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This is to certify that the

thesis entitled
SELF-CARE PRACTICES OF WOMEN
WHO EXPERIENCE NAUSEA
AND VOMITING DURING PREGNANCY

presented by

Michele K. Sturt

has been accepted towards fulfillment
of the requirements for

Master of Science degree inNursing

 

 

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Date February 26, 1992

 

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MSU Is An Affirmative Action/Equal Opportunity Institution
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SELF-CARE PRACTICES OF WOMEN WHO EXPERIENCE
NAUSEA AND VOMITING DURING PREGNANCY

BY

Michele K. Sturt

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

COLLEGE OF NURSING

1992

ABSTRACT

SELF-CARE PRACTICES OF WOMEN WHO EXPERIENCE
NAUSEA AND VOMITING DURING PREGNANCY

BY
Michele K. Sturt

A descriptive study using Orem's (1985) model was
conducted to explore the use and effectiveness of self-care
practices of women experiencing nausea and vomiting during
pregnancy (NVP). Of the small sample (N=30) of women, 63
percent experienced NVP during their pregnancy. An
investigator developed instrument included items about the
experience of pregnancy, sociodemographic information, and
39 self—care practices for NVP. All practices were tried,
however, the eight practices perceived as most effective for
nausea and/or vomiting were not necessarily the most
frequently used. Two clusters of practices were identified
and found to be associated with education and employment of
subjects. Nurses were not viewed as sources of information
about self-care by these subjects. Nurses need to provide
education about the variety and perceived effectiveness of
self-care practices prior to or very early in pregnancy.
More research information about the cluster and sequencing

of self—care practices with different samples is needed.

Copyright by

Michele K.

1992

Sturt

ACKNOWLEDGEMENTS

My sincere thanks to the members of this thesis
committee, Rachel Schiffman, R.N., Ph.D., Manfred Stommel,
Ph.D., Brigid Warren, R.N., M.S.N., and Jackie Wright, R.N.,
M.S.N. for their support and guidance throughout this
research study. I am particularly grateful to Rachel
Schiffman for not only her expertise and knowledge in the
research process, but for her steadfast encouragement and
commitment to see this research to completion. She helped
in making an often challenging long distance endeavor a
reality. I would also like to thank Manfred Stommel for his
statistical and grammatical expertise which he shared with
great patience.

My heartfelt appreciation to my husband, Dan, for his
never ending support, encouragement, and various domestic
talents. To my mother, Lili, who offered her loving
services as Grandmother whenever the call, thank you. And
finally, a special thank you to my wonderful sons, Daniel,
Wesley, Griffin, and Ryder whose in-utero development helped
me to become intimately familiar with the problem of nausea
and vomiting during pregnancy, which provided the motivation

and enthusiasm for this study.

iv

Table of Contents

List of Figures . . . . . . . . . . . . . . . . . .
List of Tables . . . . . . . . . . . . . . . . . .
List of Appendices . . . . . . . . . . . . . . . .
CHAPTER I THE PROBLEM -

Introduction of the Study . . . . . . . . . . . . .
Purpose of the Study . . . . . . . . . . . . .
Problem Statement . . . . . . . . . . . . .
Overview of Chapters . . . . . . . . . . . .

CHAPTER II CONCEPTUAL FRAMEWORK
Overview . . . . . . . . . . .
Orem's Theory of Self—Care . . .
Conceptual Definitions . .
Application to the Study . . . .
Summary . . . . . . . . . .
CHAPTER III REVIEW OF LITERATURE
Overview . . . . . . . . . . .
Self—Care for Nausea and Vomiting
Self-Care . . . . . . . . . . . .
Summary . . . . . . . . . . . . .

CHAPTER IV METHODS AND PROCEDURE

Overview . . . . . . . . . . . .
Procedures . . . . . . . .

Sample . . . . . . . . . . . . .
Instrument . . . . . . . . . . .

a e o o o o a 0

During Pregnancy

12

18

23

23

30

36

Data Collection . . . . . . . . . . .

Data Analysis . . . . . . . . . . . .

Methodological Assumptions and Limitations

Protection of Human Subjects . . . .
Summary . . . . . . . . . . . . . . .
CHAPTER V RESULTS

Overview . . . . . . . . . . . . . .
Description of the Sample . . . . . .
Experience of NVP . . . . . . . . . .
Self-Care Practices . . . . . . .
Source of Self—Care Information .
Self-Care Practice Scales . . . . . .
Analysis of Variance/Sociodemographics

Summary . . . . . . . . . . . .

CHAPTER VI INTERPRETATION, IMPLICATIONS,

Summary of the Study . . . . . . . .

Interpretation . . . . . . . . . . .

Implications for Advanced Nursing Practice

Implications for Research . .
Summary . . . . . . . . . . . . . . .
Reference List . . . . . . . . . . .

vi

43

45

47

48

48

50

50

50

52

58

58

60

61

AND RECOMMENDATIONS

64

66

71

74

75

76

List of Figures

Figure Page

1

The Relationship Between the Performance
Self-Care Practices for NVP and the Pregnant
Self-Care Agent, the Nurse Agent, and the

Therapeutic Self-Care Demand for NVP. .

vii

List of Tables

IQQLQ EQQQ
1 Sociodemographic Variables . . . . . . . . . . . . . 51
2 Frequency and Percent of 39 Self-Care Practices (SCP

Used for NVP in Rank Order . . . . . . . . . . . . . 54
3 Effectiveness Rating for Eight Most Frequently Used

Self-Care Practices for NVP . . . . . . . . . . . . 55
4 Self-Care Practices Perceived Most Effective for

Relief of Nausea . . . . . . . . . . . . . . . . . . 57
5 Self-Care Practices Perceived Most Effective for

Relief of Vomiting . . . . . . . . . . . . . . . . . 57
6 Self-Care Practice Scales--Proper Diet and

Avoidance . . . . . . . . . . . . . . . . . . . . . 59
7 Oneway Analysis of Variance for Proper Diet Scale

and Categories of Sociodemographic Independent

Variables . . . . . . . . . . . . . . . . . . . . . 62
8 Oneway Analysis of Variance for Avoidance Scale

and Categories of Sociodemographic Independent

Variables . . . . . . . . . . . . . . . . . . . . . 62

viii

List of Appendices

Appendix

A Human Subjects Approval . . . . . . . . . .
B Letter of Support for Data Collection . . .
C Letter of Instruction for Distribution

of Instrument

The Instrument:

with NVP

Self-Care Practices of Women

ix

84

86

CHAPTER I
THE PROBLEM
Introduction of the Study

Emesis gravidarum, or nausea and vomiting during
pregnancy, particularly early pregnancy, is accepted by both
the medical and lay community as an extremely common
occurrence. For centuries women have suffered from nausea
and vomiting during pregnancy and have been the recipients
of many varied therapies, some effective, some not (DiIorio,
1988; Jarnfelt-Samsioe, 1987; Kullander & Kallen, 1976;
Walters, 1987). Nausea and vomiting during pregnancy has
historically been considered one of the earliest diagnostic
symptoms for pregnancy and has even been linked with a
decreased incidence of miscarriage and stillbirth (Brandes,
1967; Fairweather, 1968; Jarnfelt-Samsioe, 1987; Klebanoff,
Koslowe, Kaslow, & Rhoads, 1985; Petitti, 1986). Incidence
rates of nausea and/or vomiting during pregnancy vary within
a range of 50 to 86% in the 0.8. (Hillard, 1985; Alley,
1984; DiIorio, 1985). Of biologic interest, there appears
to be no species other than our own that develops this
complex not even higher primates (Fairweather, 1968; Hook,
1980).

The high incidence of nausea and vomiting during
pregnancy and the variety of therapies reported in the
literature suggest that this is an important problem for
pregnant women. In addition, women appear to adopt many

different ways of coping'With the problem of nausea and

2
vomiting. However, the variety and effectiveness of the
coping strategies have not yet been explored sufficiently.
Consequently, this study will focus on what self-care
practices are used to relieve the discomfort of nausea and
vomiting during pregnancy.

The research and literature concerning nausea and
vomiting during pregnancy rarely deals with the women's
perceptions of nausea and vomiting. As a result, treatment
or therapy, including teaching and counseling, presently
offered by health care professionals, such as the Clinical
Nurse Specialist, are not necessarily based on client data
(Alley, 1984). In an effort to provide effective and
appropriate supportive care for the women suffering from
nausea and vomiting during pregnancy, it would be
advantageous for health care professionals to: 1) have an
accurate understanding of how nausea and vomiting during
pregnancy is perceived by the client to affect her life in
terms of distress; and 2) have an understanding of which
self-care practices have been and continue to be used by
those women who suffer from nausea and vomiting during
pregnancy.

In an effort to classify and categorize the varying
degrees of nausea and vomiting experienced by many pregnant
women, Katon, Ries, Bokan, and Kleinman (1980), have
identified three distinct syndromes of nausea and vomiting
during pregnancy. The first syndrome, is the least common

with nausea and vomiting beginning to occur during the third

3 .
trimester of pregnancy. This syndrome is thought to be the
most likely syndrome associated with a purely organic versus
a multi-causal etiology.

Hyperemesis gravidarum is the second syndrome. This
syndrome can be described as nausea with vomiting during
pregnancy of such severity as to warrant hospitalization for
fluid and electrolyte replacement due to dehydration and
nutritional deficits. This syndrome occurs predominantly in
the first trimester of pregnancy with the incidence rate of
between 1 to 5 women per 1000 (Fuchs et al., 1980).

The third syndrome, which is the focus of this study,
is usually called "morning sickness", or emesis gravidarum.
In this study it will be referred to as nausea and vomiting
during pregnancy (NVP). This syndrome presents as mild
symptoms of nausea with or without vomiting that are
associated with the first trimester of pregnancy. A classic
diagnostic symptom of pregnancy, NVP occurs most commonly
between 4 and 12 to 16 weeks of gestation, peaking during
the second and third months. NVP is rarely noted after
twenty weeks of gestation when incidence rates drop off to
less than 10% occurrence (Klebanoff et al., 1985). Although
there can be considerable discomfort associated with the
nausea and vomiting in this syndrome, enough food is
actually tolerated on a daily basis so that nutrition and
weight gain are not significantly affected for the fetus or

mother with morning sickness.

4

Generally, pregnant women experience greater discomfort
with nausea and vomiting in the morning, thus the term
"morning sickness". But some women experience nausea and/or
vomiting in the afternoon or evening, and a small percentage
of women experience nausea and/or vomiting throughout the
day and night (DiIorio, 1988). Symptoms of NVP include mild
to severe discomfort from nausea lasting anywhere from one-
hour to all day. Aversions to smells and tastes, such as
those of coffee, smoke, and greasy foods usually accompany
or can even incite nausea. This may be a protective
mechanism for avoidance of harmful or aggravating substances
(DiIorio, 1985; Hillard, 1985).

Necessary daily tasks such as preparing meals or
driving a car can increase the nausea and vomiting in
pregnancy. Motion of any vehicle or craft, increased heat
or hot weather and fatigue and emotional upsets have also
been identified by pregnant women to increase nausea and
vomiting (Alley, 1984; Hillard, 1985). Descriptions of NVP,
offered by pregnant women suffering from this malady,
include "queasy feeling", "stomach is going to come out",
"awful", "terrible", "annoying", and "like I'm going to die"
(Alley, 1984). This broad range of descriptions indicates
the range of discomfort experienced by women with NVP.

The etiology of NVP remains unclear (Fairweather, 1968;
Klebanoff et al., 1985). This uncertainty is also reflected
in the many variations of therapy for NVP (Jarnfelt-Samsioe,

1987). The commonality and self-limiting nature of NVP may

5
be two reasons why NVP has not been given much attention in
research studies (Klebanoff et al., 1985). Unlike
hyperemesis gravidarum, which can be debilitating and even
life threatening, NVP is at worst a very unpleasant,
uncomfortable, and annoying phenomenon.

