.

Being a nurse is to give and build meanings of lived experiences, committed to perform a significant ‘care’ of nursing towards others. In this sense, what conceptual understanding does Nursing and Nurses have of the lived experience, its meaning from the point of view of those who lived this experiences? In response to these two questions, nurses have developed phenomenological studies that have underpinned the construction of large scope and medium-range theories that support professional nursing practices. Nevertheless, we must bear in mind that the application of the phenomenological method to the discipline of Nursing, “centered mainly on the field of lived experience, as lived by the person, must be performed with the use of appropriately rigorous strategies and properly framed in the investigation process, implying knowledge of the method and its language”²2 Loureiro LMJ. Adequação e Rigor na Investigação Fenomenológica em Enfermagem - Crítica, Estratégias e Possibilidades. Referência 2006; 2(Jun):21-32., especially with regard to onto-epistemological references.

But who is this Other that challenges the Nurse in her Caring action?

For Heidegger³3 Heidegger M. Ser e Tempo. Petrópolis: Editora Vozes; 2014., only human kind (being-there) exists, being privileged, due to “the acceptance of the gift of existence enabling (him) the responsibility and the task of being and assuming that gift”, since mankind can only be “understood from his existence, from the possibility (which is his own) to be or not to be himself”.

Configuring the situation of mankind as a clearing of being, where he hides and reveals himself, Dasein, is marked by presence, which is only possible on the basis of him being seen as a being-in-the-world in general³3 Heidegger M. Ser e Tempo. Petrópolis: Editora Vozes; 2014.. The understanding of being-in-the-world, as an essential structure of presence, is what enables “a penetrating view of the existential spatiality of presence”³3 Heidegger M. Ser e Tempo. Petrópolis: Editora Vozes; 2014.. Dasein, this being-in-the-world, is someone who “spatializes”, for being present in the world in which he finds himself. In addition to these characteristics, mankind (Dasein) is a being-in-the-world and a being-with-the-other, aware of the self, affirmation of himself and his own identity, which interacts with other beings and is related to these, “[...] being simply given is the way of being of an entity that does not have the character of presence”³3 Heidegger M. Ser e Tempo. Petrópolis: Editora Vozes; 2014..

In this way, life offers mankind the experience, in which, through his understanding, he self-apprehends, returns and finds himself. In this sense, lived experience is regarded as an object of study, in which the complex set of data in an indivisible whole, creates a body of knowledge that is deeply comprehensive and interpretive. Human experience, based on a history and a culture, builds up the relationship of this with himself and with the world, in which the pre-reflected reality makes mankind become reflectively self-aware and situated⁴4 Dilthey W. Introduction to the Human Sciences. An Attempt to Lay a Foundation for the Study of Society and History. Detroit: Wayne State University Press; 1989..

In Heidegger, the act of unveiling, the opening between Dasein (being there) and the objects that fill the world, plays the role of reason, the bearer of the real. The truth is in the striving between the clearing and the concealment, in which the being itself, from its essence, makes it happen⁵5 Heidegger M. A Origem da Obra de Arte. Lisboa: Edições 70; 2008.. Under an interpretive axis, the phenomena are studied in the situations experienced by people, emphasizing the understanding of the meaning that each individuals attributes to their actions, meeting the premise of providing individualized nursing care, based on a philosophy of moral commitment to the other⁶6 Weaver K, Olson J. Understanding paradigms used for nursing research. J Adv Nurs 2006; 53(4):459-469..

Caring is at the core of nursing, requiring the development of its own scientific knowledge, in which phenomenological studies can contribute, build and deepen frames of reference, articulating concepts, values and beliefs that correspond to the concept of caring in nursing. Through the question ‘What is the lived transition experience of the maternal role of women with problems of addiction to psychoactive substances, from pregnancy to the first year of the child’s life?’ and in order to understand the lived experience transition to the role of maternal care of women with addiction problems to psychoactive substances, during pregnancy to the child’s first year of life, we set out to develop a phenomenological study that could contribute to strengthen the conceptual mapping of the problem under study, such as to support better nursing care practices to Mothers with Addiction Problems with Psychoactive Substances.

The interaction of the nurse with the lived being

According to Meleis and Trangenstein⁷7 Meleis A. Theoretical Nursing: Development and Progress. Philadelphia: Williams & Wilkins; 2012., the nurse interacts with the Other (nursing client), in a health-disease situation in which the Human Being is an integral part of his environment and is experiencing a transition. These interactions between the nurse and his client (the Other) are organized around an intention (nursing process) and the nurse uses interventions (nursing interventions) to promote, recover or facilitate health.

