Nursing Family

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O R I G I N A L R E S E A R C H

Evaluation of a family nursing intervention for distressed pregnant

women and their partners: a single group before and after studyMarga Thome & Stefana B. Arnardottir

Accepted for publication 12 May 2012

Correspondence to M. Thome:

e-mail: [email protected]

Marga Thome MSc PhD RN

Professor

School of Health Science, Faculty of Nursing,

University of Iceland, Reykjavik, Iceland

StefanaB. Arnardottir MSc RN

Advanced Practitioner in Family Health

Nursing

Primary Health Care of the Capital Area,

Reykjavik, Iceland

T H OM E M . & A R NA R DO T T IR S . B . ( 2 0 1 3 )T H OM E M . & A R N AR D OT T IR S . B. ( 2 01 3 ) Evaluation of a family nursing

intervention for distressed pregnant women and their partners: a single group before

and after study.Journal of Advanced Nursing69(4), 805816.doi: 10.1111/j.1365-

2648.2012.06063.x

AbstractAim. To report a study of the effects of an antenatal family nursing intervention for

emotionally distressed women and their partners.

Background. High levels of depressive symptoms and anxiety are common in

pregnant women, and their partners are likely to suffer from a higher degree of these

symptoms than those of non-distressed women. Maternal anxiety and depressive

symptoms influence the development of the foetus and child negatively. Distress-

reducing interventions for couples are scarce.

Design. The design was a pre- and post-test single group quasi-experiment.

Methods. All women distressed during the last two trimesters of pregnancy were

referred by midwives to a family nursing home-visiting service in a primary care

setting in Iceland. They were invited to participate in the study from November2007September 2009. The final sample was 39 couples. Assessment of distress was

through self-reporting of depressive symptoms and anxiety, self-esteem, and dyadic

adjustment. The couple received four home visits that were guided by the Calgary

Family Nursing Model.

Results. Women experienced a higher degree of distress than men before the

intervention. Couples distress was interrelated, and improvement was significant on

all indicators after the intervention.

Conclusion. Healthcare professionals who care for distressed expectant women

should attend to their partners mental health status. The Calgary Family Nursing

Model is an appropriate guide for nursing care of distressed prospective couples in a

primary care setting.

Keywords: Calgary Family Nursing Model, distress, Iceland, intervention, nurses,

pregnancy, transition

Introduction

Pregnancy is a transitional period in the lives of prospective

parents and may affect the mental health of some families, as

well as that of individual family members in a negative way

(Schumacher & Meleis 1994, Meleis et al. 2000, Hayes &

Muller 2004). Studies from Western countries have shown

that distress in pregnant women is common, and prevalence

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rates of depressive symptoms and anxiety range from 10

15% (Evans et al. 2001, Bennett et al. 2004, Rubertsson

et al. 2005). Depressive symptoms tend to peak during the

2nd and 3rd trimesters of pregnancy (Eberhard-Gran et al.

2004). In mentally healthy mothers and fathers, they decrease

from the end of pregnancy until 18-month postpartum,

whereas parents with psychopathology in pregnancy show a

tendency towards prolonged depressive phases that peak at

12-month postpartum (Perren et al. 2005). Anxiety symp-

toms during pregnancy are associated with depressive symp-

toms, stress, self-esteem, and other psychosocial variables, as

with anxiety at other times (Gurung et al. 2005, Littleton

et al. 2007, Leigh & Milgrom 2008). Low self-esteem has

been found to be a significant predictor of both anxiety and

depression in pregnant women (Jomeen & Martin 2005).

Elevated and prolonged levels of anxiety and depressive

symptoms during pregnancy influence the development of the

foetus and the child negatively (OConnor et al. 2002, Van

den Bergh et al. 2005, Talge et al. 2007). Antenatal depres-sion predicts postnatal depression and both predict depres-

sion in adolescent offspring (Robertson et al. 2004, Pawlby

et al. 2009). Expression of depression and anxiety during

pregnancy is gender specific. Although men tend to express

distress more through anxiety symptoms, women show

higher levels of depressive symptoms (Matthey et al. 2000).

Pregnancy, rather than the postnatal period, has been found

to be the most stressful period for men undergoing transition

to parenthood, but they report consistently only about half

the rate of depressive symptoms than women (Condon et al.

