Experiences of interaction between teenage mothers and visiting nurses: a phenomenological study^*

ABSTRACT

Objective

To understand the experiences of interaction between teenage mothers and visiting nurses in the Young Mothers Caregivers Program.

Method

Qualitative research using the theoretical-methodological framework of Social Phenomenology, with phenomenological interviews with visiting nurses and teenage mothers.

Results

Three visiting nurses and nine teenage mothers participated. The understanding of the experiences led to the elaboration of three categories of contexts of meanings related to the past and present: “Experiences of participation in the PJMC”; “The interaction experienced by visiting nurses and teenage mothers”; “Parenting and maternal role”.

Conclusion

The interaction between visiting nurses and teenage mothers in the program was characterized as positive, as it provided the mother with greater security in her maternal and parental role. The attitudes of nurses and adolescent mothers were fundamental for establishing a positive interaction.

Mothers; Adolescent; House Calls; Nurse-Patient Relations; Family Nursing; Pregnancy in Adolescence

RESUMO

Objetivo

Compreender as vivências de interação entre mães adolescentes e enfermeiras visitadoras no Programa Jovens Mães Cuidadoras.

Método

Pesquisa qualitativa, em que se utilizou o referencial teórico-metodológico da Fenomenologia Social, sendo realizadas entrevistas fenomenológicas com enfermeiras visitadoras e mães adolescentes.

Resultados

Participaram três enfermeiras visitadoras e nove mães adolescentes. A compreensão das vivências permitiu a elaboração de três categorias de contextos de significados relacionados ao tempo passado e presente: “As vivências de participação no Programa Jovens Mães Cuidadoras”; “A interação vivida por enfermeiras visitadoras e mães adolescentes”; “Parentalidade e papel maternal”.

Conclusão

A interação entre enfermeiras visitadoras e mães adolescentes no programa foi caracterizada como positiva, por proporcionar à mãe maior segurança em desempenhar seu papel maternal e parental. As atitudes das enfermeiras e das mães adolescentes se mostraram fundamentais para o estabelecimento de interação positiva.

Mães; Adolescente; Visita Domiciliar; Relações Enfermeiro-Paciente; Enfermagem Familiar; Gravidez na Adolescência

RESUMEN

Objetivo

Comprender las vivencias de interacción entre madres adolescentes y enfermeras visitadoras del Programa Jóvenes Madres Cuidadoras.

Método

Se trata de una investigación cualitativa, en la que se utilizó el referencial teórico-metodológico de la Fenomenología Social mediante entrevistas fenomenológicas entre enfermeras visitadoras y madres adolescentes.

Resultados

Participaron tres enfermeras visitadoras y nueve madres adolescentes. La comprensión de las vivencias posibilitó la elaboración de tres categorías de contextos significativos relacionados con el tiempo pasado y el presente: “Vivencias de la participación en el Programa Jóvenes Madres Cuidadoras”; “Interacción entre enfermeras visitadoras y madres adolescentes”; “Parentalidad y papel maternal”.

Conclusión

La interacción entre las enfermeras visitantes y las madres adolescentes del programa se caracterizó por ser positiva, lo que proporcionó a la madre una mayor seguridad en el desempeño de su función materna y parental. Las actitudes de las enfermeras y las madres adolescentes fueron fundamentales para establecer una interacción positiva.

Madres; Adolescente; Visita Domiciliaria; Relaciones Enfermero-Paciente; Enfermería de la Familia; Embarazo en Adolescencia

INTRODUCTION

According to the World Health Organization, adolescents are people between 10 and 19 years of age(¹). In this phase, adolescents commonly engage in risky sexual behavior, which, in some cases, may lead to unplanned pregnancies, especially in socioeconomically vulnerable populations(²).

Health education actions developed by the Family Health Strategy and the Health at School Program with the objective of reducing teenage pregnancy rates in Brazil resulted in a reduction of three percentage points in the rate of live births to teenage mothers in the country(³).

