Archives of Psychiatric Nursing 31 (2017) 440–446
Contents lists available at ScienceDirect
Archives of Psychiatric Nursing
journal homepage: www.elsevier.com/locate/apnu
The Effects of Nursing Care Based on Watson's Theory of Human Caring
on the Mental Health of Pregnant Women After a Pregnancy Loss
Pınar Tektaş ⁎, Olcay Çam
Department of Psychiatric and Mental Health Nursing, Ege Univesity, Faculty of Nursing, Bornova, İzmir, Turkey
a r t i c l e i n f o
Article history:
Received 15 December 2016
Revised 7 June 2017
Accepted 9 July 2017
INTRODUCTION
Prenatal loss includes early and late fetal death (miscarriage, still-
birth), and death of the newborn in the first 28 days after birth
(Armstrong, 2002). Early and late fetal death, including miscarriage
and stillbirth, occur in about 25% of all pregnancies (Hutti, Armstrong,
& Myers, 2013). Miscarriage is the death of a fetus before 20 weeks ges-
tation; stillbirth is the death of a fetus after 20 weeks gestation but be-
fore birth (Kersting & Wagner, 2012) In spite of the great advances in
the fields of medicine and obstetrics, stillbirth and the death of newborn
infants are still frequent today, and affect millions of families every year
(Hutti, 2005). In Turkey, the rate of miscarriage was 10.5% in 2008
(Hacettepe University Institute of Population Studies, 2008) and 23%
in 2013 (Hacettepe University Institute of Population Studies,
2013). The proportion of stillbirths was 1.1% in 2008 (Hacettepe
University Institute of Population Studies, 2008), and it was 3% in
2013 (Hacettepe University Institute of Population Studies, 2013).
Increase in the miscarriage rate in Turkey is remarkable.
Losses experienced for such reasons as miscarriage, stillbirth and
neonatal death cause emotional reactions such as grief and depression
(Bennet, Litz, Lee, & Maguen, 2005). The lost infant is continuously
mourned and is never forgotten (Cote-Arsenault & Mahlangu, 1999).
Though more than half of women who have experienced pregnancy
loss are pregnant again within 22 months, it has been found that most of
these women have need of great courage and hope for a new pregnancy.
So they have special psychological needs during pregnancy because of
the past loss (Gillbert, Harmon, & Taşkın, 2002).
⁎ Corresponding author.
E-mail address: pnrcnkya@hotmail.com (P. Tektaş).
http://dx.doi.org/10.1016/j.apnu.2017.07.002
0883-9417/© 2017 Elsevier Inc. All rights reserved.
© 2017 Elsevier Inc. All rights reserved.
For women who have experienced pregnancy loss, the decision to
become pregnant again is important. After a loss, pregnant women
are stressed, and they see pregnancy dangerous, and this perception
continues throughout pregnancy. While some families want to have
another child, others are afraid of experiencing the pain of loss again
(Cote-Arsenault, Bidlack, & Humm, 2001; Perry, Hockenberry,
Lowdermılk, & Wılson, 2010). For this reason, pregnancy, after loss
experience can be defined as a period of stress (Cote-Arsenault, 2007).
It is known that maternal stress experienced through pregnancy has a
negative effect on the infant and the newborn (Cote-Arsenault, 2007;
Usta & Balıkçı, 2012).
Both quantitative and qualitative studies have shown that anxiety,
depression is higher (Armstrong, 2002; Armstrong & Hutti, 1998;
Cote-Arsenault, 2003; Dereli-Yılmaz & Kızılkaya-Beji, 2013a) and pre-
natal attachment is lower (Armstrong & Hutti, 1998; Cote-Arsenault &
Marshall, 2000; Cote-Arsenault & Morrison-Beedy, 2001; Hill,
DeBackere, & Kavanaugh, 2008; Rillstone & Hutchinson, 2001) in preg-
nant women subsequent to pregnancy loss.
Pregnant women who have a history of pregnancy loss in particular,
experience greater anxiety in relation to pregnancy (Armstrong, 2002;
Bergner, Beyer, Klapp, & Rauchfuss, 2008; Cote-Arsenault, 2003), their
feelings of vulnerability increase and they are more alert to the symp-
toms of pregnancy (Cote-Arsenault, Donato, & Earl, 2006). They see
these pregnancies as a threat, and this perception is an indicator of the
pregnancy anxiety (Cote-Arsenault, 2007).
Studies have shown that the anxiety and depression levels of preg-
nant women with a history of pregnancy loss are higher than those of
women without such a history (Armstrong, 2002; Armstrong & Hutti,
1998; Cote-Arsenault, 2003; Dereli-Yılmaz & Kızılkaya-Beji, 2013a).
Also studies have shown that anxiety and depression relating to a
 P. Tektaş, O. Çam / Archives of Psychiatric Nursing 31 (2017) 440–446
previous pregnancy loss continued in the period after a healthy preg-
nancy (Armstrong, 2007; Blackmore et al., 2011). Pregnant women
with a history of loss and those with high pregnancy anxiety want to
see their doctors more frequently, want to talk more to them on the
telephone, and feel the need for more routine tests (Cote-Arsenault,
2003; Dereli-Yılmaz & Kızılkaya-Beji, 2013a).
It has been reported that anxiety and the fear of loss experienced
in pregnancy creates a difficulty for the mother in forming an attach-
ment to her new baby (Armstrong & Hutti, 1998; Wallerstedt, Lilley,
& Baldwin, 2003). Both quantitative and qualitative studies have
shown that prenatal attachment is lower in pregnancies subsequent to
pregnancy loss (Armstrong & Hutti, 1998; Cote-Arsenault & Marshall,
2000; Cote-Arsenault & Morrison-Beedy, 2001; Hill et al., 2008; Phipps,
1985; Rillstone & Hutchinson, 2001). It can be related to protect by her-
self to experience similar trauma and grief. At the same time, studies
have shown greater disturbances in attachment models of children
born after a loss and those at 12 months than attachment models of chil-
dren born into families without a history of loss (Heller & Zeanah, 1999;
Hughes, Turton, Hopper, McGaulley, & Fonagy, 2001).
Nurses in their capacity as carers must understand the experiences,
feelings and anxieties of women who are pregnant after a loss. This in-
sight will enable them to provide more therapeutic and sensitive care
(Cote-Arsenault & Marshall, 2000).
It is important to intervene to reduce anxiety because increasing
anxiety reduces prenatal attachment. These interventions include de-
termining the mother's support systems, giving information on the cur-
rent pregnancy, and performing more prenatal visits and tests such as
ultrasound scans. When families are given the possibility to express
their worries and feelings concerning their previous experiences, they
will realize that it is normal to experience these feelings. At the same
time they will be better able to see the baby as a separate individual
and pregnancy as a separate event. These parents can be directed to
post-loss pregnancy support groups set up for families to share the
same experiences (Armstrong & Hutti, 1998).
In the literature, there are no standardized practices for pregnant
women after loss, but there are support groups for the pregnant
women subsequent to pregnancy loss. In a study, which was con-
ducted to determine the effectiveness of such groups, and a determi-
nation was made of the recovery, progress, sharing and learning
possibilities which these groups provided to the women (Cote-
Arsenault & Freije, 2004). Studies have shown that families who
join support groups feel better and bond better to the new-born baby
(O'Leary & Warland, 2011; Warland, O'Leary, & McCutcheon, 2011;
Warland, O'Leary, McCutcheon, & Williamson, 2011). In the literature
there is also discussion of child birth education courses for women
who become pregnant again after a pregnancy loss (Wright, 2005).