2004). Predisposing factors for distress in pregnancy are

different from those of the postpartum (OHara et al. 1983,

Beck 1996, OHara & Swain 1996). Distress of pregnant and

postpartum women has been found to be related to partner

distress, and men living with a distressed partner are more

likely to experience a higher prevalence rate of distressing

symptoms than those living with a non-distressed partner

(Lovestone & Kumar 1993, Burke 2003). In several studies, a

correlation between higher depression and anxiety scores of

partners and with dyadic adjustment has been reported (Cox

et al. 1999, Perren et al. 2005, Figueiredo et al. 2008).

Concordance between maternal and paternal depressive

symptoms has been reported to be high and ranges from675725% (Raskin et al. 1990, Soliday et al. 1999,

Matthey et al. 2000). Depressed fathers are less satisfied

with their partner relationship, and dissatisfaction tends to

persist throughout the perinatal period (Matthey et al. 2000,

Florsheimet al.2003, Condonet al.2004). Distress in men is

associated with lower social support and difficulties in

adjustment to parenthood (Tammentie et al. 2004,

Bielawska-Batorowicz & Kossakowska-Petrycka 2006,

Vesga-Lopez et al. 2008). Emotional disturbances of

expecting parents are related to multiple factors such as

depression and anxiety levels, self-esteem, locus of control,

partner relationship, relationship with own parents,

personality, stressors and psychiatric history, social support,

and employment (Bernazzani et al. 1997, Berthiaume et al.

1998, Matthey et al. 2000). A multitude of prenatal

conditions contributes to variations in parents satisfaction

with family functioning and relationship during transition to

parenthood (Knauth 2000).

Background

To meet the need of both partners for antenatal mental health

care, a nursing service established in a primary care setting in

Iceland and described in this study was based on the

theoretical framework of the Calgary Family Nursing Assess-

ment and Intervention Model (Wright et al. 1996, Wright

2005, Wright & Leahey 2005) and on the concept oftransition in pregnancy and to parenthood (Schumacher &

Meleis 1994). The family systems approach inherent to the

Calgary Family Nursing Model appears to be an appropriate

conceptual framework for mental healthcare interventions

for expecting couples as their distress is interrelated (Matthey

et al.2001, Wright & Leahey 2005). The model is based on a

theoretical foundation involving systems, cybernetics, com-

munication, and change (Wright & Leahey 2005). Following

the model allows clinicians to focus on clinical issues in such

a way that helps family members deal with complex and

often difficult life situations and to improve their health

(Wright & Leahey 2005, Konradsdottir & Svavarsdottir

2011). According to this model, a family is constituted of

individuals who relate to each other through social and

emotional ties and the client is the family. The focus of care is

on the relationship between family members. The family

member closest to the individual receiving health care is

named as the co-recipient of care (Wright & Leahey 2005).

The Calgary Family Nursing Model consists of two parts:

(1) The Family Assessment (CFAM) and (2) The Intervention

Model (CFIM). The purpose of the family assessment is to

create a description of the familys need for health care and

the context for collaborative and relational, non-hierarchicalrelationship between family and nurse. It encourages the

synthesis of complex data about the family to identify its

strengths and problems and to devise a care plan. Major

categories of data are structural, developmental, and func-

tional (Wright & Leahey 2005).The intervention model is

meant to promote mutual cooperation between the family

and the nurse to facilitate change or adjustment to a health

problem. It guides clinicians in facilitating the improvement

M. Thome and S.B. Arnardottir

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and sustainment of effective family functioning in three

domains: cognitive, affective, and behavioural. Interventions

targeted at any or all of these domains can promote, improve,

or sustain family functioning, and changes in one domain can

carry over and affect the other domains (Wright & Leahey

2005).

To achieve commonly set goals described in a care plan, the

nurse must adapt her language to the beliefs of the family and

stimulate the creation of alternative thoughts that suit goals

for change (Wrightet al.1996). Posing interventive questions

is supposed to be a simple yet powerful nursing intervention

tool for families experiencing health problems and significant

life changes. The questions are of two types: linear versus

circular. Linear questions are meant to inform nurses,

whereas circular questions are assumed to facilitate change

and adjustment. They stimulate the sharing of concerns,

information, challenges, and problems with other family

members and the nurse. Discussion of the material can help

couples to discover new ways of seeing a problem, to acceptdifferences between partners perspectives, and to discover

solutions to problems (Wright & Leahey 2005, Konradsdot-

tir & Svavarsdottir 2011).