In the mid 1980's there was brief renewed interest in
the management of NVP when Bendectin, a widely used
antiemetic drug effective in the treatment of NVP, was
withdrawn from the market. During the 1970's and early
1980's Bendectin was used by an estimated 33 million women
worldwide (Hillard, 1985; Walters, 1987). With Bendectin no
longer available to pregnant women in the U.S., health care
providers were again at a loss as to the appropriate
treatment for NVP. The controversy and legal battles that
surround Bendectin have, no doubt, deterred other drug
manufacturers from further research efforts in the area of
antiemetics for pregnant women.

Several hypotheses concerning the etiology of NVP have
been suggested over the years. One very popular hypothesis
suggests abnormally increased hormonal levels as the
possible cause for NVP. Increased levels of human chorionic
gonadotrophin (HCG), hypofunction of adrenal cortex or lower
levels of endogenous adrenocorticotropic hormone (ACTH) have
also been identified as possible causes of NVP (Depue,
Bernstein, Ross, Judd, & Hendersen, 1987; Jarnfelt-Samsioe,

1987). Most reports focus on increased hormonal levels in

6
women with the more severe hyperemesis gravidarum rather
than those with emesis gravidarum or NVP.

Still another theory offered by Walters (1987),
suggests that stimulation of various sensory nerve endings
throughout the body triggered by one or more hormones
produced in early pregnancy act in concert with
psychological factors to produce NVP. There is a small body
of literature which supports a strong psychogenic factor in
the causation of NVP (Fuchs et al., 1980; Long, Simone, &
Tucher, 1986; Zechnich & Hammer, 1982).

Without a clear scientific understanding of the cause
or causes of NVP, a definitive medical treatment is not
likely. The treatment offered is varied and primarily-
supportive (Alley, 1984; Brucker, 1988; DiIorio, 1988).
Professional recommendations can include pharmaceuticals,
dietary adjustments, and psychologic support (DiIorio, 1985;
Hillard, 1985; Hotchner, 1979; Midwinter, 1971; Petitti,
1985). Lay resources also recommend dietary changes,
vitamin therapy, teas, and psychologic support (Cooke &
Dworkin, 1979; Eisenberg, Murkoff, & Hathaway, 1986;
Patterson, Freese, & Goldenberg, 1990). Nurses have
recognized for many years the importance of clients
achieving competence in their self-care (Kappelli, 1986;
Oren, 1985). But self-care practices of women with NVP have
been largely unreported in the literature (Alley, 1984;

DiIorio, 1985, 1988; Jenkins, 1982).

7
Self-care is a continuous process whereby a person
contributes to her own health and well-being (Joseph, 1980).
It is estimated that a significant proportion of
health/medical care is performed outside the professional
care sector, in particular, self-care may account for a
substantial proportion of health care activity (Silten &
Levin, 1981). While self-care is not a new concept by any
means, public interest in self-care has grown in the past
decade (Patterson et al., 1990; Silten & Levin, 1981).
Consumer movements which advocate participation in health
care, mounting health care costs, and the shortage or
maldistribution of nursing staff, are several of the
contributing factors which have led to the renewed interest
in self-care (Kappeli, 1986). One of the goals of self-care
is to empower the client to take responsibility for her own
care through education, reinforcement, problem solving
skills, and sharing of information (Caporeal-Katz, 1983).
In the nursing literature which focuses on self-care, there
tends to be an emphasis on the role of the nurse. Emphasis
on the client's active involvement in her nursing care and
recognition of the importance for self—care calls for
changes in the traditional role of the nurse, particularly
the role of the Clinical Nurse Specialist (Kappeli, 1986).
Kapelli (1986) suggests that the nurse should use the
client's expertise instead of subordinating the client to
the nurse's expertise in appropriate situations. This study

will enhance the Clinical Nurse Specialist's knowledge of

 

8
his/her client's expertise in coping with NVP by use of
self-care practices.

The rationale for investigating the self-care practices
of women with NVP is as follows: There has been little
research as to which self-care behaviors used for NVP are
effective. Self-care practices, or behaviors undertaken by
pregnant women in an effort to relieve the discomfort of
NVP, have not been investigated sufficiently as to enable
the health care professional to offer clear and realistic
recommendations for relief. All possible self-care
behaviors need to be identified for the health care provider
so that he/she may be effective in educating and supporting
the woman with NVP in achieving and maintaining adequate
care of herself. An investigation of the performance of
self-care practices used by women for NVP, and the effect of
sociodemographic characteristics, will add further knowledge
to the study of self-care practices for NVP.

Purpose of the Study

The purpose of this study is threefold. The first
purpose is to describe the self-care practices of a group of
women who suffer from the common syndrome of NVP. The
second purpose of the study is to determine which self-care
practices are perceived by these women as effective in
relieving the distress associated with NVP. The third
purpose is to examine sociodemographic variables such as
age, weeks of pregnancy, marital status, previous

pregnancies, number of living children, education,

9
employment, race, and income level to determine if these
variables effect the performance of self-care practices used
for NVP.
Problem Statement
The problem statement consists of three specific
questions developed to provide a clear understanding of the
purpose of this study. The specific questions are:

1. What self-care practices do pregnant women perform to
relieve the distress associated with nausea and
vomiting during pregnancy?

2. Which self-care practices performed by pregnant women
are perceived as effective in relieving nausea and
vomiting during pregnancy?

3. What effect do age, marital status, weeks of pregnancy,
previous pregnancies, number of living children,
education, employment status, race, and income level
have with the performance of self-care practices of
women with nausea and vomiting during pregnancy?
Orem's (1985) Theory of Self-Care Deficit will be the

conceptual framework utilized in this study. A researcher

developed self-report written survey was distributed to a

group of pregnant women attending prepared childbirth

classes. Data analysis was done to answer the above study
questions. The results of this study may add to the
literature of NVP, and may enable the Clinical Nurse

Specialist to have a more accurate understanding of self-

care practices used for NVP, so that effective strategies

10
can be developed to promote and support these self~care
practices.

To summarize, the chances that a pregnant woman will
experience NVP are between 50-86%. Although there have been
and continue to be many theories concerning the etiology of
NVP, empirical support for any of the theories is equivocal.
Treatment prescribed by health care professionals varies.
Few studies concerning self-care practices of women with NVP
have been reported in the literature (Alley, 1984, DiIorio,
1985, 1988; Jenkins, 1982).

Research which will answer the above questions is
needed. Documentation of the findings may begin to enable
the health care provider to have an accurate understanding
of the self-care practices used by women with NVP so that
strategies can be developed to promote and support these
self-care practices.

Overview of Chapters

This research study is organized into six chapters.
Chapter I includes an introduction to the study and
background of the problem to be examined, the purpose of the
research, the problem statement, and assumptions and
limitations of the study. In Chapter II, conceptual
definitions of the study variables and the conceptual theory
utilized as the framework for the study are identified and
discussed in relationship to the practice of nursing.
Chapter III includes a literature review which highlights

the contributions and implications of previous studies

11
relevant to this study. Methods of research and study
design are found in Chapter IV, including instrumentation
and procedures for informed consent and human rights
protection. A presentation of data and analysis are
included in Chapter V. In Chapter VI, a summary with
discussion of findings, relevant conclusions with
implications for nursing practice, and recommendations for

future research are presented.

Chapter II
CONCEPTUAL FRAMEWORK
Overview

In this chapter, a discussion of the conceptual
framework with an accompanying explanation of theoretical
concepts as they relate to the research problem are
presented. A discussion of Orem's (1985) Theory of Self-
care along with an adapted model to illustrate the
relationships between the study variables and theoretical
concepts are presented. Finally, the relationship between
this study and the practice of nursing as it relates to
Orem's (1985) theory of nursing systems is explored.

The purpose of this study is to describe the self-care
practices of pregnant women experiencing nausea and vomiting
during pregnancy, the women's perception of the
effectiveness of these self-care practices in relieving the
distress associated with NVP, and to examine the variables
of age, weeks of pregnancy, number of living children,
education, employment, race, and income level with the
performance of self-care practices for NVP. These study
questions will be examined in the context of Orem's (1985)
Nursing Theory of Self-care Deficit as the guiding
conceptual framework.

Orem's Theory of Self-Care

Orem (1985) developed a general theory of nursing

referred to as the Self-care Deficit Theory of nursing.

This theory describes the relationship between the self-care

12

13
action capabilities of individuals, the individuals demands
of self-care, and the role of the nurse in providing the
support and education necessary to enable the individual to
meet those demands. The central idea of Orem's (1985)
theory is that "people benefit from nursing because they are
subject to health-related or health-derived limitations that
render them incapable of continuous self-care or dependent
care or that result in ineffective or incomplete care" (p.
36). These limitations are what Orem (1985) terms "self-
care deficits".

The three related theoretical constructs from Orem's
(1985) theory which will be utilized in this study include:
1) self—care deficits; 2) self-care; and 3) nursing systems.
Within the construct of self-care deficit, a nursing
requirement can be determined. The self-care construct
explains why these forms of care are necessary for the
continuance of life. And finally, within the construct of
nursing systems, rationale as to how nursing can help people
to continue to engage in self-care, can be derived (Orem,
1985). By use of Orem's (1985) theory as the conceptual
framework for this study the relationship between the
performance of self-care practices used by pregnant women to
relieve the distress of nausea and vomiting during pregnancy

will also be explored.

14
Conceptual Definitions
Nausea and Vomiting During Pregnancy

Nausea and vomiting during pregnancy (NVP) can be
defined as mild to severe symptoms of nausea with or without
vomiting that is associated with the first trimester of
pregnancy occurring most commonly but not exclusively
between the 4th and 16th week of gestation. The woman with
NVP is not usually regarded by others as being "ill"
primarily because NVP is commonly known to be a self-
limiting condition and acceptable behavior during pregnancy
(Klebanoff et al., 1985; Reissman, 1983). However, changes
in human structure, in physical functioning, and in behavior
and habits of daily living brought on by pregnancy, and by
nausea and vomiting during pregnancy, are evidence of health
deviations that lead to what Orem (1985) terms therapeutic
self-care demands for action. A therapeutic self-care
demand is defined by Orem (1985) as the measure of care
required at moments in time in order to meet existent
requisites for regulatory action to maintain life and to
maintain or promote health and development and general well-
being.

Self-Care

Self-care as defined by Orem (1985) is the "practice of
activities that individuals initiate and perform on their
own behalf for the maintenance, restoration, or promotion of
health" (p. 84). For the purpose of this study, self-care

practice is defined as those activities initiated and

 

15

performed by the pregnant women to relieve the symptoms of
nausea and vomiting during pregnancy. According to Orem
(1985), self-care behaviors are "learned behaviors that
purposely regulate structural integrity, functioning, and
human development" (p. 36). Self-care practices specific to
the woman with NVP may include adjusting ways of life to
meet new self-care requirements (more rest, more
accommodating sleeping positions, dietary adjustments, and
decreased activity) and establishment of new techniques of
self-care (brushing teeth when tolerable during the day, and
undertaking an exercise regimen designed for pregnant
women). By revising patterns of daily living (easier
workload, less preparation of meals, and utilizing others to
help in daily activities) and basically changing one's
lifestyle to be compatible with the changed health status of
NVP, pregnant women learn to cope with the discomfort of
NVP. These are examples of self-care practices used by
women with NVP to meet therapeutic self-care demands (Orem,
1985; Woods, 1985).

Orem (1985) uses the term self-care deficit to explain
the relationship of self-care actions that may be required
of individuals to take (the action demand) and the action
capabilities for self-care known as self-care agency. While
the self-care agent is the provider of care and the person
taking action, self-care agency is the complex capability
for action that is activated in the performance of self-care

(Orem, 1985).

16
Determinants of Self-Care Agency

The determinants of self-care agency identified in this
study are age, previous pregnancies, marital status, number
of living children, race, education, employment, and income
level. Orem (1985) refers to the factors of age,
developmental state, conditions of living, family systems,
and sociocultural orientations as factors that can
influence, either positively or negatively, the adequacy of
the self-care agency. If the self-care agency renders the
self—care agent inadequate in meeting the therapeutic self-
care demands that NVP presents, a self-care deficit will
ensue. Intervention from a health care professional such as
a Clinical Nurse Specialist could prevent the deficit from
occurring and protect and prevent against future deficits.
This intervention is what Orem (1985) refers to in the third
theoretical construct, nursing systems.