The neurological development of teenage mothers makes them more prone to interventions offered through home visits (HV) when compared to adult mothers(⁴), considering that maternity in adolescence is a risk factor in the development of children(⁵) and in the construction of parenting(⁴,⁶).

HV represent a moment of approximation to the reality of the family, strengthening of bonds and understanding of the socio-cultural context. The visit allows for a relationship based on dialogue and openness between the home visitor and the individual(⁷), as well as a broad and collaborative interaction in relation to the individual needs(⁸).

Nurses are health professionals with the discernment and knowledge necessary to support mothers through HV, considering that they demonstrate responsibility in health care and have different skills in different areas of human development(⁹). Given the importance of these professionals, most programs choose them as the home visitors responsible for providing home interventions for mothers(⁹).

The meeting between nurses and mothers at home is considered an interaction that generates mutual influence between those involved through communication, dialogue and relationship. The quality of this interaction provides a closer approximation and better comprehension of the mothers’ needs(⁸).

Understanding the interaction between the home visitor and the mother is fundamental for these programs to know what happens during the intervention and whether the relationships established favor the objectives of the programs to be achieved. Little is known about the quality of interactions between home visitors and mothers in home visiting programs. Therefore, this study aims to understand the experiences of interaction between teenage mothers and home visiting nurses in the Young Mothers Caregivers Program (PJMC – Programa Jovens Mães Cuidadoras).

METHOD

TYPE OF STUDY

Qualitative study following the theoretical/methodological framework of social phenomenology of Alfred Schütz, which enables the understanding and interpretation of lived experiences and human actions that occur in the world of life and within the context of social relations, which result in meanings(¹⁰).

This approach has the intention of observing the other at the social level, that is, observing the experience within the context of social relations and bringing with it a social meaning(¹⁰). The “reasons-why” portray the flow of human action, giving meaning to past experiences(¹⁰).

The justification for adopting Alfred Schütz’s approach to social phenomenology in nursing research includes the valuing of care and the search for different ways of appreciating/understanding care. Therefore, social phenomenology is appropriate for nursing research(¹¹).

SCENARIO

The study was conducted in the context of the Young Mothers Caregivers Program (PJMC), implemented by a group of Brazilian researchers of the Universidade de São Paulo in the city of São Paulo (SP), Brazil. The program is being tested and implemented in the research “The effects of the visiting program for young pregnant women on child development: a pilot study” since August 2015(¹²).

Interventions with primiparous adolescents between 14 and 19 years of age who live in situations of social vulnerability occur through HV carried out by nurses, starting in pregnancy and lasting until the child is two years old. These interventions have the purpose of: improving pregnancy results by helping adolescents to improve prenatal health; improving health and social and cognitive development of the child; preparing parents and families to adjust their bond with the infant; offering sensitive and competent care; and improving the life course of mothers and parents by helping them to develop a vision for their future, restarting life projects planned before pregnancy(¹²).

On average, each adolescent receives between 58 and 63 HV during the entire period of follow-up by the nurse. This number may vary according to the gestational age in which the adolescent began to participate in the program(¹²). During the data collection period, the PJMC had three visiting nurses and 30 adolescents being monitored.

The three visiting nurses and nine teenage mothers participated in the study. The number of participants was ideal for understanding the phenomenon in qualitative research(¹³).

The inclusion criterion was visiting nurses and adolescents linked to the PJMC at the time of the interview. The inclusion criteria for teenage mothers were: having received 70% or more of the HV programmed for pregnancy, postpartum and after the child was born; and having children between 10 and 12 months old, as the mother would have already received HV in all periods provided by the PJMC.

DATA COLLECTION

Data was collected by the main researcher from January to February 2017, through a phenomenological interview used to describe the experiences(¹⁴). Interviews were conducted with each teenage mother and visiting nurse at the same time, in the teenage mother’s home. One highlights that, before data collection, the researcher had contact with the visiting nurses through the PJMC supervisions, because she was a member of the research group; however, she had no relationship with the teenage mothers.