In a randomized controlled study of pregnant women who had expe-
rienced loss, it was reported that there was no difference between the
mean scores of depression, anxiety and prenatal attachment of the
groups, and that the intervention group's level of satisfaction with the
social support was significantly higher (Cote-Arsenault, Schwartz,
Krowchuk, & McCoy, 2014). In Turkey, there is no specific protocol for
this group. There is no special assessment and follow up process for
them. Beside this, there is no randomized controlled study on this group.
In the light of this information, this study was planned with the aim
of determining the effects of nursing care based on Watson's Theory of
Human Caring on mental health of pregnant women who have experi-
enced a pregnancy loss. It can be hypothesized that nursing care based
on Watson's Theory of Human Caring will reduce anxiety, depression,
hopelessness level of pregnant women subsequent to pregnancy loss
and increase the prenatal attachment of these women.
WATSON'S THEORY OF HUMAN CARING
The use of nursing theories in practice frees nursing from being a
work-focused profession and allows concentration on nursing
441
applications rather than on medical practice (Gigliotti, 2008). For
this reason the use of a model is important in nursing.
In various studies it is seen that Watson's Theory of Human Caring
can be used in every field of nursing–practice, training, research and
management (Arslan-Özkan & Okumuş, 2012).
According to Watson, the nursing process is a person-to-person pro-
cess of care giving (Fawcett, 2006) and nursing is centered on helping
the patient achieve a higher degree of harmony in the mind, body and
soul (Watson, 2012). In this process, the individual's own capacity for
self-healing can increase and consciousness at a high level can develop
(Fawcett, 2006). The theory includes the caritas process, the transper-
sonal caring relationship, caring moments, caring occasions and
caring-healing modalities (Watson, 2012).
Watson felt the word ‘intervention’ had a mechanical meaning, so
that she did not define nursing interventions. She defined ‘Caritas
factors’. In Turkey “Caritas factors” are defined as “healing factors”
(Arslan-Özkan & Okumuş, 2012). These are:
1. Adopting such values as humanistic and altruistic, approaching
oneself and the individual with love and compassion.
2. Belief in the individual and enabling faith and hope.
3. Individual belief and being sensitive to oneself and individuals
when developing practices.
4. Developing a helping and trust-giving care relationship.
5. Allowing the expression of positive and negative feelings by truly
listening to the histories of people.
6. Using creative, scientific problem solving methods to make care
decisions.
7. Allowing teaching and learning suitable for the individual's needs
and way of understanding.
8. Creating a comfortable, beautiful and serene environment in a
physical, emotional and spiritual sense.
9. Helping with basic physical, emotional and spiritual needs.
10. The roles of such things as dreams, imagination, stories and intui-
tion to give meaning to life.
Care given using Watson's healing processes goes beyond the
doctor's requirements. It enables the care given to individuals to be
dealt with holistically. The human care model was used to create a rap-
port with pregnant women with a history of pregnancy loss, to create an
environment of care for them, and to shape nursing approaches.
Considering the feelings of pregnant women after a pregnancy loss,
and believing in strengthening these women, increasing their hope
and achieving a healthy attachment to their baby, it was decided to
use Watson's Theory of Human Caring in this study, as it aims to dis-
tance caring from centralization, it is a care-oriented nursing model,
and its philosophy is covered by psychiatric nursing philosophy.
Hypotheses
1. Depression level will be lower in the intervention group than in the
control group.
2. Anxiety level will be lower in the intervention group than in the con-
trol group.
3. Hopelessness level will be lower in the intervention group than in
the control group.
4. Prenatal attachment level will be higher in the intervention group
than in the control group.
MATERIALS AND METHOD
A randomized, controlled method was used in this study to evaluate
the effects of nursing care based on Watson's Theory of Human Caring
on the anxiety, depression, hopelessness and prenatal attachment of
pregnant women subsequent to pregnancy loss. Fig. 1 shows the CON-
SORT (Consolidated Standards of Reporting Trials) flow diagram of the
442 P. Tektaş, O. Çam / Archives of Psychiatric Nursing 31 (2017) 440–446
Fig. 1. CONSORT diagram showing participant flow through the study.
research. The research was conducted in the maternity polyclinics of
two university hospitals in Izmir, Turkey between November 2013
and November 2014.
The inclusion criteria were as follows: i) pregnant not N12 weeks ii)
older than 18 years old iii) ability to speak, read and write Turkish.
The exclusion criteria were as follows: i) being under the age of
18 years old ii) insufficient Turkish language skills and/or being a for-
eign national iii) having high risk pregnancy.
Sampling
There are no similar studies examining the results of interven-
tions conducted on pregnant women with a history of pregnancy
loss, this gives an effect size of 0.05. The research power was deter-
mined as 0.80 (80%), and the level of statistical significance as p b
0.05 (Akgül, 1997). In this way, the estimate of the medium-level ef-
fect size (d = 0.50), and the 80% power and 95% confidence levels in
each group (the intervention and control groups) were calculated,
(Portney & Watkins, 1993), 128 participants needed to be included
in the analysis. Our study concluded with 55 participants in the ex-
perimental group and 46 participants in the control group. At the
end of the study, using mean scales scores, standard deviations and
tests in independent groups, effect size was calculated and found to
be strong at 0.9 (http://www.danielsoper.com/statcalc/calculator.
aspx?id=48).
Randomization
A simple randomization method was used in the study. According to
the number of the sample, 128 random numbers were assigned by
someone other than the researcher. Sixty of the random numbers
were even, and 68 were odd.
The pregnant women who came to the polyclinic were first
assessed for eligibility, then study consent was obtained, and after
that it was seen whether they had odd or even numbers, and in
this way it was determined which group they should be assigned
to. It was determined that the sociodemographic characteristics
and the pregnancy characteristics of the women in the two groups
were homogeneous (Table 1).
Preparation of the nursing care program and the process of application
Nursing care based on Watson's Theory of Human Caring was ap-
plied to the intervention group in the study. The ten healing process
were used for intervention group. The control group had no nursing
care in the out-patient unit as usual.
In order to conduct the care program, a semi-structured nursing care
program was developed as a guide. The program was arranged in five
sessions. Each session was arranged according to healing processes se-
lected from the theory. The interview programs were planned to be si-
multaneous with the women's out-patient unit monitoring programs.
 P. Tektaş, O. Çam / Archives of Psychiatric Nursing 31 (2017) 440–446 443