The Calgary Family Nursing Model has been implemented

in several countries, most often regarding chronic health

problems in families (Bell 2009, Svavarsdottir & Jonsdottir

2011). In Iceland, the model was recently implemented in a

hospital setting (Svavarsdottir 2008) and has already led to

several quantitative evaluations of family nursing interven-

tions for long-term health problems in paediatric care and

results indicate benefits for families (Svavarsdottir & Sigur-

dardottir 2005, 2011, Konradsdottir & Svavarsdottir 2011).

The model has been infrequently tested with couples in

transition to parenthood and in primary care settings. A study

involving postpartum couples from Canada shows that they

welcome the opportunity to be approached by nurses as a

family (Holtslander 2005). Despite the importance of family

and partner relationships in determining well-being during

pregnancy and for transition to parenthood, little research

has focused on healthcare assessment and interventions for

families and couples (Fieldet al.2008). Because of the severe

consequences of anxiety, depression, and stress during

pregnancy on mothers, partners, and children alike, it hasbeen suggested that clinicians may identify a range of

psychosocial distress in pregnant women and provide effec-

tive distress-reducing interventions (Dennis et al. 2007,

Austin et al. 2008). As distress in couples is interrelated, it

is recommended that primary healthcare workers assess

distress in fathers as well as in mothers, provide supportive

interventions, and/or refer to a specialist service (Matthey

et al. 2001, NICE 2007). Nurses and midwives working in

primary care settings are able to assess different levels of

emotional distress in pregnant women. They may also

provide support to those who suffer from mild to moderate

distress (NICE 2007, Furber et al. 2009). Effective psycho-

social interventions are crucial to reduce distress at any level,

and interpersonal psychotherapy has been shown to be

effective for treatment of severe distress (Spinelli & Endicott

2003). However, there is a general lack of evidence-based

intervention studies related to pregnancy-related distress of

prospective fathers (Dennis et al. 2007). This paper contrib-

utes to the literature by redressing the lack of family and

relationship-based interventions for distressed couples during

pregnancy.

Origin

This study originated during the development of a primary

antenatal mental healthcare service for distressed women

living in Iceland during 2007. The service started as a home-visiting programme by psychiatric community nurses for

mentally and chronically ill patients living in the community.

Although community nurses provided services to postpartum

distressed mothers at the time, there was no specific service

for antenatal distressed women. This gave rise to the

establishment of the new nursing service described in this

paper. Midwives started referring an increasing number of

distressed pregnant women to the service, although there was

no evidence at the time it would benefit the prospective

parents. This study was developed in response to this lack of

evidence.

Based on the review of the literature and the theoretical

framework guiding this study, the following hypotheses were

tested:

1.Before the intervention, there is a significant difference

between womens and mens self-reports on:

(a) Depressive symptoms (EDS),

(b) Trait anxiety (STAI),

(c) State anxiety (STAI),

(d) Self-esteem (RSES),

(e) The quality of dyadic adjustment (DAS).

2.Couples improvement on the following indicators is

interrelated with regard to:(a) Depressive symptoms (EDS),





3.After the intervention, there is a significant difference in

couples:

(a) Depressive symptoms (EDS),

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The study

Aim

The aim of this study was to evaluate the clinical effects of an

antenatal family nursing intervention for distressed women

and their partners on depressive symptoms, anxiety, self-

esteem, and dyadic adjustment.

Design

A single group, before and after, quasi-experimental study

was designed with the purpose of testing the family nursing

intervention in standard practice.

Participants

Women attending antenatal care at community health centres

who were found to be distressed by midwives were referred to

the service. These women and their partners were eligible for

the study (n = 70). The couples providing consent were

recruited (n = 61). Inclusion criteria were pregnancy had

progressed to the second or third trimester and the woman

herself had confirmed experiencing distress. Exclusion criteria

were no understanding of Icelandic and the notification of

treatment elsewhere. Due to the lack of distress-reducing

intervention studies for pregnant women that address sample

size, the number of participants recruited for this study was

oriented on intervention studies for postpartum depressed

women. It has been found that there is a 32% difference in

the rate of recovery at 3-month postpartum between groups

of treated and untreated depressed women (Holden et al.

1989). Based on these findings, it has been suggested that a

sample of 44 in an experimental group is sufficient to achieve

80% power (5% significance) to detect a significant differ-

ence (Cooper et al. 2003).