Nursing Svgtgmg

Orem (1985) states that "nursing systems are formed
when nurses use their abilities to prescribe, design, and
provide nursing for legitimate patients (as individuals or
groups by performing discrete actions and systems of action
(p. 38). A nursing system is defined by Orem (1985) as a
continuing series of actions produced when nurses link one
way or a number of ways of helping to their own actions or
the actions of persons under care that are directed to meet
these person's therapeutic self-care demands or to regulate

their self—care agency" (p. 31). Inherent in this

 

17
statement, is the assumption that the patient is "under
care" and has entered the health care system.

Orem (1985) further defines nurse agency as "the
complex capability for action that is activated by nurses in
their determination of needs for design of and production of
nursing for persons with a range of types of self-care
deficits (p. 31). In general, nursing systems represent all
actions and interactions of nurses and patients in nurse
practice situations (Orem, 1985). Within the design of
nursing systems that Orem (1985) describes, the actions of
nurses, performed for the benefit of others, or "nursing"
has two orientations. These include first, the ability of
others to engage in self-care effectively and continuously,
and second, the continuous and effective meeting of the
existing self-care demands of others in the event of health-
derived or health-related self-care deficits.

Orem (1985) identifies the supportive-educative nursing
system based on the principle that both the nurse and
patient together can act to meet the patient's self-care
demands. The supportive-educative system is the focus of
intervention in this study. The nurse in the supportive-
educative system acts primarily as a consultant in
regulating the exercise and development of self-care agency.
The patient also regulates the exercise and development of
self-care and does accomplish self-care. The patient

requires help in decision-making, behavior control, and in

18
acquiring knowledge and skills in the supportive-educative
system.
Application to the Study

To illustrate the relationship between the therapeutic
self-care demands for the woman with NVP discussed above,
the performance of self-care practices and the outcomes, a
model was developed. This model (Figure 1) is the
conceptual framework for this study and is an adaptation and
combination of the models presented by Orem (1985) and the
"self-care concept of nursing" model which is based on Orem
(1980) presented by Joseph (1980).

At the top left of the model in Figure 1 is the
therapeutic self-care demand for NVP. The existence of this
self-care demand requires some kind of action for relief
from the woman with NVP, depicted in the model as the self-
care agent. Self-care determinants listed under the self-
care agent (woman with NVP) will define her self-care
capabilities or "self-care agency". The line which begins
with the pregnant self-care agent, follows through to the
middle of the model, then divides the model into two
portions, with pathways toward two expected outcomes. The
top portion of the model describes the pregnant woman whose
self-care agency is adequate. As the pregnant self-care
agent, she will have the ability to perform self-care
practices to meet the therapeutic self-care demands of NVP
effectively and her outcome will be relief of nausea and

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20
increase of self-care agency that her successful self-care
practices have supported.

The lower portion of the model describes the pregnant
self-care agent whose self-care agency has limitations and
is inadequate. As the pregnant self-care agent she will be
unable to perform self-care practices to meet the
therapeutic self-care demands of NVP effectively and will
have a resulting self-care deficit. Her outcome will be no
relief from nausea and vomiting, difficulty in activities of
daily living, and a decreased self-care agency. The nurse
agent, depicted at the right of the model, uses the
educative-supportive system of nursing to design appropriate
interventions that will be effective not only for the
pregnant self-care agent with the self-care deficit, but for
the pregnant self-care agent at any point in the model where
he/she determines that intervention is appropriate. The
arrows which point in both directions around the model
indicate an interactive process, an exchange of self-care
practice knowledge and ideas, between the nurse agent and
self-care agent throughout the model.

In summary, Orem (1985) believes that self-care is
deliberate action that is practical in orientation and which
involves a decision or choice for performance. Knowledge of
one's present condition and circumstances, known care
measures, and basic human functioning provide a basis with
which to determine what should be done and how. As modeled

in Figure 1, self—care practices of the woman with NVP is

21
the theoretical concept of interest in this study. Research
has shown that various self-care behaviors are being
performed by women with NVP, some more effective than
others (Alley, 1984; DiIorio, 1985; Jenkins, 1982). This
research study will investigate which self-care practices
are being utilized by the woman with NVP, how effective the
self-care practices are perceived to be, and the effect of
the selected variables of age, weeks of pregnancy, previous
pregnancies, number of living children, marital status,
education, employment, race, and income level, with the
performance of self-care for NVP. If the self-care practice
is not meeting therapeutic self-care demands for NVP, a
deficit will ensue that will necessitate aid from the nurse
agent in some capacity. The nurse agent will utilize the
supportive-educative nursing system described by Orem
(1985), to design a plan to educate and support the woman
with NVP, which will allow her to meet her therapeutic self-
care demands. The nurse agent will need to be well informed
as to all possible self-care practices for NVP, so that she
may effectively educate and support her client.
Summary

In this chapter, theoretical concepts pertinent to this
research study were presented and the relationship among
them explored. A discussion of Orem's (1985) Theory of
Self-care Deficit along with a model depicting the
conceptual framework that is utilized in this study, was

presented in relationship to the woman with NVP. The

22
relationship between Orem's (1985) Theory of Self-care
Deficit and the practice of nursing was explored. The
conceptual definitions of NVP and self-care were discussed.
A further discussion of study concepts and operational
definitions will be presented in Chapter IV.

A review of current literature relevant to the
examination of self-care behaviors of the woman with NVP
will be presented in Chapter III. The strengths and
weaknesses of previous studies will be presented in
relationship to this study, as well as pertinent

controversial issues that exist in the literature.

CHAPTER III
REVIEW OF THE LITERATURE
Overview

In this chapter, relevant literature pertaining to the
study concepts and associated research is presented. The
purpose of this chapter is to review and synthesize research
findings that support and contribute to this study as well
as to present existing knowledge that directly or indirectly
affects the study of self-care practices of women with NVP.
A review of existing studies most similar to this study is
presented first, followed by a brief review of the
literature concerning nausea and vomiting during pregnancy,
which includes recent approaches 0f treatment such as
acupressure, visual imagery and stimulus control, and
hypnotherapy. Finally, a review of pertinent literature
concerning self-care practices is presented and the role of
the health care provider is discussed.

Self-Care for Nausea and Vomiting During Pregnancy

A review of the medical literature concerning self-care
for NVP, along with nursing and lay literature of the last
ten years reveals that there have been three descriptive
studies that have specifically examined the self-care
practices of women with NVP (Alley, 1984; DiIorio, 1985;
Jenkins, 1982). Jenkins (1982) asked pregnant women (N=37)
to rank self-care practices for NVP in order of
effectiveness. A symptom distress scale was used to measure

the degree of distress associated with NVP. This was the

23

 

24
first study noted in the literature to attempt to list all
of the known self-care practices for NVP, and the first
study to examine perceived effectiveness of these actions as
well as to measure the perceived distress associated with
NVP. For these reasons, Jenkins (1982) research study was
of significance in providing a basis for this study for
further examination of self-care practices and perceived
effectiveness of those practices for women with NVP. The
small sample size, a newly developed, lengthy questionnaire,
and simple data analysis methods, are weaknesses of the
Jenkin's (1982) study as well as a similar study done by
Alley (1984). Nevertheless, the novel approach of
investigating the problem of NVP from the client's
perspective, in the Jenkin's (1982) study, the Alley (1984)
study, and a study done by DiIorio (1985), make their
research findings valuable for further study of self-care
practices of women with NVP and perceived efficacy.

Alley (1984) reported that the commonly prescribed
self-care behaviors of eating dry crackers and drinking
carbonated drinks for NVP did not help many of the pregnant
women. The women in her sample (N=39) used a variety of
other self-care behaviors such as lying down, eating acidic
foods, spicy foods, drinking juices, water, and eating salty
foods, which are not noted elsewhere in the literature as
being effective in relieving nausea. These findings
supported Jenkins (1982) and DiIorio (1985) in that no one

self-care action helped a majority of women with NVP. The

25
Alley (1984) study lent further support for the need for a
change in thinking for practitioners and researchers alike
in their treatment of NVP.

DiIorio (1985) also reported that women with NVP
(teenagers aged 19 years and younger) used a variety of
self-care practices with varying effectiveness. Of
significance to this study is the finding that 64% of her
sample (N-78) did obtain relief from at least one self-care
practice tried even though the measures varied from person
to person. The most common self-care practice among this
sample, with a 46% effective rate, was to lie down, a self-
care practice not listed in the literature before the
Jenkins (1982) study. In DiIorio's (1985) study, the sample
of pregnant teenagers limits the generalizability of results
to non-teenaged pregnant populations. However, further
knowledge of self-care practices of women with NVP was
obtained, and is an important contribution to the
literature.

Alley (1984), DiIorio (1985), and Jenkins (1982)
attempt to bring nursing care up to date on NVP by gathering
data that focuses on the client's perspective of how these
symptoms affect her life, what measures have been tried to
alleviate the symptoms, how effective those measures were,
and the client's source of information concerning NVP. The
main objective for the Alley (1984) study was to dispel
stereotypical thinking of nurses about counseling women with

NVP, and to gain insight as to more comprehensive effective

26
treatment for NVP. The common results of these three
studies indicate that usual recommendations for treatment of
NVP do not help all women, that there are a variety of
responses to NVP that women are choosing even before seeing
a health professional for prenatal care and that further
sound studies using advanced statistical analysis need to be
undertaken to determine which self-care practices for NVP
are used, which are effective, and for whom. As a result of
the above studies, important insight as to what women with
NVP are saying and doing about their symptoms has been
gained. Future studies such as this one can continue to
investigate useful self-care practices for women with NVP.

A careful literature review concerning NVP which
precedes the aforementioned three self-care studies reveals
research that is based entirely on the medical
practitioner's perspective of NVP. This research includes
the testing of etiologic theories (Depue et al., 1987;
Jarnfelt-Samsioe, 1987; Jarnfelt-Samsioe, Samsioe, &
Velinder, 1983; Klebanoff et al., 1985; Soules, Huges,
Garcia, Livengood, Prystowsky, & Alexander, 1980), examining
the incidence of NVP (Brandes, 1967; Fairweather, 1968;
Hook, 1980; Midwinter, 1971), and studying management of NVP
with pharmaceuticals (Kullander & Kallen, 1976; Walters,
1987), and psychotherapy (Fuchs et al., 1980; Long et al.,
1986; Zechnich & Hammer, 1982). The primary focus of the
above studies was on hyperemesis gravidarum rather than the

more common emesis gravidarum or NVP (Brandes, 1967;

27
Fairweather, 1968; Katon et al., 1981; Klebanoff et al.,
1985; Midwinter, 1971; Petitti, 1986; Walters, 1987).
Jarnfelt-Samsioe and colleagues (1983) reported that since
1950 there had been less than 30 papers published which
dealt with NVP.

Coppen (1959), Klebanoff et al., (1985) and Medalie
(1957), examined the concept of vomiting in pregnant women
in relationship to abortion rate and epidemiology. Their
findings of a moderately decreased rate of spontaneous
abortion with vomiting, and a moderately decreased risk of
fetal loss and preterm delivery, support other studies that
examine these outcomes in light of nausea and vomiting
(Brandes, 1967; Depue et al., 1987; Hook, 1976). Pettiti
(1986) found similar results when isolating nausea in
pregnancy, as the studies done isolating vomiting, in terms
of outcomes of pregnancy. Both Klebanoff et al., (1985) and
Pettiti (1986) found that younger women with higher parity
were more likely to be nauseated and experience vomiting.

Recent approaches to the treatment of NVP include
hypnotherapy, visual imagery and stimulus control, and
acupressure. Fuchs and colleagues (1980) found that of 138
subjects suffering from hyperemesis gravidarum, receiving
either group or individual hypnotherapy, 70% and 68%
reported an excellent response to hypnotherapy,
respectively. An excellent response constituted no vomiting
and no nausea. This study gave credence to the practice of

hypnotherapy, particularly group hypnotherapy, as a viable

28
treatment for hyperemesis gravidarum. Use of hypnotherapy
for NVP which is less severe than hyperemesis gravidarum has
not been studied thus far but it does seem possible that
this treatment may also be effective for NVP.