Table 1
Comparison of socio-demographic and pregnancy characteristics of the women in the intervention and control groups.

Intervention Control Total Test value p

n % n % n %

Sociodemographic characteristics
Age
18–35 59 86.8 55 91.7 114 89.1
36 years and above 9 13.2 5 8.3 14 10.9 0.786a 0.375
Education
Primary or middle school 20 29.4 14 23.3 34 26.6
High school 31 45.6 32 53.3 63 49.2 0.868a 0.648
University 17 25.0 14 23.3 31 24.2
Employment status
Working 29 42.6 23 38.3 52 40.6
Not working 39 57.4 37 61.7 76 59.4 0.246a 0.620
Monthly income
Income less than expenditure 5 7.4 4 6.7 9 7.0
Income and expenditure equal 63 92.6 56 93.3 119 93.0 0.023b 1.00
Duration of marriage mean ± SD 4.60 ± 3.00 4.28 ± 3.30 1737.50c 0.141

Pregnancy characteristics
Total number of pregnancy
Two 33 48.5 27 45.0 60 46.9
Three 28 41.2 25 41.7 53 41.4 0.338a 0.845
Four or more 7 10.3 8 13.3 15 11.7
Number of surviving children
None 35 51.5 32 53.3 67 52.3
One 28 41.2 21 35.0 49 38.3 0.971a 0.615
Two or more 5 7.4 7 11.7 12 9.4
Number of losses
One 66 97.1 51 85.0 117 91.4 5.901a 0.015
Two 2 2.9 9 15.0 11 8.6
Type of lossd
Miscarriage 55 80.9 55 93.2 110 86.6
Stillbirth 9 13.2 1 1.7 10 7.9 5.935a 0.051
Neonatal death 4 5.9 3 5.1 7 5.5
Desire for pregnancy
Yes 65 95.6 54 90.0 119 93.0 1.523 0.304
No 3 4.4 6 10.0 9 7.0
a
Chi-square test.
b
Fisher's exact test.
c
Mann-Whitney U value.
d
The one person responding “Other” was left out of the analysis.