To schedule the interviews, the researcher searched the program’s database to find the number of teenage mothers who met the inclusion criteria, and then contacted the visiting nurse.

After scheduling the best day and time for the participants, the interview was conducted in a single meeting at the mothers’ home, with the presence of the main researcher, the visiting nurse and the adolescent.

The following guiding questions were adopted in the interview: “How was the participation in the PJMC for you?” and “How did the experiences of interaction affect parenting and the construction of the maternal role?”, selected after a pilot test.

The nurse and the mother described their interaction experiences in the same interview, that is, a question was asked and both answered, complementing each other and not interfering in each other’s statements. Each interview lasted an average of 50 minutes.

DATA ANALYSIS

The analysis and organization of the data followed the recommended steps of the methodological framework adopted(¹⁰). First, interviews were transcribed verbatim by the main researcher; then each interview was carefully and fully read and reread, with the objective of gaining familiarity with the lived experiences.

After this stage, the interviews were reread with the purpose of grouping significant content of the speeches for the construction of the concrete categories of the lived, which emerged from the experiences of the participants to understand the phenomenon(¹⁰).

This study is part of a doctoral dissertation that investigated the interactions between visiting nurses and teenage mothers. However, this piece only addresses the experiences of interaction, including only the context of meanings understood in social phenomenology as the “reasons-why”, which are related to past experiences that have developed throughout life(¹⁰).

ETHICAL ASPECTS

The study was approved by the Research Ethics Committee of the Faculty of Medicine of the Universidade de São Paulo, protocol number 1.397.051, 2015.

All ethical precepts on research with human beings established in Resolution No. 446/2012(¹⁵) of the National Health Council were respected. Before obtaining the interviews, a detailed explanation of the objective, methods and potential risks and benefits of the study was provided. All research participants read, along with the researcher, and signed the Informed Consent Term (TCLE).

In cases where the adolescent was under the age of 18 years, her legal guardian signed the consent form.

RESULTS

The study included nine teenage mothers and three visiting nurses. Among the teenage mothers, seven were between 18 and 20 years old and two were 16 years old; seven mothers were single, one was married, and one was in a stable relationship; all had not completed high school. As for their children, three were 10 months old, two were 11 months old and four were 12 months old. The number of HV received ranged from 15 to 18 during pregnancy, from 5 to 6 in the puerperium and from 15 to 20 when the children were between 1 and 12 months.

The age of the visiting nurses ranged from 28 to 51 years; two were single; two had graduate, specialization and master’s degrees. Only one nurse had previous professional experience. Two of them had been in the program for 24 months and the other one for 18 months. The number of teenage mothers that nurses visited varied from eight to 12.

The analysis of the interviews led to the elaboration of categories that represent typical characteristics regarding the understanding of the experiences of interaction between nurses and teenage mothers in the program, based on the context of meanings related to the past and present (“reasons-why”). The categories were called: “Experiences of participation in the PJMC”; “The interaction experienced by visiting nurses and teenage mothers”; “Parenting and maternal role”. All categories are presented below.

EXPERIENCES OF PARTICIPATION IN THE PJMC

Adolescent mothers feel privileged to participate in the PJMC since pregnancy and affirm that this participation allowed them to acquire knowledge about childcare.

It’s very good! It came at the right time [laughs], this program. I liked it a lot. It’s good! I have been part of the program since I was pregnant, to learn about my daughter’s development, and nobody has that. I feel privileged (A5).

For visiting nurses, being part of the team of professionals in the program is gratifying, and they refer to it as a positive experience, which provides professional and personal growth.

For me it was an experience, it has been a very good experience, professionally too (...) so I think that professionally and personally it has been very gratifying (N2).

Participation in the PJMC makes the teenage mothers happy to receive the visiting nurse at home to talk, help, provide support and keep them company.

I am alone here in São Paulo, I have no one to help me, only [name of the nurse], she is the only one who helps and supports me. That’s why this program is so important to me, I don’t feel so alone (A9).