Data collection

Data collection took place from the beginning until the end of

the intervention study which lasted from November 2007

October 2009. Four self-report scales were mailed to the

couple before the intervention with a letter informing

participants about the study and their rights. They were

asked to return informed and signed consent with the

completed scales during the first home visit. The self-report

scales answered, before and after, are as follows: EDS

Edinburgh Depression Scale (Cox et al. 1987), STAI State

and Trait Anxiety Inventory (Spielberger 1983), RSES

Rosenberg Self-Esteem Scale (Rosenberg et al. 1995, Vilhj-

almssonet al.1998), and the DAS Dyadic Adjustment Scale

(Spanier 1976). In addition, assessment by a genogram was

carried out during the first home visit as part of the CFAM

(Wright & Leahey 2005). The self-report scales selected for

this study are related to the cognitive and affective domains

of family functioning, and this information is complemented

by a genogram (Wright & Leahey 2005).

Edinburgh Depression Scale

The Edinburgh Postpartum Depression Scale (EPDS) is a self-

report scale that was originally designed to identify post-

partum depressed women (Cox et al. 1987). It has been

renamed Edinburgh Depression Scale (EDS) after evaluation

for antenatal women and for couples during transition toparenthood (Murray & Cox 1990, Mattheyet al.2001, Cox

& Holden 2003). The scale consists of ten items, and its sum

yields a score ranging from 030. The cut-off point for the

diagnosis of depression is based on studies from other

Western European countries for postpartum women and set

at 12, indicating a high degree of psychiatric morbidity

(Appleby et al. 1997, Guedeney & Fermanian 1998).

Matthey et al. (2001) suggest that a lower cut-off point

should be set for depression or anxiety disorders in fathers

compared with mothers and a score of 5/6 to indicate a dis-

tress case. A validation study for the Icelandic version of the

EDS is not yet available. Two tests of reliability have

confirmed the homogeneity of the translated Icelandic version

with a national sample of 734 postpartum mothers (Cron-

bachs alpha 087; split-half 083) (Thome 1996, 2000).

Cronbachs alpha for women in this study was 081 pre-test

and 089 post-test; for men, respectively, 081 pre-test and

077 post-test.

State and Trait Anxiety Inventory

The measure distinguishes anxiety as either situational or

personality related (Spielberger 1983). The State Anxiety

Scale is used to assess anxiety as a situation-specific response,whereas the Trait Anxiety Scale assesses personality-related

anxiety. Each scale consist of 20 items that asses the intensity

of anxiety symptoms. Scores for each scale can vary from a

minimum of 20 to a maximum of 80, and scores 40 on

either scale indicate severe anxiety. An Australian study

found that men are more likely than women to experience

anxiety disorders without depression in the perinatal period,

and it has been concluded that their anxiety levels should be

M. Thome and S.B. Arnardottir

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assessed, as well as their depression levels (Matthey et al.

2001). The Icelandic version of the STAI has been tested with

a sample of postpartum women aged 1939 and was shown

to be reliable (Cronbachs alpha: Trait anxiety 087 and State

anxiety 082). Mean values of this sample for Trait anxiety

are 354 (SDSD 63) and for State anxiety 302 (SDSD 6 6) (Thome

1996). Cronbachs alpha of State anxiety for women in this

study was 088 pre-test and 091 post-test; for men, respec-

tively, 087 pre-test and 089 post-test. Cronbachs alpha of

Trait anxiety for women was 091 pre-test and 094 post-test;

for men, respectively, 097 pre-test and 095 post-test. Inter-

pretation of these results must take into account little varia-

tion in responses and few respondents.

Rosenbergs Self-esteem Scale

The scale is a 10-item self-report measure of self-esteem. It

has been shown to have test-retest reliability, as well as

convergent and concurrent validity (Rosenberg et al. 1995).

The Icelandic version was tested in a health survey with arandom sample of 1200 adults and has been found reliable

(Cronbachs alpha = 084) (Vilhjalmsson et al. 1998). Cron-

bachs alpha for women in this study was 091 pre-test and

093 post-test; for men, respectively, 090 pre-test and 081

post-test.

Dyadic Adjustment Scale

The self-report scale consists of 32 items and assesses dyadic

adjustment to couple and similar dyadic relationships

(Spanier 1976). Most items are constructed as a Likert-type

scale indicating how well a characteristic fits the subjects

perception of his or her relationship. The sum of weighted

scores varies from a minimum of 0 to a maximum of 151.

The higher the score, the more satisfaction there is with the

relationship and the higher the commitment level to contin-

uing the relationship (Elek et al. 2003). Scores between 92

107 have been proposed to distinguish satisfied partners from

those who are dissatisfied with their relationship (Prouty

et al.2000, Grahamet al.2006). The scale has been used in

studies internationally and distinguishes between distressed

and non-distressed samples (Crane et al. 1990). It has inter-

nal consistency (Cronbachs alpha = 084) (Spanier 1976).