According to this planning, the first interview was conducted in the
10th or 12th week of pregnancy. The other interviews were conducted
in the 16th, 20th, 24th and 28th weeks. Interviews took 30 min. At the
first interview the care healing environment was set up: this is the
first stage of the care process. In order to reach the woman's internal en-
vironment, she was treated sincerely and relevantly. For her external
healing environment, the surroundings of the interview were made ap-
propriate from the point of view of lighting, sound, comfort, security
and privacy. In order to set up an interpersonal care relationship, the
feelings, expectations and experiences of the women were shared and
the statement ‘To help her, to understand her’ was made there. After
that, the care healing process was used according to the needs of the
women. The interpersonal care healing methods of touch, relaxation ex-
ercises and listening to music were used.
Instruments used
In the collection of data, a characteristics information form, the Beck
Anxiety Scale, the Beck Depression Scale, the Beck Hopelessness Scale
and the prenatal attachment inventory were used.
1. Characteristics information form
This form consisted of: 1) a demographics section, 2) and obstetric
characteristics section, and 3) current pregnancy characteristics.
2. Beck Anxiety Scale
This scale was created by Beck et al. and was translated into Turkish
by Ulusoy, Şahin and Erkmen. It is a Likert type scale consisting of 21
items, answered with the choices ‘not at all’, ‘slightly’, ‘to a medium
extent’ and ‘to a serious extent’, which score 0–3 points. The
score is from 0 to 63, and shows the degree of anxiety of the indi-
vidual. The Cronbach Alpha coefficient of the scale was found 0.93
(Ulusoy, Sahin, & Erkmen, 1998). The test-retest reliability coeffi-
cient is r = 0.57. In our study, the Cronbach Alpha coefficient was
found to be 0.92.
3. The Beck Hopelessness Scale
The Beck Hopelessness Scale was developed by Beck et al. Validity
and reliability studies in Turkey were performed by Seber et al., and
it is used to determine negative expectations of an individual's
future. In Seber's validity and reliability studies, the Cronbach Alpha
coefficient was found to be 0.86 (Seber, Dilbaz, Kaptanoğlu, &
Tekin, 1993). In our study the Cronbach Alpha coefficient was
found to be 0.63.
4. The Beck Depression Scale
This is a four-way Likert type scale developed by Beck to deter-
mine the risk of depression in a subject and to determine the
level of depressive indications. Validity and reliability of the Turk-
ish version was investigated by Hisli, and the Cronbach Alpha co-
efficient was found to be 0.80. The total score on the scale varies
from 0 to 63 (Hisli, 1989). In our study the Cronbach Alpha coeffi-
cient was found to be 0.89.
5. The prenatal attachment inventory
The Prenatal Attachment Inventory was developed in 1990 by Mary
Muller. It consists of 21 items and was developed to show the
thoughts, feelings and condition of women during pregnancy and
444 P. Tektaş, O. Çam / Archives of Psychiatric Nursing 31 (2017) 440–446

Table 2
Comparison of findings on mean scores of anxiety, depression, hopelessness and prenatal attachment of women in the intervention and control groups before and after intervention ac-
cording to intention to treat analysis.

Groups

Scales Intervention group (n = 68) Control group (n = 60) Pretest Posttest

Pretest Posttest Pretest Posttest

Mean ± SD Mean ± SD Mean ± SD Mean ± SD Test valuea p Test valuea p

Beck anxiety 14.2 ± 8.2 5.7 ± 4.0 14.0 ± 7.1 14.0 ± 8.0 2021.5 0.930 720.0 0.000
Beck depression 15.4 ± 7.0 7.9 ± 3.8 15.6 ± 6.2 15.8 ± 7.2 1933.0 0.609 709.0 0.00
Beck hopelessness 2.0 ± 1.9 0.5 ± 1.0 2.4 ± 1.7 2.2 ± 1.7 1724.0 0.124 699.0 0.00
Prenatal attachment 34.2 ± 3.2 51.2 ± 8.9 38.3 ± 10.9 42.4 ± 9.2 1850.0 0.362 1010.5 0.00
a
t value and Mann-Whitney U value.

to determine their level of attachment to their baby in the prenatal
period. Each item is of four-way Likert type, and can score from 1
to 4 points. Thus the lowest score on the inventory is 21 and the
highest is 84, and a higher score shows greater attachment. Validity
and reliability studies for this inventory in Turkey gave a reliability
coefficient of 0.84 (Dereli-Yılmaz & Kızılkaya-Beji, 2013b). In our
study the Cronbach Alpha coefficient was found to be 0.91.
sociodemographic characteristics (p N 0.05), and in terms of their preg-
nancy characteristics the only significant difference was in the number
of losses (p = 0.015) (Table 1).
Findings on mean scores of anxiety, depression, hopelessness and prenatal
attachment of women in the intervention and control groups before and af-
ter intervention according to Intention to Treat Analysis (ITT)