Long and colleagues (1986) employed a combination of
stimulus control and imagery in their study involving four
nurses suffering from mild to moderate NVP during their 8th‘
week of pregnancy. Three of the four subjects experienced
no further vomiting after treatment, with the fourth
experiencing continued occasional vomiting. While the
results of this study are of interest in that there were
definite results of relief for NVP, generalization to other
populations is limited due to the small self-selected
sample. Use of both stimulus control and imagery together
in this study, makes contributions of either to a positive
response difficult to determine and the need for further
research paramount.

The use of acupressure to prevent nausea and as the
treatment for "morning sickness", has recently received
attention in the nursing and medical literature (Dundee,
Sourial, Ghaly, & Bell, 1988; Hyde, 1989). The Hyde (1989),
and Dundee and colleagues (1988) studies used randomly
selected samples with control groups for their studies of
acupressure and NVP. Their findings support a significant
reduction of not only nausea and vomiting with acupressure,
but Hyde (1989) found that anxiety, depression, and

hostility were also greatly reduced. In a related study

29
done by Stannard (1989), 27 non-pregnant chemotherapy
patients experiencing nausea from their treatment, used
acupressure over a three month period of treatment. The use
of "sea-bands" (elastic acupressure bands with a button '
positioned to apply pressure at P6 Nei-Kuon acupuncture
point) worn by these patients, did greatly reduce nausea,
vomiting, and the amount of drugs used to treat these
symptoms. A side benefit reported was the feeling of
control in their own care, reports of less depression, and
reports of less fear of returning for further treatments.
In a study done by Dundee et al., (1988), the P6 acupressure
point showed a significant difference in decreased severity
of sickness compared to two other groups, one with a dummy
point or placebo and the other with no bands worn. This
finding indicated that acupressure may indeed hold
therapeutic value in the treatment of NVP. Further study is
warranted to support these findings so that acupressure
therapy, which is a safe and non-invasive treatment, can
become a recommended self-care practice option for NVP.

The implications of hypnotherapy (Fuchs et al., 1980)
stimulus control and imagery procedures (Long et al., 1986),
and acupressure (Dundee et al., 1988; Hyde, 1989; Stannard,
1989) as viable, effective treatment alternatives for NVP
are significant. While the current research of hypnosis,
stimulus control, imagery, and acupressure for NVP remains
scant, the results are promising and merit further study.

They are self-care behaviors that have been studied in

30
relationship to other illnesses and conditions, but not to
any great extent in relationship to NVP. Research in the
area of self-care for NVP, thus far, has been limited to the
three studies discussed earlier done by Jenkins (1982),
Alley (1984), and DiIorio (1985). However, there has been a
significant amount of research in the area of universal
self-care practices and illness related self-care that is
relevant to this study of self-care practices for NVP. For
this reason, the following self-care studies which have
contributed to the development of this study will be
presented.
Self-Care

Kearney and Fleischer (1979) determined the need for a
valid and reliable instrument to measure a person's
perception of his/her self-care agency, and developed an
instrument to measure exercise of self-care agency. They
found neither an internal nor external locus of control had
any bearing on the degree of exercise of self—care agency
among 306 volunteer nursing, psychology, and other students
in a small town. These significant findings indicate that
self-care practices can be from self-directing motivation or
from compliance to external authority figures, such as
health care providers. Other findings included
characteristics of those who exercise a high degree of self-
care to be, self-controlled, dependable, assertive,
intelligent, confident, responsible, helpful, and adaptable.

Characteristics not found in those who exercise a high

31
degree of self-care agency are competitiveness,
aggressiveness, and dependence on others. These findings
should be of interest to health care providers who seek a
better understanding of self-care counseling.

Freer (1980) found that self-medication was the most
commonly used self-care action among young married women
aged 35 to 44 when examining self-care for the 12 most
commonly reported symptoms in their self-reported health
diary. Freer's (1980) study also concluded that there were
many illness related self-care actions reported that were
not described in earlier studies of self-care. The findings
of self-medication as the most common self-care practice
used were further supported by Nail, Jones, Greene, Schipper
and Jensen (1989) when studying chemotherapy patients, male
and female, aged 21 to 78, seen in a medical oncology
clinic, suffering from nausea. Both studies used a self-
report diary to obtain information about the symptoms and
efficacy of self-care activities used to deal with each
symptom.

Self-medication with anti-emetics was also found to be
the most efficacious self-care activity used for nausea and
vomiting in a study done by Woods (1985). A self-reported
family health diary for data collection was used by a sample
of married women aged 20 to 40 years who were registrants of
a family health clinic. Wood's (1985) primary interest was
to examine universal self-care activities and illness

related self-care activities of the 96 women who

32
participated in this study. Among the findings of the most
common universal self-care activities employed was the use
of vitamins and contraception. The most common illness
related self-care activities included self-medication and
alteration of activity.

The relevance of the findings of Freer (1980), Nail et
al. (1989), and Woods (1985) to this study, lays in the fact
that during pregnancy medications of any kind are generally
not advised due to the possible deleterious effects to the
fetus. Thus, self-medication, which these studies have
found to be a common self-care activity, is not a
recommended option for the woman with NVP. Reaching for
medication may be a difficult self-care practice to change
for some. Awareness of this situation to health care
providers and their clients should be heightened by these
research results and the need for self-care counseling
realized. Woods (1985) concluded in her study as did Freer
(1980) and Nail et al. (1989) that women employ a wide
variety of self-care measures that have, until recently, not
been explored.

Nail et al. (1989) developed from the literature a tool
which listed self-care activities known to be used for
various symptoms of chemotherapy, including nausea and
vomiting. This tool was used to collect data concerning the
efficacy of self-care activities. The self-care activities
listed in the Nail et al. (1989) instrument, were adapted

for inclusion in the tool used in this study and are a

33
significant source of self-care strategies. McLaughlin and
Sliepcevich (1985) developed a Self-Care Behavior Index
(SCBI) to assess self-care behaviors of patients with
Multiple Sclerosis. While the SCBI was developed for use
with chronic disease, this tool was also useful for this
study as a model to assess self-care behaviors. The SCBI
contributed to the development of a self-care behavior
inventory for NVP.

The findings of the above mentioned Freer (1980), Nail
et al. (1989) and Woods (1985) studies lend support to the
need for further research and investigation into the self-
care practices of women with NVP. Self-care activities have
been shown to be efficacious for treatment of universal and
illness related health care. Nail et al. (1989) pointed out
that the finding of the use of combinations of self-care
activities needs further examination. There is a potential
limitation of the evaluation of the efficacy of single self-
care activities since no research to date exists that
examines a combination of self-care activities. Further
inquiry may reveal an important contribution to the
knowledge base of self-care activities for women with NVP.

The literature concerning self-care actions and the
relationship between those actions and health care
utilization reveals that visiting a health care professional
is one of the least commonly used self-care activities
(Woods, 1985). Patterson and colleagues (1990) found, by

use of a health care utilization diary, that self-care

34

practices of changes in lifestyle in the areas of diet,
rest, exercise, alcohol consumption, and medication were
engaged in by women who came in for early or late prenatal
care, or none at all. This further supports the data
collected by Kearney and Fleischer (1979), which indicates
that the source of reinforcement for self-care practices is
not significant and may be either from self-directed
motivation or from compliance to external authority figures.

Kapelli (1986) observed that nurses seemed to manage
rather than assist patients in self-care activities, thus
jeopardizing the maintenance and development of the
patients' performance of self-care activities. Although
this was a small (N=4) study of hospital nurses, the results
are significant if indeed further research maintains that
nurses and health care providers alike do not support their
patients self-care activities. Silten and Levin (1980)
support the premise that inherent in the concept of self-
care is learner preference of self-care rather than
professional preference of self-care. Much more research
needs to be done to determine how effective health care
providers are in the area of self-care education and
counseling and how they can become self-care advocates
instead of adversaries.

Summary

In this chapter, a review of the current literature of

self-care practices of women with NVP were presented along

with a discussion of significance to this study and future

35

studies. Next, a brief review of the literature concerning
NVP was offered, followed by a presentation of the most
recent approaches to relieve NVP, including acupressure,
visual imagery and stimulus control, and hypnotherapy.
Pertinent self-care literature was examined with specific
studies highlighted which contributed to the support of this
study. And lastly, a review of the literature describing
the relationship between self-care practices and health care
providers was presented.

In Chapter IV, a description and discussion of the
study design, including research methods and procedures will

be presented.

CHAPTER IV
METHODS AND PROCEDURES
Overview
Chapter IV includes a review of the research questions,
a description of the instrument for data collection, and the
operational definitions of the study variables. A
discussion of the data collection and data analysis
procedures is also included, followed by the methodological
assumptions, limitations, and the procedures adopted for the
protection of human subjects.
Procedures
In this research study there is a threefold purpose
with three accompanying research questions. The first
purpose is to describe the self-care practices of a group of
women who suffer from nausea and vomiting during pregnancy.
The second purpose is to determine which of these self-care
practices are perceived by these women as effective in
relieving the distress from NVP, and the third purpose is to
examine the sociodemographic variables of age, marital
status, weeks of pregnancy, previous pregnancies, number of
living children, education level, employment, race, and
income level, and their effect on the performance of self-
care practices used for NVP.
A retrospective/descriptive study design was used for
this research study. The sample of pregnant women was asked
to recall their experiences with nausea and vomiting during

their current pregnancy. A 64-item questionnaire was

36

37

developed to collect data to answer the research questions.

The research questions are presented below as a review.

They are:

1. Which self-care practices do pregnant women perform to
relieve the distress associated with nausea and
vomiting during pregnancy?

2. Which self-care practices performed by pregnant women
are perceived as effective in relieving nausea and
vomiting during pregnancy?

3. What effect to age, marital status, weeks of pregnancy,
number of previous pregnancies, number of living
children, education, employment, race, and income level
have with the performance of self-care practices of
women with nausea and vomiting during pregnancy?

Sample
The subjects were a self-selected, non-random sample of

30 pregnant women attending four different prenatal classes

offered by Expectant Parent Organization in the Lansing,

Michigan area. The subjects' stage of pregnancy when

answering the questionnaire ranged from 24 to 39 weeks of

gestation. Thus, subjects were required to recall to their
first trimester of pregnancy when nausea and vomiting of
pregnancy is most commonly experienced, when answering the
main portion of the questionnaire. The Expectant Parent
Organization supported the research and provided access to

their classes (see Appendix B for letter of support).

38
Instrument

The instrument developed for this study (see Appendix
D) by the investigator, was a written questionnaire designed
to obtain information about the self-care practices used to
relieve NVP, the perceived effectiveness of self-care
practices used for NVP, and the incidence of and degree of
distress associated with NVP. The questionnaire consisted
of 64 closed-ended questions which included a list of 39
self-care practices. The questionnaire was divided into
three distinct sections which addressed: 1) the incidence
and experience of the respondent's nausea and vomiting; 2)
the frequency and relief measures of self-care practices
used for nausea and vomiting; and 3) the sociodemographic
characteristics of the respondents.

The first section of the instrument consisted of 11
items dealing with the presence, the incidence, and the
perceived severity of nausea and vomiting. Respondents were
required to fill in the blanks or choose one most
appropriate answer. In the second part of the instrument 39
specific self-care practices identified from the nursing and
lay literature for nausea and vomiting during pregnancy were
listed (Alley, 1984; DiIorio, 1985; Jenkins, 1982; Nail et
al., 1989; McLaughlin & Sliepcevich, 1985). Next to each
self-care practice were three separate measures, one dealing
with the frequency of use, the second with the degree of
relief obtained from nausea, and the third dealing with the

degree of relief obtained from vomiting. One open-ended

39
item was provided at the end of the 39 self-care practices
for subjects to write in any self-care practices that may
not have been included. The last section of the instrument
contained nine sociodemographic questions regarding age in
years of the subject, number of weeks of current pregnancy,
marital status, number of previous pregnancies, number of
living children, education level, employment, race, and
income level.