The support and advice provided by visiting nurses was essential for facing problems or difficulties, and together, mothers and nurses talked about strategies to deal with situations.

At the beginning of my pregnancy I was going through a very difficult time. So it was important for me to have someone to talk to (...) and [name of the nurse] was someone I saw as an older person that I could talk to, who could give me advice, because I had no one (A2).

I think it was more in the realm of family conflicts (...) we had to face this together, thinking about strategies, thinking about ways of dealing (N2).

THE INTERACTION EXPERIENCED BY VISITING NURSES AND TEENAGE MOTHERS

This category reveals that the interaction was perceived as positive by the teenage mothers, because they trusted the nurse and felt safe and since they had developed a relationship of friendship and felt free to express themselves, to speak, to be heard and to receive advice, support and help without judgment.

I think we became friends first; you know? Having the freedom to talk about anything and not having this thing where you say something and the person comes at you to reprimand you and lecture you. First, she listens to me and then she says what she thinks is best. A relationship of trust, I trust [name of the nurse] a lot. You feel safe. It is a trust that I have (A1).

Visiting nurses also understand that the interaction was positive because it allowed them to establish a peaceful, close, intimate, honest relationship with mothers, with freedom to express themselves.

I think it’s a peaceful relationship, you know? [Name of the adolescent] is free to tell me what she wants to (...) it is a respectful relationship too (N1).

I think that, with the passing of the days, we grew more intimate, you know? I think this is an interaction, we got closer to each other (N3).

The attitudes of visiting nurses that helped to establish a positive interaction were: tone of voice, being calm, thoughtful, polite, sincere and showing affection.

I think she is a very nice person. I understand everything she says. She speaks calmly, her voice is very soft (...) I think she is very polite and honest (...) the way she explains things is calm, we understand everything (A6).

I really like her [nurse], the way she acts with me, she shows affection, love, fondness all the time that we are together, we have a nice interaction (A8).

In addition, some attitudes of teenage mothers, such as openness to dialogue, receptivity and interest, helped to establish a positive interaction.

The relationship with [name of the adolescent] was very easy since the beginning. She is very receptive and was always very interested in everything we did (...) so our visits were always very rich, we were able to interact with each other very well (N1).

She [adolescent] is very open and free to talk and tell things and ask, I think it has been very good for both of us, for us to be able to interact (N2).

Positive interaction is recognized when teenage mothers follow and apply everything that they have been taught, due to the trust and interaction with the visiting nurse.

(...) I feel safe with her, it is a trust that I have, everything she says I follow to the letter (A2).

Her [teenage] willingness to learn, her receptivity to having me here made her put into practice everything that I tried to teach during the visits, and we were able to interact with each other (N1).

The teenage mothers contacted the nurses through text messages, social media and/or phone calls when it was not visiting week, so they could clear up any questions, keep in touch and/or when an important event happened, which also demonstrates the positive interaction between them.

And in addition to the visits, I tried to contact her [nurse] through other ways, by phone, text, to talk to her when I needed to know something or wanted to tell her something new (A4).

And she [adolescent] sends me texts too! In addition to texts with questions, I received comforting messages, to keep in touch, I guess. I don’t know, the interaction between us is very strong (N3).

I was happy when it was visiting day, you know? I also liked it a lot when she [nurse] came to visit me, I didn’t miss any visits (A5).

Another fact that demonstrates a positive interaction is when teenage mothers verbalize that they like to receive the HV and that they feel anxious to know the date of the next HV so that they do not miss it.

I think that when the day of the visit is coming, I already call her [nurse] to ask what day it will be. Because I like it, I like that my son is well cared for, and so am I [laughs] (A4).

The fact that the interventions occurred at the teenage mother’s home was important for the establishment of a positive interaction and a closer relationship.

If I receive this care elsewhere, I will not interact like I interact here, at home (...) so it is good that it is at home! (A4).

I think that being at home only strengthened the care, you know? I feel closer to her [adolescent], to her environment, here I can have a sense of how things happen (N2).