Table 2 shows findings on mean scores of anxiety, depression, hope-

Research ethics
Before commencing the study, approval was obtained from Nursing
Faculty Ethics Committee and approvals were obtained from the hospi-
tals. Oral and written approval was obtained from the pregnant women
who volunteered to take part in the study.
Data evaluation
The Statistical Package for Social Science (SPSS) 17.0 was used in the
evaluation of data. The level of statistical significance was as α: 0.05. We
determined statistical methods after assessing the shape of the data
distribution.
Intention to treat analysis
Because losses were experienced in the sample during the time
of the study, intention to treat (ITT) analysis was performed. The
aim was to compare by ITT analysis the intervention results in
groups which were randomly assigned if an individual in the sample
group leaves the sample during the study (Hollis & Campbell, 1999).
In order to apply ITT analysis completely, it is necessary to reach all
individuals who took part in the randomization. As this could not be
achieved in this study, measurements resulting from the most re-
cent data obtained are filled in again for constant data (Üstün &
Günüşen-Partlak, 2009). ITT analysis was performed by writing pre-
test measurement data in the post-test section of the women in the
intervention group (n = 13) and control group (n = 14) who left
the study.
In comparing the sociodemographic characteristics and the
pregnancy characteristics of the pregnant women in the interven-
tion and control groups, numerical values, percentages, means,
chi-square test, and Mann-Whitney U test were used. In the com-
parison of Beck anxiety, Beck depression, Beck hopelessness and
prenatal attachment mean scores of the women in the intervention
and control groups before and after intervention Mann-Whitney U
test was used.
RESULTS
There was no statistical difference between the women assigned by
randomization to the intervention and control groups in terms of their
lessness and prenatal attachment of women in the intervention and
control groups before and after intervention according to ITT.
No statistically significant difference was found between mean
scores of anxiety, depression, hopelessness and prenatal attachment of
women in the intervention and control groups before intervention ac-
cording to ITT (Table 2).
A highly statistically significant difference was found between mean
scores of anxiety, depression, hopelessness and prenatal attachment of
women in the intervention and control groups after intervention ac-
cording to ITT (p b 0.001) (Table 2).
DISCUSSION
It was found that there was a highly significant difference between
the mean scores on depression, anxiety, hopelessness and prenatal at-
tachment after intervention of the women in the intervention and con-
trol groups. It is thought that this difference arises from nursing
interventions based on Watson's Theory of Human Caring.
The significant difference between the mean scores of the interven-
tion and control groups can be explained by the out-patient unit doctor
working in a more work-focused way because of the number of patients
seen every day, inability to achieve good communication and inability
to create empathy with the pregnant women. In Turkey; at government
hospitals at obstetrics out-patient units, one doctor looks after about 50
patients from 9:00 am to 5:00 pm. So it is not possible to listen to the pa-
tients and achieve good communication. At the same time there is no
nurse for pregnant women to care them. These pregnant women were
not receiving any kind of nursing intervention in the out-patient units.
However, this group needs special care. At this point this result is impor-
tant in showing the important effect of performing nursing care on
pregnant women with a history of loss.
In a study by Carrera et al. (1998) comparing pregnant women who
had experienced a pregnancy loss and mothers who had given birth to
healthy babies using the Beck Depression Scale, it was found that the de-
pression levels of mothers who had experienced a loss and received
psychological support for one year were lower than those of the group
who had experienced a loss but had received no intervention, and
were similar to the depression levels of mothers who had given birth
to healthy babies. This result shows that effective interventions applied
to pregnant women with a history of loss will have a positive effect on
their depression. Although there are no studies using this theory in a
similar group, it was determined in one study using Watson's Theory
 P. Tektaş, O. Çam / Archives of Psychiatric Nursing 31 (2017) 440–446
of Human Caring on depressive women that the model was effective in
reducing depression (Mullaney, 2000).
As no study was found using the Beck Anxiety Scale on a similar
group, it was not possible to make a complete comparison. In studies
carried out in other countries, the Pregnancy Anxiety Scale has been
used to determine anxiety levels during pregnancy (Armstrong, 2002;
Armstrong & Hutti, 1998; Cote-Arsenault, 2003). In a study by Cote-
Arsenault (2003), the fact that there was a difference between mean
pregnancy anxiety scale scores despite the lack of difference between
mean state anxiety scores can be explained by other measurement in-
struments relating to anxiety not completely showing worries experi-
enced in pregnancy after a pregnancy loss. No measurement
instrument was encountered in the literature relating to anxiety over
pregnancy in this country. In our study, anxiety levels in the interven-