The instrument was evaluated for content validity by a
four member nursing faculty panel before it was used. One
member of the panel was a statistician and statistics
educator, two members were nursing educators in the areas of
maternal and family nursing, and were also prenatal
instructors. The fourth member was a nursing educator of
theory of self-care.

The instrument was pretested with five women who had
been pregnant in the past to determine instrument clarity
and readability. The results of the pretest indicated that
a few minor changes for clarity were necessary. Reliability
of the instrument was not determined prior to use of the
instrument.

Scoring of the Instrument

The data were computer coded item by item. In the
first section of the questionnaire, yes answers were coded
as 1 and no answers were coded as 0. Throughout the

instrument, blank answers were coded as non-applicable and

40
missing answers were coded as 9. There were no negative
items.

Items 12-51 were scored by use of three measures: 1) a
frequency of use measure; 2) a relief of nausea measure; and
3) a relief of vomiting measure. The frequency of use
measure was a 5-point Likert type scale with choices ranging
‘trom never, rarely, sometimes, often, and always. The
relief of nausea and relief of vomiting measures were also
Likert type scales with choices ranging from (1) no relief,
(2) moderate relief, (3) good relief, (4) complete relief,
and (0) not used. Items on the relief measures were scored
only if the frequency of use score was two or more,
indicating the item was used.

Item 52 required a rank order of sources of information
about NVP. Only the responses with number (1) were used for
comparative information since not all choices were used by
every subject.

Operational Definitions

The operational definitions for nausea and vomiting
during pregnancy for self-care practices and for the
sociodemographic variables are described below:

Nausea and Vomiting During Pregnancy

Nausea and vomiting during pregnancy is the subjective
experience of moderate to severe nausea with or without
vomiting during pregnancy occurring any time of the day or
night, most commonly between the 4th and 16th week of

gestation. This is the conceptual definition. Nausea and

41

vomiting during pregnancy was operationally defined by self-
report in questions 1-11 of the instrument developed for
this research. These questions asked if NVP was experienced
(questions 1—2), when it began, and when if at all NVP
ceased (questions 3-5). Subjects were also asked at what
time during the day nausea and vomiting was the worst
(questions 6-7), how severe the nausea and vomiting was, (by
use of a 5-point scale in questions 8-9), and how NVP
affected their lives (a 5-point scale in questions 10-11).
Sglf-Care Practices

Self-care practices are the activities initiated and
performed by the pregnant woman to relieve the symptoms of
NVP. This concept was operationally defined by questions
12-50 of the instrument where 39 listed self-care practices
derived from the nursing and lay literature were presented.
Self-care practices were self reported by the subjects, who
were asked to respond to the frequency of use for each self-
care practice listed, by circling one best answer on a five
point scale describing their use of the practice. If they
had used the practice, they were to self-report the relief
obtained from nausea and the relief obtained from vomiting,
by use of a four point scale of relief. These three
measures, the frequency of use measure, the relief of nausea
measure, and the relief of vomiting measure, were the
measures used to determine self-care practices performed to

relieve the symptoms of NVP.

42
Sociodemographic Variables
The following sociodemographic variables were measured
by single item questions 53-63 in the instrument:
Agg. The variable of age was self-reported by the
subject as chronological age in years.
Weeks of Pregnancy. Subjects were asked to self-report
the number of weeks that they were pregnant when
answering the questionnaire.
Npmber of Preyious Pregnancies. Number of previous
pregnancies was also self-reported.
Number of Living Children. Number of living children
was self-reported.
Education. Education was a self-reported item on the
sociodemographic portion of the instrument. Subjects
were asked to check one choice from the six choices of
1) finished grade school or less, 2) completed some
high school, 3) graduated from high school, 4) some
college/technical training, 5) graduated from college,
or 6) graduate or professional degree.
Marital Status. Marital status was a self-reported
item on the sociodemographic portion of the instrument.
Subjects were asked to check one choice from the six
choices of 1) married, 2) single, 3) widowed, 4)
divorced, 5) separated, or 6) other.
Employment. Employment was a self-reported item on the
sociodemographic portion of the instrument. Subjects

were asked to check one of the three choices listed,

43

which included 1) full-time, 2) part-time, and 3) not
employed.
ngg. Race was a self-reported optional item on the
sociodemographic portion of the instrument. Subjects
were asked to check one of the seven choices listed,
which included, 1) Caucasian, 2) Black, 3) Hispanic, 4)
American Indian, 5) Oriental, 6) Asian, or 7) other.
Income Level. Income level was a self-reported item at
the end of the sociodemographic portion of the
instrument. Subjects were asked to choose among six
categories of income levels ranging from 1) 0-$9,999,
up to 6) $80,000 and over. Income was defined in this
question as, the families (all wage earners) total
income before taxes, for the previous tax year.

Data Collection
Two weeks ahead of the scheduled data collection class,
prenatal instructors for the Expectant Parent
Organization (EPO) were sent a package for data
collection procedures. This package contained
instructions for the instructors, (see Appendix C)
copies of the questionnaires with directions for the
subjects in the form of a cover letter, and a stamped
addressed envelope to return questionnaires to the
investigator.
One week before distribution of the instrument,~
prenatal instructors were instructed to announce to the

subjects that a questionnaire concerning nausea and

44
vomiting during pregnancy would be distributed during
the next class. Instructors informed their classes
that the questionnaire would take approximately 10-15
minutes to complete. Subjects were advised to complete
the questionnaire during break time or after class,
since all questionnaires would be collected on the
night of distribution.
At the beginning of the class in which the
questionnaire was distributed, the EPO instructors were
instructed to read aloud to their classes, the cover
letter containing directions for completing the
questionnaire (see Appendix D). Instructors were to
inform the subjects that they could help them with
questions only if they needed assistance in
understanding the answer format of the question.
The questionnaire were distributed by the EPO
instructors to all of the pregnant women in their
classes. Consent to participate was established if the
subject completed the questionnaire.
EPO instructors designated an area where all
questionnaires were to be returned, completed or not
completed, by the end of the class time.
The prenatal instructor returned all questionnaires to
the investigator by mail, using the pre-stamped, pre-

addressed envelope provided.

45
Data Analysis

The data were computer coded. Descriptive statistics
were tabulated to identify the characteristics of the
sample, and the incidence and severity of NVP. Frequencies
were tabulated for the three self-care practice measures: 1)
frequency of use of the self-care practices; 2) relief of
nausea obtained from use of the self-care practice; and 3)
relief of vomiting obtained from use of the self-care
practice.

Data pertinent to the first research question, which
seeks to identify self-care practices used to relieve nausea
and vomiting during pregnancy were obtained by use of a rank
order of self-care practices tried, and by self-care
practice frequency scores.

The second question of this research study concerns the
perceived effectiveness of the self-care practices used for
nausea and vomiting during pregnancy. This question was
analyzed by use of a rank order of the mean item
effectiveness scores for relief of nausea and vomiting for
each self-care practice. Mean relief scores were tabulated
for all items, eliminating scores where three or fewer
subjects used the practice for nausea and two or fewer
subjects used the practice for vomiting.

Prior to analysis of the third research question, the
self-care items were grouped on the basis of the correlation
among the frequency scores. Two scales consisting of

groupings of self-care items were identified as a result of

46
this process. These items appeared to correlate
sufficiently with each other, and seemed to be measuring the
same conceptual dimensions. The two scales were then
subjected to a reliability analysis, then correlated with
the remaining frequencies of self-care practices used, to
determine if any other practices could be included in the
two scales. The trial and error process was employed as a
substitute for exploratory factor analysis which would have
required a much larger sample. The third research question
examined the relationship of the sociodemographic variables
of age, marital status, number of previous pregnancies,
number of weeks of pregnancy, number of living children,
education, employment, race and income, with the performance
of self-care practices for NVP.

An analysis of variance with the two self-care practice
scales as outcome variables and the nine sociodemographic
characteristics as independent variables, was done to
investigate the association these variables had on the
performance of self-care practices which made up the two
scales. Only those subjects who responded yes to
experiencing nausea or vomiting during this pregnancy, were

included in the investigation of this question.

47

Methodological Assumptions and Limitations

Assumptions

The following assumptions have been made for this

research:

1.

The women surveyed can be identified through self-
report as having NVP.
The women surveyed have adequate recall of self-care
practices used to cope with NVP.
The women surveyed can judge the effectiveness of self-
care practices in reducing NVP.

Emilia—11m

The following limitations have been made for this

research:

1.

Subjects who agreed to participate in this study were a
self-selected, non-random sample of pregnant women from
one geographic location and setting. The sample size
was small, limited to 30 subjects and was a convenience
sample. Therefore, the findings may not be generalized
to all pregnant women with NVP.

The women in the sample were between 24 and 39 weeks
pregnant. Since NVP most commonly occurs in the first
trimester of pregnancy or the first 12 weeks, the
subjects were asked to recall the experience of NVP and
their use and perceived effectiveness of self-care
practices when responding to the questionnaire.
Therefore, their responses may not accurately reflect

the experience of nausea and vomiting during pregnancy.

48
3. The instrument used in this research was a newly
developed, untested questionnaire. Thus,
dimensionality, reliability, and validity were unknown
prior to administration of the instrument.
Protection of Human Subjects

Completion of the questionnaire indicated voluntary
participation and consent. 'Subjects could choose not to
participate, or could withdraw from the study at any time.
Subjects were not required to identify themselves in any
way, as part of the data collection process, thereby,
remaining anonymous to the researcher and others.

In accordance with the Michigan State University
Committee for Research Involving Human Subjects, all
volunteers were 21 years of age or older. The Michigan
State University Committee for Research Involving Human
Subjects reviewed this research proposal and gave written
approval (see Appendix A).

Summary

The study questions were presented for review.
Measurement of research concepts which included a discussion
of instrumentation and operational definitions of the
research concepts of NVP, self-care practices, and
sociodemographic variables were presented. A description of
the sample and of data collection procedures was followed by
a discussion of the data analysis for the three study
questions. Methodological assumptions and limitations were

presented next, and a discussion of procedures for the

49
Protection of Human Subjects was presented at the end of

this chapter.

CHAPTER V
RESULTS
Overview
In this chapter, the findings of this study will be
presented. A description of the sample will be followed by
an analysis of findings to answer the study questions.
Description of the Sample
The subjects were an average of 30 years of age and 32
weeks pregnant. Most were white, married, and employed
full-time. The majority of the subjects were college
educated with none having less than a high school education.
The average yearly household income was $40-59,999. Table 1
includes a summary of the demographics described above.
Twenty-two subjects reported experiencing nausea and/or
vomiting. Only the 22 subjects who did experience nausea
and/or vomiting were considered in the analyses of the
research questions, however there were several questions
that had missing responses of 1-3 subjects for reasons
unknown.
Experience of NVP
There were 22 subjects who experienced nausea, with 19
subjects reporting nausea within the first 9 weeks of
pregnancy (i=6 weeks). Vomiting was reported by 9
respondents within the first 9 weeks as well (i=7 weeks).
There were 9 respondents who experienced nausea and
vomiting. The mean days of nausea experienced was 58, with

a mode of 42 days. The greatest frequency was from 3-12

50

 

Table 1

Sociodemoqraphic Variables

 

Age in Years

Weeks Pregnant

Previous Pregnancies

Income
$0-9,999
SID-19,999
$20-39,999
$40-59,999
$60-79,999
$80-over

Education/yrs.

of schooling

Grade school/less
Some High School
High School Grad
Some College
College Grad

Grad or Prof Degree

Marital Status
Married
Single

# Living Children
none
one

Employment
Full-time
Part-time
Not Employed

Race

White
Black
Asian

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30
32
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52
weeks of pregnancy. There were 8 respondents who
experienced vomiting which lasted a mean of 75 days with a
mode of 49 days. In previous pregnancies four respondents
reported experiencing nausea and no respondents experienced
vomiting.

Of the 20 subjects who rated severity of nausea, 17
reported nausea to be not at all severe, or moderately
severe. There were 2 respondents who rated nausea very
severe. Eight subjects rated severity of vomiting with all
rating vomiting as either not at all severe or only
moderately severe.