Based on this understanding, human beings are experienced subjects in the health-disease processes and nurses, the professionals who accompany the experienced situations (in the health and disease processes), as well as in the elaboration and subsequent meaning and in the careful exploration of the meaning of the lived for those who lived it”⁸8 Lopes J. Ser Cuidado por Um Enfermeiro Gestor de Caso. A Experiência Vivida da Pessoa com Problemas de Adição [tese]. Lisboa: Universidade de Lisboa; 2012..

If the human being can only be understood from his own existence, the women’s lived experience during pregnancy, childbirth, postpartum and the child’s first years of life, allows the exploration of what they lived and allows the knowledge of nurses about the adjustment and transition processes to the maternal role so that later they can conceive significant care processes for them.

Continuing to witness a naturalistic and essentialist conception of the process of ‘becoming and becoming a mother’⁹9 Henriques C, Botelho M, Catarino H. Tornar Refletido o Pré-Refletido: O Contributo da Fenomenologia para a Disciplina de Enfermagem. Investigação Qualitativa em Saúde. CIAIQ: Atas do 7º Congresso Ibero-Americano em Investigação Qualitativa, 2018; 1497-1506., we perceive the need to unveil the lived experience of women with problems with addition to psychoactive substances in view of the transition to the maternal role, considering them as experienced beings, in which nursing can contribute to the understanding of the phenomenon, thus dealing with the human response to life processes⁹9 Henriques C, Botelho M, Catarino H. Tornar Refletido o Pré-Refletido: O Contributo da Fenomenologia para a Disciplina de Enfermagem. Investigação Qualitativa em Saúde. CIAIQ: Atas do 7º Congresso Ibero-Americano em Investigação Qualitativa, 2018; 1497-1506..

Method

This is a phenomenological, transversal and retrospective study, with an interpretive nature based on Heidegger’s existential phenomenology³3 Heidegger M. Ser e Tempo. Petrópolis: Editora Vozes; 2014.^,55 Heidegger M. A Origem da Obra de Arte. Lisboa: Edições 70; 2008. and Gadamer’s hermeneutics¹⁰10 Gadamer HG. Truth and Method. 56 ed. London: Continuum Publishing Group; 2006

11 Gadamer HG. Verdade e método I: traços fundamentais de mais uma hermenêutica filosófica. Petrópolis: Vozes; 2015.^-1212 Gadamer HG. Verdade e Método II. Complementos e Índice. Petrópolis: Vozes; 2011.. Considering that phenomenology tends to be descriptive and interpretive, linguistic and hermeneutic⁹9 Henriques C, Botelho M, Catarino H. Tornar Refletido o Pré-Refletido: O Contributo da Fenomenologia para a Disciplina de Enfermagem. Investigação Qualitativa em Saúde. CIAIQ: Atas do 7º Congresso Ibero-Americano em Investigação Qualitativa, 2018; 1497-1506., this constitutes a way of accessing the world as we experience it pre-reflexively¹³13 Smith JA, Flowers P, Larkin M. Interpretative Phenomenological Analysis: Theory, Method and Research. London: Sage Publications Ltd; 2013.. For Gadamer¹¹11 Gadamer HG. Verdade e método I: traços fundamentais de mais uma hermenêutica filosófica. Petrópolis: Vozes; 2015., the mankind located in a time, a space and a culture is what makes him immersed by prejudices transmitted or constructed during his life, on the other hand, each interpreter is immersed in a set of prejudices that are part of his being.

The interpretative act is a meeting, which occurs in the opening to the otherness in order to find the meaning that one seeks to understand¹¹11 Gadamer HG. Verdade e método I: traços fundamentais de mais uma hermenêutica filosófica. Petrópolis: Vozes; 2015.. It is in the fusional moment of the encounter with the other that the dialogical process of understanding is anchored, a process that is muChart and dynamic.

The hermeneutic circle of interpretation moves back and forth, starting in the present. The interpretive process underlying meaning arises from interactions, working outward and backward, from subject to the event and from the event to subject. The phenomenological research applied to nursing allows us to answer questions about how the experience of human beings are lived and how it gives meaning to human life, enabling us to understand how reality is constructed as it is, experienced by subjects¹³13 Smith JA, Flowers P, Larkin M. Interpretative Phenomenological Analysis: Theory, Method and Research. London: Sage Publications Ltd; 2013..

Given our research question and seeking to understand the lived experience transition to the maternal role of women with problems with psychoactive substances addition, from pregnancy to the child’s first year of life, we set out for meaningful encounters with these women, through a purposive sampling.

The selection was guided with the assistance of nursing teams that integrated three Specialized Technical Treatment Teams in the Central Region of Portugal (Service of Intervention in Addictive Behaviours’ and Dependencies, Sicad). As eligibility criteria for participation in our study we defined: mothers aged between 18 and 35 years, who could read and write and who voluntarily agreed to participate in the research. All participants were under therapeutic programs (narcotic opioid substitution therapy) within the Integrated Response Centers, from the prenatal period until the time of data collection. Fourteen women participated in the study (Chart 1).