Because of little variation in responses and few respondents inthe sample of this study, internal consistency of the Icelandic

version of the scale was determined by GuttmanFlanagan

split-half. For women pre-test, it was 095 and post-test 095;

for men, respectively, pre-test 093 and post-test 094.

Genogram

The assessment by a genogram generates data on demo-

graphics, the family, and health status. Demographics include

residence, parental age, and parity. Data on family relate to

family structure and relationships, patterns of relationships,

and family response to previous change and difficult life

experience. The health status describes general health and

perceived trauma (Wright & Leahey 2005).

The family nursing intervention

The family nursing intervention consisted of four home visits,

either weekly or monthly depending on the starting point of

the intervention in the second or third trimester. The closing

visit was scheduled near to the due date. Male partners were

offered attendance during the first and last visit, and the

importance of their participation was emphasized. A hypoth-

esis was constructed for each visit according to suggestions by

the authors of the family nursing model (Wright & Leahey

2005). The hypothesis constituted the focus of the conver-

sation with the couple. Each hypothesis followed one opening

question. The sequence of visits, the hypotheses, and theopening questions are summarized in Table 1.

After opening the conversation, the remainder of the

conversation was guided by the items that were uppermost in

the minds of the partners. The conversation was related to

pregnancy and expected parenthood as a transitional period

(Schumacher & Meleis 1994). During the last home visit, the

couple viewed a short video of interaction and communica-

tion between infant and parents and was invited to discuss it

afterwards. After the four home visits, the nurse finalized the

intervention by writing a letter to the couple for the purpose

of enhancing mutual affective and cognitive support and to

remind them of their strengths (Moules 2002, Bohn et al.

2003).

Ethical considerations

Permission for the study was granted by the Icelandic

National Bioethics Committee (VSNb2007030017/03-7). A

prerequisite to participate in the study was informed and

written consent by the medical and nursing directors of the

Primary Health Care of the Capital area. Participation was

voluntary and contained no known risk factors, and all data

were kept confidential.

Data analysis

Differences in mean scores before the intervention between

women and men were analysed by paired t-test. Thechange for

couples over time was analysed in R (version 2.14.0 obtained

from r-project.org) using the package lme4. The data on

couples improvement on all relevant scores were analysed

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separately using an augmented version of repeated measures

ANOVAANOVAto account for the correlation between partners with a

random effect representing couples in addition to the usual

subject effect. The significance of the couple effect and

treatment effect was tested using a likelihood ratio test, whose

test statistic is distributed according to the chi-squared distri-

bution, with significance level of 5%.

Results

The sample and response

The majority of women (95%) who consented to the study

along with their partners named their partner as the closest

family member. One participant named her mother, as the

partner was imprisoned and two women had long-distance

relationships with their partners. The pre-test was completed

by 61 women and 51 men. Data from the post-test were

available for 39 pairs for the EDS, STAI-Trait and State, and

RSES and for 35 pairs for the DAS. There were no significant

differences on the self-report scales between men and womencompleting and those not completing the study with excep-

tion of the EDS for men. Non-completing men had a

significantly lower mean score on the EDS compared with

completers, or 388 (SDSD 12) vs. 642 (SDSD 41); t(49) = 173,

P < 0002. Explanations for not completing the post-test

were inferred from the genogram and the conversations:

problematic relationship (n = 5), heavy workload of partner

or working away from home (n= 6), severe illness (2),

imprisonment of partner (n = 1), moved away (n = 1), and no

clear reason (n = 6). All women participated initially in the

conversations and one dropped out after two home visits. Of

their partners, 32% participated twice or more often, 49%

attended once, and 19% never attended. Two-thirds of those

never attending did not complete the post-test.

All couples resided in the Capital area. The mean age of the

women was 27 (SDSD 5 1) years, and the mean age of the men

was 30 (SDSD 56); 44% of the women were primiparas and

56% were multiparas. Sedative drugs were taken by 246%

(n = 15) of the women, although they had reported receiving

no treatment elsewhere.

Symptoms of depression and anxiety, self-esteem, and

dyadic adjustment before the intervention

Testing of hypothesis one revealed that men and women differ

significantly on all self-report scalebefore the intervention with

exception of dyadic adjustment: EDS t(50) = 951,

P < 0001); STAI-trait [t(48) = 293,P < 0005; STAI-state

t(49) = 5

95,P

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