Activities of daily living (ADL) were reported to be
either not affected or minimally affected by nausea in 16 of
21 respondents. The affect of vomiting on activities of
daily living was also reported by 6 of 8 respondents as not
affecting or minimally affecting ADL.

The time of day nausea was most severe was reported by
subjects to be upon rising in the morning (6 of 18
respondents), and in the evening (5 of 18 respondents). The
time of day vomiting was most severe was reported to be upon
rising in the morning (2 of 8 respondents), at dinnertime (2
of 8 respondents), and in the evening (2 of 8 respondents).
No respondents reported midday as a choice.

Self-Care Practices

There were 39 self-care practices presented to the

subjects in the instrument. All of the 39 self-care

practices were tried by at least one of the subjects.

53
Frequencies are presented in Table 2 in order of highest use
to lowest use. The findings presented in this table answer
the first study question of what are the self-care practices
used by the women in this sample to relieve nausea and
vomiting during pregnancy. The most frequently used
practice was to get fresh air while the least frequently
used practices were taking non-prescription anti-nausea
medication and taking extra B Vitamins.

The second study question exploring the effectiveness
of self-care practices for relief of nausea and vomiting
during pregnancy, is answered by the findings in Tables 3,
4, and 5. Of the eight most frequently used self-care
practices not all were perceived as equally effective. The
self-care practice tried most frequently (to get fresh air)
was reported to have a mean effectiveness score of 2.50 that
is, moderate to good relief for nausea, and a mean
effectiveness score of 2.50 that is moderate to good relief
for vomiting. However, eating small and frequent meals had
a mean effectiveness score of 3.06 for nausea that is good
relief but was used less frequently. The five self-care
practices that were perceived most effective by pregnant
women in relieving nausea and in relieving vomiting during
pregnancy are presented in Tables 4 and 5. The mean
effectiveness scores for nausea fell in a range of 3.06
(good relief) to 2.50 (moderate to good relief). The mean
effectiveness scores for vomiting were lower with a range of

2.50 (moderate to good relief) to 2.00 (moderate relief).

54
Table 2

Frequency and Percent of 39 Self-Care Practices (SCP) Used for MVP in
3.2mm

 

Cases Who Have Tried

 

_C£ # % It
Get Fresh Air 19 90 21
Keep Busy 18 90 21
Eat Crackers 18 90 20
Avoid Spicy Food 18 90 20
Eat Less at Meals 18 86 21
Eat When Feeling Nauseous 18 86 21
More Sleep Than Usual 18 86 21
Eat Small Frequent Meals 17 81 - 21
More Exercise 16 76 21
Ask for extra attention

from others ' 16 76 21
_Clean mouth/teeth more often 15 75 20
Drink clear liquid 15 75 20
Avoid sight/smell of food .15 71 21
Eat more slowly 15 71 21
Avoid bad smells 15 71 21
Avoid fatty foods 14 70 20
Cut down on drinks w/ caffeine 14 67 21
Avoid sweet foods 13 65 20
Eat bland foods 13 62 21
Avoid cooking 13 62 21
Rest after meals 12 57 21
Avoid riding in the car 11 55 20
Share experience of NVP w/

another mother 11 52 21
Eat midnight snacks 11 52 21
Eat sweet foods 11 52 21
Eat cold rather than hot food 10 48 21
Eat more acid foods 9 43 21
Suck on mints/hard candy 8 44 18
Avoid drinking liquid w/ meals 8 38 21
Take vitamins at bedtime 8 38 21
Eat dry toast/crackers before

getting out of bed in a.m. 7 35 21
Drink herbal teas 6 29 20
If you smoke/cut down on smoking 3 30 10
Relaxation i.e, yoga meditation

imagery 5 24 20
If drinking alcohol/cut down 2 25 8
Avoid vitamins with Fe 4 19 21
Take Rx anti—nausea meds 2 10 21
Take non-Rx anti-nausea meds 1 5 21
Take extra B vitamins l 5 21

 

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57
Table 4

Self-care Practices Perceived Most Effective for Relief of Nausea

 

 

 

 

 

 

Self Care Mean Valid
Practice Effectiveness 5.0. fl
eat small

frequent meals 3.06 .77 16
eat when

nauseated 3.00 .91 18
get more sleep 2.86 .77 14
eat crackers 2.56 .92 18
get fresh air 2.50 .71 18
Table 5

Self-care Practices Perceived Most Effective for Relief of Vomitjpg

 

 

Self Care Mean Valid
Practice Effectiveness Syfly fl
eat less during meals 2.60 .54 5
get fresh air 2.50 .57 4
get more sleep 2.40 1.14 5
avoid fatty foods 2.33 1.21

avoid spicy foods 2.00 1.26 6

 

58

There were three relief of vomiting self-care practices
that had mean scores of 4.00 indicating complete relief,
however, this reflected the responses of only one subject
per item. These practices were taking non-prescription
medications, taking prescription medication, and one write
in response of "gum".

Source of Self-Care Information

The first source of information that subjects listed
concerning knowledge of the self-care practices was the
doctor (33%). "Myself" (trial and error) was the next
highest response with 27 percent, followed by reading (20%),
friends (13%), and relatives (7%). Not one subject listed a
nurse or midwife as their first source of information about
self-care practices used for NVP.

Self-Care Practice Scales

Given the small sample size a full-scale exploratory
factor analysis of the self-care practices was not possible.
Instead, self-carepractices were grouped based on
inspection of inter-item correlations into six groups. The
six groups were subjected to reliability analysis. Two
scales emerged as a result of this process which were
conceptually as well as statistically meaningful. They were
the Proper Diet Scale and the Avoidance Scale. The Proper
Diet Scale consisted of four self-care practice items which
had a mean inter-item correlation of .32 and Cronbach's

alpha of .66 (Table 6). The Avoidance Scale also had four

59
Table 6

Salf-care Practice Scales--Proper Diet and Avoidance

 

 

 

Mean No. Mean Inter—Item
of SCP Used S.D. Correlation Alpha
Prober Diet Scalp
Eat small freq meals
Eat when nauseous
Avoid sweets
Avoid spicy foods 3.09 .88 .32 .66

Avoidance Scalp

Avoid sight/smell of food

Clean mouth more often

Avoid cooking

Avoid bad odors 2.66 1.14 .58 .85

 

60
self-care practice items with a mean inter-item correlation
of .58 and an alpha of .85 (Table 6).
The mean relief of nausea score for the Proper Diet
Scale was 2.85 indicating good relief. This was slightly

higher than the mean relief of nausea score for the

 

Avoidance Scale (2.24) indicating moderate relief. Mean
relief scores for vomiting with the Proper Diet Scale (2.03)
and the Avoidance Scale (1.69) were lower than the scores

for relief of nausea.

 

The two scales did not show a relationship when
correlated, with a correlation coefficient of .09 (p=.697)
indicating that they may be independent scales both
conceptually and statistically.

Analysis of Variance/Sociodemographics

The third study question was to examine the
relationship of sociodemographic variables of age, weeks of
pregnancy, marital status, number of previous pregnancies,
number ofliving children, education level, employment,
race, income level, and the performance of self-care
practices of women with nausea and vomiting during
pregnancy. Oneway ANOVA's were done using the above
sociodemographic variables as independent variables, and
using as the dependent variables, the mean scores of the
Proper Diet Scale and the mean scores of the Avoidance
Scale. The oneway ANOVA's showed that most sociodemographic
variables did not seem to be associated with variations in

self-care practices on the two scales. However, the

61
variables of employment and education were the exception
(Tables 7 and 8). There was a significant difference of
mean scores for the Proper Diet Scale and the level of
education, and of mean Avoidance Scale scores and
employment. The F-ratio for the Proper Diet Scale and
education categories was significant, however, the
confidence intervals overlapped for all of the education
categories indicating that further testing would be needed
to determine which groups differed in their responses on the
items comprising the score. The confidence intervals for
the Avoidance Scale and employment categories showed a
difference between the categories of full-time and part-time
employment.. The part-time category mean was lower (1.00)
than the full-time mean (2.65), indicating that the self-
care practices were done together more often by full-time
employees than by part-time employees.
Summary

In this chapter, a presentation of data findings
obtained from the study questionnaire was presented. A
description of the sample based upon demographic findings
was given. An analysis of the incidence and severity of
nausea and vomiting during pregnancy for the sample was
presented next. The 39 self-care practices listed in the
questionnaire with findings of perceived effectiveness for
nausea and vomiting were analyzed. Two scales of self-care
practices were presented and the findings of ANOVA's from

these scales with sociodemographic characteristics were

 

 

62
Table 7

Oneway Analysis of Variance for Proper Diet Scaleand Categories of
Sociodemographic Independent Variables

 

 

 

Education Mean 89 df E-Ratio
Between 1.9334 13 3.7356*
Within .5176 15

95% Confidence

Mean S D. Interval
H.S. n=2 3.37 .88 -4.57 to 11.32
Some College n=5 2.90 .74 1.98 to 3.82
College Graduate n=5 3.61 .58 3.13 to 4.10
Graduate Degree n=4 2.18 .89 .757 to 3.52
N=16’

*p<.05
Table 8

Oneway Analysis of Variance for Avoidance Scaleyand Categories of
Sociodemographic Independent Variables

 

 

Employment Mean 89 9f F-Ratio
Between 4.2454 2 4.9720*
Within .8539 17
95% Confidence
Mean S.D. Interyal
Full-time n=17 2.65 .94 2.1719 to 3.1418
Part-time n=1 1.00 1.00
Not Employed n=2 4.37 .53 -.3898 to 9.1398
N=20

 

*p<.05

63
discussed. In Chapter VI, an interpretation of results will

be presented.

 

 

CHAPTER VI
INTERPRETATION, IMPLICATIONS, AND RECOMMENDATIONS
Summary of Study

A retrospective/descriptive study design was used for
this research study. A sample of 30 pregnancy women
attending prenatal classes were given a 64-item
questionnaire, developed by the investigator, to collect
data concerning self-care practices used for nausea and
vomiting during pregnancy. The questionnaire was designed
to examine which self-care practices for NVP were used,
which were perceived to be effective for nausea and for
vomiting, and to investigate the association of
sociodemographic characteristics of the women with the
performance of self-care for NVP.

The average subject was 30 years of age, 32 weeks of
pregnancy, married, employed full-time, and white. She had
a college degree or higher education, had no children, and
had a yearly household income of $40,000-$59,999. For the
majority of subjects this was the first pregnancy.

The incidence of nausea and vomiting for the subjects
was 63 percent or 22 women in the sample. Nausea and
vomiting lasted an average of 6-7 weeks, with the greatest
frequency from 3-12 weeks of pregnancy.

The severity of nausea and vomiting was reported to be
not at all to moderately severe by 17 of 20 subjects. Only
two subjects rated nausea severe. Nausea was found to be

most severe upon rising, and in the evening. Vomiting was

64

65
found to be equally distributed, upon rising, at dinnertime,
and in the evening. Activities of daily living were
reported by subjects as not affected or minimally affected
by both nausea and vomiting during pregnancy.

All of the 39 self-care practices listed in the
questionnaire were tried by at least one subject. Mean
effectiveness scores for relief of nausea (3.06-2.62) were
higher than mean effectiveness scores for vomiting (2.50-
2.00). Self-care items that were effective in relieving
nausea were not necessarily the same items that were
effective in relieving vomiting, but when the same items
were used for both, the mean effectiveness scores were lower
for those used for vomiting. The self-care items that were
tried most often were "get fresh air", and "keep busy". The
self-care items that were most effective for nausea were
"eat small frequent meals", and "eat when feeling
nauseated". The most effective self—care items used for
relief of vomiting were "avoid cooking" and "avoid the sight
and smell of food".

Oneway ANOVA's of the Proper Diet Scale and Avoidance
Scale by categories in the sociodemographic variables of
education and employment, resulted in the finding of a
significant F-ratio for the education categories and the
Proper Diet Scale, and a significant F-ratio for employment
categories and the Avoidance Scale. A pattern was not
possible to determine without further testing for the

education groups., Other sociodemographic characteristics

66
were not found in this study to have had an effect on the
performance of self-care practices for NVP.