A phenomenological interview was undertaken with an unstructured approach in data collection, seeking that the participants narrate their lived experience of the phenomena understudy.

The study was authorized by the Regional Administration of the Center - Portugal, and by the Service of Intervention in Additive Behaviours’ and Dependencies. It was approved by the respective Ethics Committee of the Regional Administration of the Center, Portugal. After conducting the interviews, the researcher proceeded to their transcription, associating field notes taken during the interviews. Simple genograms were also performed based on the information provided by the participants (Figure 1).

After the complete transcription, the narrative text was sent to the participants in order to validate the transcription process carried out by the researcher. For methodological rigor, no interview was conducted without the previous one having been transcribed. This particular aspect is of special relevance in phenomenological studies, in which the aim is to seek understanding of a certain phenomenon and to reveal the subjects’ experiences⁹9 Henriques C, Botelho M, Catarino H. Tornar Refletido o Pré-Refletido: O Contributo da Fenomenologia para a Disciplina de Enfermagem. Investigação Qualitativa em Saúde. CIAIQ: Atas do 7º Congresso Ibero-Americano em Investigação Qualitativa, 2018; 1497-1506.. “Language is the universal medium in which understanding itself takes place. The way of realizing understanding is interpretation”¹¹11 Gadamer HG. Verdade e método I: traços fundamentais de mais uma hermenêutica filosófica. Petrópolis: Vozes; 2015..

Having the participants corroborated with the interview transcription process, the texts were reanalysed and the narrative content referenced by the participants unrelated to the phenomenon under study were removed, allowing the researcher to focus on the phenomenon, leaving aside abstract aspects or ramblings related to other subjects, allowing the researcher to collect and uncover the phenomena¹⁴14 Van Manen M. Phenomenology of Practice. Meaning-Giving Methods in Phenomenological Research and Writing. Walnut Creek: Left Coast Press Inc.; 2014..

Entering specifically in the phenomenological analysis, the researcher immersed herself in the data, by using multiple circular reading reviews¹³13 Smith JA, Flowers P, Larkin M. Interpretative Phenomenological Analysis: Theory, Method and Research. London: Sage Publications Ltd; 2013., in order to seek the understanding of each piece of data, regarding the whole, and the whole in relation to each piece of data (hermeneutic circle). Subsequently in the circular readings and re-readings process, we used Van Manen’s procedural assumptions¹⁴14 Van Manen M. Phenomenology of Practice. Meaning-Giving Methods in Phenomenological Research and Writing. Walnut Creek: Left Coast Press Inc.; 2014., in which the researcher focusses the nature of the lived experience, dedicating herself and concentrating on the phenomenon of her interest and accessing the “structures of experience”¹⁴14 Van Manen M. Phenomenology of Practice. Meaning-Giving Methods in Phenomenological Research and Writing. Walnut Creek: Left Coast Press Inc.; 2014., enabling the building of phenomenological themes based on lived and narrated experience.

Constituting phenomenology as a method to reach the meaningful structures of the lived experiences, also referred as reduction, this method consists of two opposite movements that complement each other¹⁴14 Van Manen M. Phenomenology of Practice. Meaning-Giving Methods in Phenomenological Research and Writing. Walnut Creek: Left Coast Press Inc.; 2014.. In one motion, we will try to underline (Epoché or Bracketing) the pre-existing or preconceived ideas of the researcher facing the phenomenon. In another motion, in the opposite direction, the essence of the phenomenon under study will be sought through reduction (Reduction), in which an abounding description of the experience regarding the phenomenon under study will be sought and its translation “through clusters, insights or set of themes based on the understanding of the statementes”¹⁴14 Van Manen M. Phenomenology of Practice. Meaning-Giving Methods in Phenomenological Research and Writing. Walnut Creek: Left Coast Press Inc.; 2014.^,1515 Moreira DA. O método fenomenológico na pesquisa. São Paulo: Thompson Pioneira; 2004..

Results and discussion

Using the metaphor of ‘being afloat of water’, these women looked for the possibility of transcendence and change in pregnancy. In an unplanned and unwanted way, pregnancy appears in the lives of these women, generating feelings of ambivalence, but with the expression of a strong connection and attachment to their baby (Chart 2). The communication and relationship established between the mother and the future baby occurs gradually over the months of pregnancy and is undoubtedly responsible for the development of the bond mother/child dyad¹⁶16 Moura-Ramos M, Canavarro MC. Adaptação parental ao nascimento de um filho: Comparação da reactividade emocional e psicossintomatologia entre pais e mães nos primeiros dias após o parto e oito meses após o parto. Análise Psicológica 2007; 3(XXV):399-413..