Monitoring and conducting interventions during pregnancy helped to establish the interaction between the teenage mother and the visiting nurse, and made the teenage mother recognize the nurse as someone important in her life.

She [nurse] started to accompany me during my pregnancy, so it seems like she is part of my family. Because each month, each minute, each kick of her [daughter], her first word, her first steps, her first smile, I told her [nurse] (...) we have a good interaction (A5).

And I see her [adolescent] as a daughter [laughs], I take care of all of them with great affection, like they’re my family. It’s been a long time together, since pregnancy (N3).

The participants only expressed one difficulty for establishing the interaction, which was the change of the visiting nurse that occurred during the program.

In the beginning I was quieter, I hardly spoke, because she was the third nurse who accompanied me. When I started to let loose, they changed nurses. But now she has won me over, now we are close (A6).

I thought it was a little weird, when I started to get used to it, they changed nurses. Then I got used again, and it changed again (...) it was difficult to interact with the nurse (A9).

In the beginning, she [name of the adolescent] was cold (...) when I tried to get closer, she would create a barrier. Then I said, “I will have to really get to know (name of the adolescent) in order to help”, and I started to make her feel at ease and make her trust that there would be no more change of nurses, that I would take care of her until the end. Then it went like this, until I gained her trust (N3).

PARENTING AND MATERNAL ROLE

The positive interaction established between visiting nurses and teenage mothers promotes knowledge, parenting competencies and construction of the maternal role. Teenage mothers point out that the positive interaction with the nurse and the knowledge obtained in the HV helped them to assume their role as mothers.

There is really care for me and for my son, you know? What is right, what is wrong, when I’m undecided, you know? (...) it helped me to remain a strong mother, a capable mother, she showed me that I am able of being a mother even at a young age (A7).

And visiting nurses recognize that adolescents were able to assume their maternal role through positive interaction.

In her care with [child’s name] you can see that she [teenage mother] received the information and that through our interactions during visits we managed to build a very good care for her to be a good mother (N2).

[Name of the adolescent] has what I think is a gift, let’s say it’s a gift, it’s her natural gift to be a mother and our interactions only enhanced that in her (N3).

Positive interaction and HV were fundamental for the development of parenting competencies such as: mother-child interaction, playing, talking, inclusion of the father in care such as feeding and bathing and promotion of a healthy development and growth.

I was taught that a happy child is a child who receives attention, who knows when to play, when it’s bath time, who talks a lot, plays a lot, because everything is new for him [son] (...) so I talk to him a lot, I play with him, I have to be a child too, you know? (...) the program has showed me that I am his mirror (A7).

I couldn’t manage without anyone to help me, you know? When I have to put him to sleep, when it’s time to play, these things. It was all her [nurse], she was the one who helped me (A8).

We always talked a lot about how it would be after the birth of the child, what it was like to be a mother. In her care with [child’s name] you can see that she received the information and that we managed to build a very good care for her to be a good mother for her [child] (N2).

DISCUSSION

The experience of interaction with the home as the locus leads to the construction of meanings and promotion of a teaching and learning process of positive parenting practices and construction of the maternal role, which helps the adolescent to restructure and adapt to her new role.

Participation in intervention programs with HV has a significant meaning for mothers, as it promotes knowledge about their health during pregnancy and puerperium and about appropriate child development(¹⁶-¹⁷).

A study carried out in the United Kingdom on a visitation program called Family Nursing Partnership points out that visiting nurses like to do their job of listening and intervening according to the mothers’ demands at home. In addition, the professionals recognize this action as a gratifying job and as a source of positive transformations in their personal and professional life(¹⁷).

The visits from nurses are important for adolescent mothers, as they can have someone to talk to, who listens to them and provides support in the care during pregnancy and after the child’s birth(¹⁶). Moreover, when there is any complication, concern and/or insecurity, mothers seek the visiting nurse for help and reassurance(¹⁶,¹⁸).

Thus, visiting nurses can be important for teenage mothers when they establish a friendly and non-critical relationship. In these cases, the nurse is seen as a friend, sister or second mother(¹⁶).