tion and control groups were measured using the Beck anxiety scale.
This is a scale which evaluates anxiety in a general way. Nevertheless,
a significant difference was found between the mean anxiety scores of
the intervention and control groups after intervention, and this shows
that nursing care based on Watson's Theory of Human Caring had a pos-
itive effect on the anxiety levels of pregnant women with a history of
pregnancy loss.
Studies have shown that pregnant women with a history of preg-
nancy loss have a need to speak in a supportive and unprejudiced at-
mosphere (Caelli, Downie, & Letendre, 2002; Cote-Arsenault & Freije,
2004). For these women, communication skills such as eye contact,
therapeutic touch and effective listening are important. These are
skills which will make it easier to understand the needs of these
women. At the same time, giving information on pregnancy and re-
laxation exercises are interventions which are used on these
women and which reduce anxiety (Wright, 2005). These interven-
tions are part of the healing process of Watson's Theory of Human
Caring, and were applied to the women in the intervention group.
It can be said that these interventions are effective in reducing
anxiety.
A loss experienced in pregnancy destroys the hopes and dreams for
the future of parents (Carrera et al., 1998; Cote-Arsenault, 2003). In a
study by Cote-Arsenault and Donato (2007), it was determined that
the hopes of having a healthy child of women with a history of pregnan-
cy loss rose as the pregnancy progressed. However, fear and hope for
these women are emotions which are paradoxically experienced in
pregnancy after a loss. It the same study, it was reported that speaking
with their care givers about their hopes and fears concerning pregnancy
was important for normalizing the emotions which they were
experiencing and for developing positive feelings concerning their preg-
nancy. In our study, the nursing approaches of help for needs, the help-
trust relationship, expression of feelings, developing belief and hope,
and teaching and learning, which are part of the healing process of
Watson's Theory of Human Caring were used. It can be said that these
interventions raised awareness of the women's thoughts and feelings,
increased their confidence in themselves and their pregnancy, and sup-
ported their hopes on this point. No descriptive and interventional
study was found in the literature measuring the hopes of this group.
For this reason it was not possible to compare the results of the study
on this point. However, the difference between the mean hopelessness
scores of the intervention and control groups shows that the interven-
tion carried out in our study was effective.
The prenatal attachment levels of the women in the intervention
group after the intervention were found to be higher than those of
women in the control group. It is reported that anxiety and fear of loss
make it difficult for mothers to form an attachment to the new baby
(Armstrong & Hutti, 1998; Wallerstedt et al., 2003). The reduction in
anxiety with the interventions carried out on the intervention group
and the support of hope can be said to be a factor in increasing attach-
ment. Statements such as “Giving regular information on the develop-
ment of my baby calmed me down. I feel greater attachment to it” and
“Having someone listening to my worries in this process and giving
445
their time to me surprised me. I wish there was always someone like
that – someone caring about me and my baby” support this.
In a randomized controlled study, it was found that there was no dif-
ference in mean scores for depression, anxiety and prenatal attachment
in pregnant women who received care-based home visits in pregnan-
cies after a loss (Cote-Arsenault et al., 2014). This result may arise
from the sample size (intervention group: 13, control: 11) or from cul-
tural differences. Our study was conducted on a larger sample group,
and this may be the reason why there was a significant difference be-
tween the mean depression scores of the intervention and control
groups. At the same time, state, trait and pregnancy anxiety scales
were used in the same study. Although there was a difference in these
scores between the intervention and control groups, the women made
this kind of statement about taking part in the study: “Being in the
study was good for me because it made me feel that I was safe and
not alone.” Another said the following: “It provided me with great sup-
port in freeing myself from stress and worry while I was pregnant.” “It
was very nice to know that there was someone I could talk to, someone
who knew about pregnancy, anxiety and my feelings…” It was found
that discussion with the nurse increased their confidence in themselves
and reduced their anxiety. For this reason it is important that nurses
should use interventions to reduce anxiety in these groups. In this
study the last monitoring in which scales are completed is in weeks
32–34 of pregnancy (Cote-Arsenault et al., 2014). Therefore, as the
pregnancy progresses, the increasing hopes of having a healthy child
and especially closer monitoring of physical symptoms such as fetal
movement and more frequent checkups by doctors can increase
women's confidence in their pregnancy. This may be the reason for
the lack of difference between the women's depression, anxiety and
prenatal attachment mean scores.
In our study, a confidence-giving care relationship was set up with
the women in the intervention group by reflecting the ten healing pro-
cesses in the Human Caring Model in care, the women were enabled to