It is during labour and delivery that these women express feeling the difference in caring, fear, but also happiness and love for their babies (Chart 3). Health professionals should be promoters in the fight to ensure there is no stigmatization of these woman, which seems to condition the lives of these and other women, leading to lost opportunities to change, loss of self-esteem and self-concept, quality of life, social support and empowerment¹⁷17 Xavier S, Klut C, Neto A, Ponte G, Melo J. Mental Health Stigma: Where do We Stand? Psicologos 2013; Vol.11(2):10-21.. According to Banwell and Bammer¹⁸18 Banwell C, Bammer G. Maternal habits: Narratives of mothering, social position and drug use. International Journal of Drug Policy 2006; 17(6):504-513., women who use illicit drugs are often blamed for difficulties in exercising parenting, unlike other groups of women, which translates into stigmatization towards these women, representing an obstacle to the realization of their personal projects.

In the postpartum period and the first month of their children’s life, these women express their feeling of being mothers and the ability to take care of their infants, where the demands initiated in it, and the possibility of institutionalizing the child, surveillance by others and the social stigma in relation to the ability to be mothers, make them express themselves with sadness and revolt (Chart 4). An English study that sought to understand how rehabilitation programs for drug addiction can create opportunities for affirming maternal identity, demonstrate that addict women in rehabilitation process are motivated to overcome this problem in the supreme interest of their descendants, constituting an opportunity to rehabilitate from drug use¹⁹19 Radcliffe P. Motherhood, pregnancy, and the negotiation of identity: The moral career of drug treatment. Soc Sci Med 2011; 72(6):984-991..

Returning to their children’s first year of life, these women blamed themselves for their past life history. If the perception of social stigmazation regarding their ability to be mothers is emphasized by these women, it is with the feeling of pride and strength of the bond to their child, that they feel as mothers and with the capacity in caring of their children, evoking those who were able in the past (their parents), to take care of them (Chart 5).

Through this research, nurses will be able to access the lived experience of these women, and with it reflect on the unequivocal need to provide significant nursing care to others in similar conditions. On the other hand, we approach the phenomenological method as a basic method in the exploration and conceptual clarification of nursing science, as traced by the author Swanson²⁰20 Swanson KM. Nursing as Informed Caring for the Well-Being of Others. J Nurs Sch 1993; 25(4):352-357. through three phenomenological investigations in the field of maternal health, building a medium-range theory, which led to the definition of nursing care as “[...] the way of relating growing with another significant, for whom we feel personally involved and responsible”.

According to Swanson²⁰20 Swanson KM. Nursing as Informed Caring for the Well-Being of Others. J Nurs Sch 1993; 25(4):352-357.^,2121 Swanson KM. Empirical Development of a Middle Range Theory of Caring. Nurs Res 1991; 40(3):161-166., one of the cornerstones of nursing care is the maintenance of true belief in the person and their ability to overcome events and transitions. On the other hand, as this study proposed, knowing, means understanding the events and its meaning in the person’s life.

Nurses must also be with, that is, be emotionally present, in which emotional presence is perceived as a way of sharing meanings, feelings and the experience lived by the person. The nurse is the one who is able provide this know-how to do, and who does it in a sense that this doing includes comforting the person; anticipating their needs; perform health care assistance with competence; advocate the person and preserve their dignity²⁰20 Swanson KM. Nursing as Informed Caring for the Well-Being of Others. J Nurs Sch 1993; 25(4):352-357.. Finally, the nurse is the health professional who has the competence to enable and train the person, facilitating her passage in events and life transitions (Figure 2).

Final considerations

The transition to the Maternal Role of Women with Problems with Addition to Psychoactive Substances, from pregnancy to the child’s first year of life is revealed when these women narrate and have presently a past of drug consumption history, when they felt themselves invested and cared by the health professionals; when they perceive themselves in a difficult past in which family relationships are often fleeting and poorly structured; when they feel disinvested and uncared for by others; but fundamentally when they found themselves placed in a binding and affective Mother-Child relationship, valuing the moments of the present time and allowing themselves to dream and project a better future.

From the findings obtained, we found that the phenomenon under study is highly complex. Unveiling a stereotyped image, these women emphasize the need for better understanding, visibility regarding health teams and the unveiling of their experiences as mothers. In the possibility of achieving their maternal role, these women gravitate transitionally towards the identity of being mothers, blaming themselves for a past life history and all the consequences that these past choices determined their lives and of their children, feeling, therefore, the need to cut with a past that is still highly present. If the perception of social stigma in relation to the ability to be mothers is emphasized by these women, it is with the feeling of pride and strength of bond to their child, that they feel mothers and with the ability, in some cases, to take care of their children.

Due to the need to adjust to the phenomenon of motherhood, adaptation and the simultaneous experience of a developmental, situational and health-disease transition, maternal achievement is built, for these women, in a past and a history of drug consumption, in which the project motherhood is present, strongly based on the mother-child dyad.

References

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History