A positive interaction facilitates communication and exchange of information(¹⁸). It also make mothers follow the guidelines received during visits to promote child development and growth(¹⁶,¹⁹)and to perform their maternal role(¹⁷,²⁰), resulting in positive parenting(²¹).

As in other studies, it was observed that a positive interaction between the visitor and the mother/family is the main element for HV to be enhanced and have good results(¹⁹).

However, establishing an interaction with the mother is a challenge for the visiting nurse when the program changes the visitor, considering that that the mothers do not connect with the new visitor(²²).

In order to obtain positive results and to be successful, a visiting program must take into consideration the needs of each mother and the necessity to establish a helping relationship based on the positive interaction between those involved(²²).

The home is the ideal environment for individualized care and positive interaction(¹⁹). These programs are designed to provide support for young mothers in the construction of parenting, helping them to build their own maternal capacities and promoting the appropriate development of the child(²³).

A limitation of the study is that it was carried out in a single setting, the PJMC, which is implemented in only one region of the city of São Paulo. Therefore, carrying out similar studies in other realities can bring new perspectives for the interpretation/understanding of the experience of interaction between visiting nurses and teenage mothers.

As implications for practice, the results of the present study can contribute to the improvement and optimization of the work of visiting nurses in home visiting programs, and can support their understanding and comprehension of the interventions they perform.

CONCLUSION

A positive interaction is one in which the professional is able to achieve the objective of the visit and which brings benefits and changes of attitudes to those involved. Thus, the positive interaction between teenage mother and visiting nurse, in this study, was characterized by trust, friendship, intimate and close relationship, freedom of expression, open and judgment-free communication, respect, promotion of information, support to deal with different situations and contact outside the HV through calls and texts.

The nurses’ actions that promoted a positive interaction were: being available to listen; using a calm tone of voice; allowing the exchange of knowledge and experiences; establishing open, direct and easy-to-understand communication; meeting the demands and clearing up the questions of the mothers; honesty; showing affection, care and attention to the mother; being friendly and not judging and criticizing.

The experiences of interaction with the visiting nurses were characterized as positive when teenage mothers followed and reproduced the care that was taught and discussed during the HV. Also, the teenage mothers followed the guidelines of the visiting nurse when they felt safety and trusted in them, and when they longed for the day of the HV.

The results of this study showed the need to value and recognize the positive interaction between visiting nurses and adolescent mothers in HV as support for positive parenting and for the construction of the maternal role.

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  » https://doi.org/10.1080/10888691.2017.1357475
• ²¹
  Huntington C, Vetere A. Coparents and parenting programmes: do both parents need to attend? J Fam Ther. 2016;38(3):409-34.DOI: https://doi.org/10.1111/1467-6427.12092
  » https://doi.org/10.1111/1467-6427.12092
• ²²
  Sierau S, Dähne V, Brand T, Kurtz V, von Klitzing K, Jungmann T. Effects of home visitation on maternal competencies, family environment, and child development: a randomized controlled trial. Prev Sci. 2016;17(1):40-51. DOI: 10.1007/s11121-015-0573-8
  » https://doi.org/10.1007/s11121-015-0573-8
• ²³
  Slade A, Holland ML, Ordway MR, Carlson EA, Jeon S, Close N, et al. Minding the Baby®: enhancing parental reflective functioning and infant attachment in an attachment-based, interdisciplinary home visiting program. Dev Psychopathol. 2020;32(1):123-37. DOI: 10.1017/S0954579418001463.
  » https://doi.org/10.1017/S0954579418001463

• *
  Extracted from the thesis: “Construção do papel maternal: um estudo fenomenológico acerca das vivências de interação entre mães adolescentes e enfermeiras”, Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem, Universidade de São Paulo, 2019.

Publication Dates

• Publication in this collection
  27 Nov 2020
• Date of issue
  2020

History

• Received
  30 Sept 2019
• Accepted
  18 Dec 2019