express their positive and negative feelings and thoughts, these feelings
were accepted, information was given concerning their pregnancy and
their babies, they were encouraged to ask questions and they were en-
abled to feel positive about their pregnancy by the use of individual
problem solving processes. In addition it is thought that treating the
women with love and compassion, creating a healing environment, set-
ting up a helping and secure relationship, and giving information on the
development of their babies was effective in reducing depression, anxi-
ety and hopelessness levels and in increasing prenatal attachment.
In conclusion, it was determined that nursing care based on
Watson's Theory of Human Care had a positive effect on the mental
health of pregnant women with a history of pregnancy loss. In the
light of these results, it is recommended that nurses providing care in
the obstetrics polyclinic should be informed about the difficulties expe-
rienced by pregnant women with a history of loss, individual interviews
should be conducted with pregnant women starting from the day when
pregnancy monitoring begins and continuing as long as necessary, ob-
stetrics polyclinics should be arranged in accordance with a ‘healing en-
vironment’, a care guide based on theory of human caring should be
prepared and the possibility of applying it to pregnant women with a
history of loss, its effects on patients and its nursing care results should
be evaluated, and validity and reliability studies should be carried out
on the Turkish version of the Pregnancy Anxiety Scale. At the same
time, the research results of this study were evaluated based on quanti-
tative data. It is recommended to use qualitative design which will give
a chance to pregnant women with a history of pregnancy loss to explain
deeply their pregnancy experience.
Acknowledgements
The authors wish to thank Ali Ceylan for statistical analysis and Alec
Rylands for language editing. This study is an unpublished research of
the first author, based on the author's doctoral thesis.
446 P. Tektaş, O. Çam / Archives of Psychiatric Nursing 31 (2017) 440–446
References
Akgül, A. (1997). Tıbbi Araştırmalarda İstatistiksel Analiz Teknikleri (Statistical Analysis
Tecniques in Medical Research). Ankara, Turkey: Yükseköğretim Kurulu Matbaası.
Armstrong, D. S. (2002). Emotional distress and prenatal attachment in pregnancy after
perinatal loss. Journal of Nursing Scholarship, 34(4), 339–345.
Armstrong, D. S. (2007). Perinatal loss and parental distress after the birth of a healthy in-
fant. Advances in Neonatal Care, 7(4), 200–206.
Armstrong, D. S., & Hutti, M. H. (1998). Pregnancy after perinatal loss: The relationship
between anxiety and prenatal attachment. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 27(2), 183–189.
Arslan-Özkan, İ., & Okumuş, H. (2012). Bakım ve İyileşmenin Kesiştiği Bir Model:
Watson'ın İnsan Bakım Modeli [A Model Where Caring and Healing Meets: Watson's
Theory of Human Caring]. Hemşirelikte Araştırma Geliştirme Dergisi, 2, 61–72.
Bennet, S. M., Litz, B. T., Lee, B. S., & Maguen, S. (2005). The scope and impact of perinatal
loss: Current status and future directions. Professional Psychology, Research and
Practice, 36(2), 180–187.
Bergner, A., Beyer, R., Klapp, B. F., & Rauchfuss, M. (2008). Pregnancy after early pregnancy
loss: A prospective study of anxiety, depressive symptomatology and coping. Journal
of Psychosomatic Obstetrics and Gynaecology, 29(2), 105–113.
Blackmore, E. R., Cote-Arsenault, D., Tang, W., Glover, V., Evans, J., Golding, J., & O'Connor,
T. G. (2011). Previous prenatal loss as a predictor of perinatal depression and anxiety.
The British Journal of Psychiatry, 198, 373–378.
Caelli, K., Downie, J., & Letendre, A. (2002). Parents' experiences of midwife-managed care
following the loss of a baby in a previous pregnancy. Journal of Advanced Nursing,
39(2), 127–136.
Carrera, L., Diez-Domingo, J., Montanana, V., Sancho, M. J., Minguez, J., & Monleon, J.
(1998). Depression in women suffering perinatal loss. International Journal of
Gynaecology and Obstetrics, 62, 149–153.
Cote-Arsenault, D. (2003). The influence of perinatal loss on anxiety in multigravidas.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(5), 623–629.
Cote-Arsenault, D. (2007). Threat appraisal, coping, and emotions across pregnancy sub-
sequent to perinatal loss. Nursing Research, 56(2), 108–116.
Cote-Arsenault, D., Bidlack, D., & Humm, A. (2001). Women's emotions and concerns dur-
ing pregnancy following perinatal loss. The American Journal of Maternal Child
Nursing, 26(3), 128–134.
Cote-Arsenault, D., & Donato, L. K. (2007). Restrained expectations in late pregnancy fol-
lowing loss. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 36(6), 550–557.
Cote-Arsenault, D., Donato, L. K., & Earl, S. S. (2006). Watching and worrying: Early preg-
nancy after loss experiences. The American Journal of Maternal Child Nursing, 31(6),
356–363.
Cote-Arsenault, D., & Freije, M. M. (2004). Support groups helping women through preg-
nancies after loss. Western Journal of Nursing Research, 26(6), 650–670.
Cote-Arsenault, D., & Mahlangu, N. (1999). Impact of perinatal loss on the subsequent
pregnancy and self: women's experience. Journal of Obstetric, Gynecologic, and
Neonatal Nursing, 2883, 274–282.
Cote-Arsenault, D., & Marshall, R. (2000). One foot in-one foot out: Weathering the storm
of pregnancy after perinatal loss. Research in Nursing and Health, 23, 473–485.
Cote-Arsenault, D., & Morrison-Beedy, D. (2001). Women's voices reflecting changed ex-