The source of information concerning knowledge of self-
care practices used for NVP with the highest frequency score
was from a doctor (33%). "Myself" (trial and error) was the
next source (27%), followed by reading, friends, and
relatives. A nurse or midwife were not listed by the
subjects as their first source of information.

Interpretation

The small homogeneous (i.e., highly educated, married,
white, full-time employed) sample of pregnant women with NVP
used in this study must be held in consideration when
interpreting the findings, especially those findings from
the Oneway ANOVA's that were done. The high incidence of
nausea and/or vomiting during pregnancy (63% nausea, 29%
vomiting) found in this study does, however, correspond with
previous research where the incidence was reported to be 50
to 86 percent in the United States (Hilliard, 1985; Alley,
1984; DiIorio, 1985). The findings of onset and duration
also correspond with findings of earlier research reports
(Klebanoff et al., 1985).

The high incidence of NVP and the variety of self-care
practices tried in this study (39) for relief of NVP
strongly supports the suggestion that NVP is indeed a
significant event for pregnant women with many possibilities
for self-care. Varied treatment recommendations for NVP

currently offered by health care professionals typically

 

67
focus on food intake and meal patterns rather than rest,
activity level, relaxation, or other non-food oriented
interventions (Brucker, 1988; Walters, 1987). Yet, self-
care practices found to be used frequently in this study and
in studies by DiIorio (1988) and Jenkins (1982) with
moderate to good relief included "getting fresh air",
"keeping busy", and "getting more sleep" as non-food
oriented practices. Health care professionals may be
limiting their recommendations to food-oriented
interventions while their clients are trying non-food
oriented practices that seem to be effective.

The 39 self-care practices for NVP compiled from the
literature and included in the instrument for this study is
the most comprehensive list available at this time. Yet, by
no means should it be considered inclusive. One can assume
that there are other self-care practices that were not
included in this study that may be effective for NVP, yet
few women in this sample identified other self-care
practices.

The results of this study indicate that the pregnant
women in this study used a wide variety of self-care
practices for NVP. Not all of the practices were perceived
as equally effective for all of the women who tried them,
but there were many practices that had effectiveness scores
indicating moderate to good relief. This finding would
suggest a change in thinking for health care providers in

the development of intervention strategies. A change that

 

68
would require individualized self-care practice strategies
for each client rather than an across-the-board
recommendation to try eating crackers and drinking soda.

The clustering of self-care practices for NVP into
Scales was an approach not found in the literature to date.
It is an interesting concept to add to the literature of
self-care practices for NVP. The findings of this study
indicate that the two scales were statistically different
therefore there was no significant relationship between
them. The scales were conceptually different as well. The
possibility exists that there are some clusters of self-care
practices that may prohibit the use of other self-care'
practices. For example, one cannot avoid the sight and
smell of food (Avoidance Scale) if one is eating small and
frequent meals (Proper Diet Scale). The Avoidance Scale
mean inter-item correlation of .58 was higher than the
Proper Diet Scale mean inter-item correlation .32 indicating
the self-care practices on the Avoidance Scale were done
together more often than items were done together on the
Proper Diet Scale.

The clustering of self-care practices was found to vary
significantly in this study in terms of the sociodemographic
variables of education and employment. A difference was
found in the performance of self-care practices of the
Proper Diet Scale and the education level of the subjects.
However, a consistent pattern did not exist for the means of

education levels and confidence intervals overlapped in all

69
categories. The sample size was too small to show a single
pair difference. For the Avoidance Scale a significant
difference in means was found in the categories of full-time
and part-time employment. The small sample size in this
study and unevenly distributed number of full-time employed
women (N=17) and part-time employed women (N=1) make these
findings weak. Self-care practices of the Avoidance Scale
(avoid cooking, avoid bad odors, avoid the sight and smell
of food, clean mouth more often) may be more appealing to
the working woman who could undertake these activities more
easily while at work. DiIorio (1985) found that pregnant
teenagers with NVP, used the self-care practice of laying
down most frequently and with the highest effective rate in
the study of 46 percent. This specific self-care practice
may be one that a working woman would not be as inclined to
use as often as perhaps a teenager. Thus, these two studies
indicate that sociodemographic characteristics may play an
important role in the choices women make for self-care
practices for NVP.

The guiding conceptual framework for this study was
that of Orem's (1985) Self-care Deficit Theory. The adapted
model of this framework (Figure 1) is presented in Chapter
II. The findings of this study indicate the potential
importance of the self-care agents determinants for the
performance of self-care practices for NVP specifically
those of education and employment. The determinants for

this study were the sociodemographic characteristics of the

70
sample with the exception of number of weeks of pregnancy.
Since this was a retrospective study and subjects were asked
to recall their experience of NVP, the number of weeks of
pregnancy was not used as a variable in this study, but
should be included in the model as a determinant of self-
care agency. Although the subjects in this study were a
relatively homogeneous group of women the model does allow
for heterogeneous samples as well. The determinants serve
as important information for assessing the knowledge, skill,
and motivation for the performance of self-care practices by
the woman with NVP.

Of particular interest in regard to the conceptual
framework and model used for this study is the finding that
the nurse (nurse agent) was not perceived as a source cf
information for the woman with NVP. The model depicts the
possible explanation for this finding in that the
intervention of the nurse agent occurs concurrent with the
therapeutic demand for self-care for NVP. In order for the
nurse agent to become a source of information for women with
NVP, she would have to intervene either before the demand
for self-care arises in an anticipatory guidance role or
concurrent with the demand. The timing of the intervention
which is crucial for the nurse and self-care agent is not
appropriate for the woman with NVP in this model.

Therefore, this model would need to be modified to clearly
position the nurse agent as having the opportunity to

intervene before, as well as, concurrent with the

71
therapeutic self-care demand for NVP. Orem's (1985) Theory
of Self-Care Deficit assumes the self-care agent has entered
the health care delivery system. For the women with NVP,
this may not be the case and intervention will need to be
done outside of the health care delivery system.

The model does succeed in depicting an interactive
relationship between the nurse agent and the self-care agent
necessary for the effective performance of self-care
practices. The self-care agent must participate in the
decision making of which self-care practices to try, which
to exclude, and which to continue to use for relief.

Studies such as this one, and others done in the past ten
years, which examine self-care practices for NVP (Alley,
1984; DiIorio, 1985; Jenkins, 1982) can provide knowledge as
well as sharing of ideas that would facilitate this
interactive relationship. However, this relationship was
not seen in this study. This may be due in part to the
sample who may not have sought prenatal care from settings
which included direct intervention with a nurse or CNS.
Implications for Advanced Nursing Practice

Thus far, there has been a scant amount of research
conducted concerning self-care practices for NVP, although
there has been a renewed public interest in self-care during
the past decade (Patterson et al., 1990; Silten & Levin,
1981). While nurses recognize the importance of self-care
for their clients (Kapelli, 1986; Orem, 1985), this study is

in agreement with studies done by Alley (1984) and DiIorio

72
(1985), which indicated that nurses were not a primary
source of information for women with NVP. Sources such as
"trial and error", "doctor", and "friends" have been
reported as first sources of information for NVP, but never
nurses.

It is possible that the lack of research to support the
effectiveness of non-pharmaceutical interventions for NVP
may be why nurses are hesitant to suggest many
interventions, but most likely nurses are not interacting
and/or educating pregnant clients until late in their
pregnancies when NVP may have subsided. With incidence
rates as high as 63% for NVP the nurse should be assured
that he/she will be seeing clients who will require
information and education concerning self-care practices for
NVP. Many clients do not seek prenatal care until the
beginning of the second trimester. The challenge for the
advanced practice nurse will be to intervene early in the
first trimester of pregnancy, when onset and duration of NVP
are most frequent, or before pregnancy for those of
childbearing age. Nurses are not presently in the
information loop either within the health care system or
outside of the system, to facilitate this early
intervention. Thus, they must find ways to reach their
clients more effectively, they cannot wait for women to come
to them.

One of the ways that this challenge can be met is

through the role of the educator for the advanced practice

73
nurse. Educating women who are of childbearing age and are
interested in starting a family as well as those who are in
their early weeks of pregnancy may be done by way of
reaching parenting groups and support groups affiliated with
health departments, obstetrical practices, pediatric
practices, or community service programs. The advanced
practice nurse must strive to change the image of the nurse
from a non-existent source of information to a valuable,
approachable, and available source of information for
pregnant women with NVP, not only within the health care
system, but outside of the health care system as well. By
sharing information concerning self-care for NVP with the
media, through T.V. and radio talk shows, and by writing
articles for popular lay publications and newspapers the
advanced practice_nurse could promote visibility and
credibility through his/her role as an educator.

In practice, interventions for NVP offered by the
advanced practice nurse should include not only food
oriented self-care practices, but non-food oriented self-
care practices such as those found to be effective in this
study (fresh air, more sleep). The clustering of practices
should be suggested as well.’ The advanced practice nurse
would use the roles of assessor and collaborator to
incorporate the clustering of self-care practices into
his/her intervention strategy. He/she would need to assess
the lifestyle (determinants) of the self-care agent and

collaborate with her to develop the appropriate self-care

74
interventions that would be realistic and effective for NVP.
For example, for the working women self-care practices on
the Avoidance Scale may be suggested to relieve NVP.
Ongoing collaboration and communication would enhance
effective strategies.

The advanced practice nurse may often be in a position
to conduct research either formally or informally in the
primary care setting. Seeking out and sharing information
concerning self-care practices for NVP with other health
care professionals who deal with non-pregnancy induced
nausea clients would be beneficial to expand the knowledge
base for self-care practices for nausea and vomiting. The
sharing of information would also help to change the image
of the advanced practice nurse to that of a valuable source
of information among colleagues.

Implications for Research

It is recommended that a replication of this study be
done with a large sample of pregnant women representing a
cross section of sociodemographic factors that would be more
heterogeneous than the sample in this study. While the
instrument used in this study allowed for the grouping of
self-care practices into scales, the small sample size and
homogeneity of the sample was a limiting factor in the
development and analysis of the scales. Further research
should be done to test the validity and reliability of the
instrument used in this study so that it can become a

valuable tool for the study of self-care practices.

 

 

75

The concept of clustering self-care activities into
groups for maximum effectiveness should be pursued by health
care professionals in research and in practice. There is
need for further investigation as to if and how activities
are clustered so that the health care professional can offer
groupings of self-care practices as an intervention
strategy.

Self-care practices for chemotherapy induced nausea and
illness related self-care practices (Nail et al., 1989;
Woods, 1985) were included in the questionnaire for NVP, and
were used and tried by pregnant women in this study. This
finding suggests that research should not be limited to
pregnancy induced nausea and vomiting alone, but should
include investigations of self-care practices in general.

Summary

In this chapter a summary of the study with
interpretation of results and implications for advanced
practice and research were presented. Recommendations for

further study were also suggested.

References

List of References
Alley, N.M. (1984). Morning sickness: The client's
perspective. Journal of Obstetrics, Gynecological, and

Neonatal Nursing, 185-189.

Brandes, J.M. (1967). First-trimester nausea and vomiting
as related to outcome of pregnancy. Obstetrics and
Gynecology, ;Q(3), 427-431.

Brucker, M.C. (1988). Management of common minor
discomforts in pregnancy. Journal of Nurse Midwifery,
aa(2), 67-72.

Caporeal-Katz, B. (1983). Health, self-care and power:
Shifting the balance. TopiC§ in Clinical Nurgipg, 1;,
31-41.

Cooke, C.W. & Dworkin, S. (1979). The ms. guide to a
yomen'g health. Garden City, NY: Anchor Press.

Coppen, A.J. (1959). Vomiting of early pregnancy:
Psychological factors and body build. The Lancet,
12(1).

Depue, R.H., Bernstein, L., Ross, R.K., Judd, H.L., &
Hendersen, B.E. (1987). Hyperemesis gravidarum in
relation to estradiol levels, pregnancy outcome, and
other maternal factors: A seroepidemiologic study.
American Journal of Ob§tetrics and Gynecology, 5, 1137-
1140.

DiIorio, C. (1985). First-trimester nausea in pregnant

teenagers: Incidence, characteristics, intervention.

Nursing Research, ;£(6), 373-375.