pectations for pregnancy after perinatal loss. Journal of Nursing Scholarship, 33(3),
239–244.
Cote-Arsenault, D., Schwartz, K., Krowchuk, H., & McCoy, T. P. (2014). Evidence-based in-
tervention with woman pregnant after perinatal loss. The American Journal of
Maternal Child Nursing, 39(3), 177–186.
Dereli-Yılmaz, S., & Kızılkaya-Beji, K. N. (2013a). Prenatal bağlanma envanterinin
Türkçe'ye uyarlanması: Güvenirlik ve geçerlik çalişmasi (Turkish version of prenatal
attachment inventory: A study of reliability and validity). Anadolu Hemşirelik ve
Sağlık Bilimleri Dergisi, 16(2), 103–109.
Dereli-Yılmaz, S., & Kızılkaya-Beji, N. (2013b). Effects of perinatal loss on current preg-
nancy in Turkey. Midwifery, 29, 1272–1277.
Fawcett, J. (2006). Watson's theory of human caring. In J. Fawcet (Ed.), Contemporary
nursing knowledge analysis and evaluation of nursing models and theories (Second edi-
tion ). Philadelphia: F.A. Davis Company.
Gigliotti, E. (2008). The value of nursing models in practice. Dokuz Eylül Üniversitesi
Hemşirelik Yüksekokulu Elektronik Dergisi, 1(1), 42–50.
Gillbert, E. S., Harmon, J. S., & Taşkın, L. (2002). Yüksek riskli gebeliğin psikolojik yönü.
(Psychological aspects of high-risk pregnancy). Yüksek Riskli Gebelik ve Doğum El
Kitabı (pp. 118–183). Palme Yayıncılık: Ankara.
Hacettepe University Institute of Population Studies (2008). Turkey Demographic and
Health Survey 2008. Ankara. Retrieved from: http://www.hips.hacettepe.edu.tr/
TNSA2008-AnaRapor.pdf.
Hacettepe University Institute of Population Studies (2013). Turkey Demographic and
Health Survey 2013. Ankara. Retrieved from: http://hips.hacettepe.edu.tr/TNSA_
2013_ana_rapor.pdf.
Heller, S., & Zeanah, H. C. (1999). Attachment disturbances in infants born subsequent to
perinatal loss: A pilot study. Infant Mental Health Journal, 20(2), 188–199.
Hill, P., DeBackere, K., & Kavanaugh, K. (2008). The parental experience of pregnancy after
perinatal loss. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 37(5), 525–537.
Hisli, N. (1989). Beck depresyon envanteri'nin üniversite öğrencileri için geçerliği ve
güvenirliği. Psikoloji Dergisi, 7(23), 3–13.
Hollis, S., & Campbell, F. (1999). What is meant by intention to treat analysis? Survey of
published randomised controlled trials. BMJ, 319, 670–674.
Hughes, P., Turton, P., Hopper, E., McGaulley, G. A., & Fonagy, P. (2001). Disorganised at-
tachment behaviour among infants born subsequent to stillbirth. Journal of Child
Psychology and Psychiatry, 42(6), 791–801.
Hutti, M. H. (2005). Social and professional support needs of families after perinatal loss.
Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34(5), 630–638.
Hutti, M. H., Armstrong, D. S., & Myers, J. (2013). Evaluation of the Perinatal Grief Intensity
Scale in the subsequent pregnancy after perinatal loss. Journal of Obstetric,
Gynecologic and Neonatal Nursing, 42(6), 692–706.
Kersting, A., & Wagner, B. (2012). Complicated grief after perinatal loss. Dialogues in
Clinical Neuroscience, 14(2), 187–194.
Mullaney, J. A. B. (2000). The lived experience of using Watson's actual caring occasion to
treat depressed women. Journal of Holistic Nursing, 18(2), 129–142.
O'Leary, J., & Warland, J. (2011). International parenting of childeren born after a perinatal
loss. Journal of Loss and Trauma, 17, 137–157.
Perry, E. S., Hockenberry, M. J., Lowdermılk, D. L., & Wılson, D. (2010). Maternal child nurs-
ing care (4th edition ). Mosby Elsevier.
Phipps, S. (1985). The subsequent pregnancy after stillbirth: Anticipatory parenthood in
the face of uncertainty. International Journal of Psychiatry in Medicine, 15, 243–264.
Portney, L. G., & Watkins, M. P. (1993). Foundations of clinical research. Applications to prac-
tice. Norwalk, Connecticut: Appleton & Lange.
Rillstone, P., & Hutchinson, S. A. (2001). Managing the reemergence of anguish: Pregnan-
cy after a loss due to anomalies. Journal of Obstetric, Gynecologic, and Neonatal Nursing,
30(3), 291–298.
Seber, G., Dilbaz, N., Kaptanoğlu, C., & Tekin, D. (1993). Ümitsizlik Ölçeği Geçerlik Güvenirlik
(Validity and Reliability of the Hopelessness Scale). Kriz Dergisi, 3, 134–138.
Ulusoy, M., Sahin, N. H., & Erkmen, H. (1998). Turkish version of the Beck anxiety inven-
tory psychometric properties. Journal of Cognitive Psychotheraphy: An International
Quarterly, 12(2), 163–172.
Usta, G. M., & Balıkçı, A. (2012). Prenatal stresin nörogelişimsel etkileri (Neurodevelopmental
Outcomes of Prenatal Stress). Psikiyatride Güncel Yaklaşımlar, 4(1), 99–111.
Üstün, B., & Günüşen-Partlak, N. (2009). Randomize kontrollü çalişmalarda örneklemde
kayiplar olduğunda gerekli bir istatistiksel analiz: Intention to treat analizi (Intention
toı treat analysis: A statistical analysis necessary when sample loss occur in random-
ized controlled trial). Dokuz Eylül Üniversitesi Hemşirelik Yüksekokulu Elektronik
Dergisi, 1, 46–56.
Wallerstedt, C., Lilley, M., & Baldwin, K. (2003). Interconceptional counseling after perina-
tal and infant loss. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(4),
533–542.
Warland, J., O'Leary, J., & McCutcheon, H. (2011). Born after infant loss: The experiences of
subsequent children. Midwifery, 27, 628–633.
Warland, J., O'Leary, J., McCutcheon, H., & Williamson, V. (2011). Parenting paradox: Par-
enting after infant loss. Midwifery, 27, e163–e169.
Watson, J. (2012). Human caring science: A theory of nursing (2nd ed.). Sudbury, MA:
Jones & Bartlett Learning.
Wright, M. P. (2005). Childbirth education for parents experiencing pregnancy after peri-
natal loss. The Journal of Perinatal Education, 14(4), 9–15.