76

77

DiIorio, C. (1988). The management of nausea and vomiting
in pregnancy. Nurse Practitioner, ;;(5), 23-28.

Dundee, J.W., Sourial, F.B.R., Ghaly, R.G., & Bell, P.F.
(1988). P6 acupressure reduces morning sickness.
Journal of the Royal Society of Medicine, g1, 1014-
1015.

Eisenberg, A., Murkoff, H.E., & Hathaway, S.E. (1986). Egg:
to eat when you're expecting. New York: Workman
Publishing.

Eisenberg, A., Murkoff, H.E., & Hathaway, S.E. (1988). Whap
to expact when you're expecting. New York: Workman
Publishing.

Fairweather, D.V., (1968). Nausea and vomiting in
pregnancy. American Journal of Obstetrics and
Gynecology, 1Q2(1), 135-175.

Freer, C. (1980). Self-care: A healthy diary study.
Medical Cara, aa, 853-861.

Fuchs, K., Paldi, E., Abramovici, H., & Peretz, B.A. (1980).
Treatment of hyperemesis gravidarum by hypnosis. Tpp
International Journal of Clinical and Experimental
Hypnosis, aa(4), 313-323.

Hillard, P.A. (1985). Morning (and all day) sickness.
Parents, p, 116-118.

Hook, E.B. (1980). Influence of pregnancy on dieting
selection. International Journal of Obagitv, 4, 338-

340.

78

Hotchner, T. (1979). Pregnancy and childbirth: A complete
gpide to a new life. New York: Avon Books.

Hyde, E. (1989). Acupressure therapy for morning sickness:
A controlled clinical trial. Journal of Nurse
Midwifery, 34(4). 171-178.

Jarnfelt-Samsioe, A. (1987). Nausea and vomiting in
pregnancy: A review. Obstetrical and Gynecological
Survey, 11(7), 422-427.

Jarnfelt-Samsioe, A., Samsioe, G., & Velinder, G.M., (1983).
Nausea and vomiting in pregnancy: A contribution to
its epidemiology. Gynecologic Obstetric Investigation,

_p, 221-229.

Jenkins, M.L. (1982). A survey of self-care actions and
their perceived effectiveness in reducing morning
sickness. Unpublished Master's Thesis, University of
Missouri--Columbia.

Joseph, S.L. (1980). Self-care and the nursing process.
Nursing Clinics in North America, 15(1), 131-143.
Katon, W.J., Ries, R.K., Bokan, J.A., & Kleinman, A. (1980).
Hyperemesis gravidarum: A biopsychosocial perspective.
International Journal of Psychiatry in Medicine, 19(2),

151-162.

Kappeli, S. (1986). Nurses' management of patients' self-
care. Nursing Times, §;(11), 40-43.

Kearney, B.Y., & Fleischer, B.J. (1979). Development of an

instrument to measure exercise of self-care agency.

Research in Nursing and Health, 1(1), 25-34.

79

Klebanoff, M.A., Koslowe, P.A., Kaslow, R., & Rhoads, 6.6.
(1985). Epidemiology of vomiting in early pregnancy.
Obstetrics and Gvngcoloqv, 66(5), 612-616.

Kullander, S., & Kallen, B. (1976). A prospective study of
drugs and pregnancy. Acta Ob§tetrica at Gvnecologica
Scandinavica, pp, 105-117.

Little, R.E., & Hook, E.B. (1979). Maternal alcohol and
tobacco consumption and their consumption with nausea
and vomiting during pregnancy. Acta Obstetrica and
Gvnacologica, pg, 15-17.

Long, M.A.D., Simone, S.S., & Tucher, J.J. (1986).
Outpatient treatment of hyperemesis‘gravidarum with
stimulus control and imagery procedures. Journal of
Behavioral and Experimental Psychiatry, 11(2), 105-109.

Medalie, J.H. (1971). Relationship between nausea and/or
vomiting in early pregnancy and abortion. The Lancet,
;, 117-119.

McLaughlin, J., & Sliepcevich, E.M. (1985). The self-care
behavior inventory: A model for behavioral instrument
development. Patient Education and Counselin , 1, 289-
301.

Midwinter, A. (1971). Vomiting in pregnancy. Tpg
Practitioner, ;_p, 743-748.

Nail, L.M., Jones, L.S., Greene, D., Schipper, D.L., &
Jensen, R. (1991). Use and perceived efficacy of self-

care strategies in patients receiving chemotherapy.

Oncology Nursing Forum, 1§(5), 883-887.

80

Orem, D.E. (1980). Nursing: Concepts of practice. New
York: McGraw-Hill. 2nd Edition.

Orem, D.E. (1985). Nursing: Concepts of practice. New
York: McGraw-Hill. 3rd Edition.

Patterson, E.T., Freese, M.P., Goldenberg, R.L. (1990).
Seeking safe passage: Utilizing health care during
pregnancy. Image: Journal of Nursing Scholarship,
11(1), 27-31.

Petitti, 0.8. (1986). Nausea and pregnancy outcome. g1ppp,
11(4), 223-226.

Riessman, C.K. (1983). Women and medicalization: A new
perspective. Social Policy, 14(1),‘3-18.

Silten, R.M., & Levin, L.S. (1979). Self-care evaluation.
In P.M. Lazes (Ed.) Tpp Handbook of Health Education,
Germantown, MD: Aspen Systems Corp.

Soules, M.R., Huges, C.L., Garcia, J.A., Livengood, C.H.,
Prystowsky, M.R., & Alexander, B. (1980). Nausea and
vomiting of pregnancy: Role of human chorionic
gonadotropin and 17-hydroxyprogesterone. Obstetrics
and Gynecology, pp, 696-700.

Stannard, D. (1989). Pressure prevents nausea. Nursing
T1pgg, a§(4), 33-34.

Wagnild, G., Rodriguez, W., & Pritchett, G. (1987). Orem's

self-care theory: A tool for education and practice.

Journal of Nursing Education, ;§(8), 342-343.

81
Walters, W.W. (1987). The management of nausea and vomiting
during pregnancy. Medical Journal of Australia,
111(290), 338-339.
Woods, N.F. (1985). Self-care practices among young adult

married women. Research in Nursin and Health, 8, 227-

233.
Zechnich, R., & Hammer, T. (1982). Brief psychotherapy for

hyperemesis gravidarum, AFP, ;§(5), 179-181.

 

APPENDIX A

Human Subjects Approval

MICHIGAN STATE UNIVERSITY

 

OI’HCF, OI VICE "IFS!“ItNT I‘OI RESEARCH EAST LANSING ° MICHIGAN 0 488200-66
AND DEAN OF THE GRADUATE SCHOOL

February 20. 1991

Ms. Michele Sturt
5444 Jones Landing Road
Petoskey, MI 49770

RE: SELF-CARE PRACTICES OF WOMEN WITH NAUSEA & VOMITING DURING PREGNANCY, IRB#90-612
Dear Ms. Sturt:

The above project is exempt from full UCRIHS review. The preposed research
protocol has been reviewed by another committee member. The rights and
welfare of human subjects appear to be protected and you have approval to
conduct the research.

You are reminded that UCRIHS approval is valid for one calendar year. If you
plan to continue this project beyond one year. please make provisions for
obtaining apprOpriate UCRIHS approval one month prior to February 5, 1992.

Any changes in procedures involving human subjects must be reviewed by UCRIHS
prior to initiation of the change. UCRIHS must also be notified promptly of
any problems (unexpected side effects. complaints, etc.) involving human
subjects during the course of the work.

Thank you for bringing this project to my attention. If I can be of any
future help, please do not hesitate to let me know.

ely, 6?
wQE’oU J
David E. Wright, Ph.D.

Chair, UCRIHS

 

 

DEW/deo

cc: Dr. Rachel Schiffman

AISU is at. Allimaluv Action/Egan! Opportunity lull-Valian-

82

APPENDIX B

Letter of Support for Data Collection

R
*4 ’11
K Expectant Parents Organization

V-X % >\F 2620 Monrego Drive

lansing. Michigan 48912
TcIcphonc (517) 337-7365

January 18. 1991

This letter is to serve as a document of intent for Michele Sturt to
distribute a questionnaire through the Expectant Parents Organization
Childbirth Education classes to examine nausea and vomiting during
pregnancy. Our agency fully supports this effort.

”5. Sturt’s proposal is timely and related to the needs of pregnant
women in our state. This study will give direction and support for
improving the quality of care for women.

Sincerely.

come. do. ”47/1779
Carol Buzzitta
Executive Director

Expectant Parents Organization

CB/sp

83

APPENDIX C

Letter of Instruction for Distribution of Instrument

Dear Prenatal Instructors:

Thank you for your participation in the distribution
and collection of my questionnaire. I have enclosed the
following in your package:

15 questionnaires with cover letters

1 letter of instruction for prenatal
instructors

1 stamped, self-addressed, return envelope

It is important that all prenatal instructors proceed
in the same manner:

1. In an effort to prevent any disruption to your class
time, I am suggesting that you advise your students one week
ahead of questionnaire distrubution that they will be asked
to complete this questionnaire. I am hopeful that by having
prior knowledge of the need for 10-15 minutes to spend on
the questionnaire, the participants will be able to save
some time during your break to complete the questionnaire.
If you don’t think this is necessary, then please distribute
the questionaires the week that you receive them.

2. Distribution and Collection Procedures:

Please hand out a questionnaire to every pregnant woman
in your class at either the beginning or break time of
class, and ask them to read the cover letter with you as you
read it out loud to them. Emphasize that participation is
strictly voluntary and will in no way affect them in their
prenatal class if they chose not to participate. They will
remain anonymous, as it is not necessary to identify them in
this study. Indicate a time that you will be available to
answer any questions concerning the answer format but that
you cannot cannot help them determine the best answer. If
someone is having trouble, please have them write in next to
the question their questions or uncertainties.

Identify an area where they may turn in their
questionnaires whether completed or not completed, by
placing the unused questionnaires that were not passed out,
in a stack.

At the end of your class time, ask if all have handed
in their questionnaires to the designated area. Place all

84

questionnaires in the return envelope and send as soon as
conveniently possible.

If you have any questions or concerns, please call me-
at anytime, Home 616-347-7874 T-TH, Work 616-347-5424 MWF
and reverse the charges. I hope all directions are clear
and that the distribution and collection process goes well.

Again, I thank you for your help in this data
collection process. I will send a summary of the findings
of the completed study to you before the summer of this
year.

Sincerely,
Michele Sturt R.N., C.F.N.P.

MSN Candidate
Michigan State University

85

APPENDIX D

The Instrument: Self-Care Practices of Women with NVP

Dear Prospective Volunteer:

I am a graduate student in the College of Nursing at
Michigan State University where I am conducting a study
about nausea and vomiting during pregnancy, commonly known
as "morning sickness“, and what pregnant women do to relieve
these symptoms. I believe that pregnant women have much
valuable information to share with others.

Your partiCipation in this study is voluntary. You may
choose not to participate at all. Either way, your
participation in your prenatal class will not be affected.
There will be no attempt made to identify you in any way.
Every pregnant woman in your class will be handed the
questionnaire to complete and return to the area designated
by your instructor as a collection pile, by the end of class
today. If you choose not to participate, return the blank
questionnaire to the same collection pile. Neither your
instructor, nor your classmates will know if you have or
have not completed the questionnaire. You will indicate
your voluntary agreement to participate by completing and
returning the questionnaire to the designated area for
collection.

The questionnaire should take approximately 10-15 minutes to
complete. The directions for filling it out are included
throughout the questionnaire. If you have any questions at
all, please ask your prenatal instructor for help. Please
fill this out during your break time or at the end of class
so as not to interfere with your class.

Your time and effort spent answering this questionnaire is
very much appreCiated. By answering this questionnaire, you
are contributing information that may be helpful to other
pregnant women who are experiencing morning sickness. A
summary of the findings of this study will be made available
to you if you wish. through the Expectant Parents
Organization by the summer of 1991.

Thank you for participating in this study.

Sincerely,

Wain? RN,CFNP,

MSN Candidate

Michigan State University
College of Nursing

A 230 Life Sciences

E Lansing. Mi. 48824

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