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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.4 São Paulo Aug. 2012
Marialda MartinsI; Marisa MonticelliII; Odaléa Maria BrüggemannIII; Roberta CostaIV
student in Nursing, by the Nursing Graduate Program at Federal University of
Santa Catarina. Assistant Professor at Federal University of Paraná.
Member of the Research Group on Nursing for Women's and Newborn Health (Grupo
de Pesquisa em Enfermagem na Saúde da Mulher e do Recém-Nascido
- GRUPESMUR). Curitiba, PR, Brazil. firstname.lastname@example.org
IIPh.D. in Nursing. Associate Professor of the Department of Nursing and the Nursing Graduate Program, Federal University of Santa Catarina. Vice-Leader of the Research Group on Nursing for Women's and Newborn Health. Florianópolis, SC, Brazil. email@example.com
IIIPh.D. in Obstetrics and Gynecology. Adjunct Professor of the Nursing Undergraduate Course and Graduate Program, Federal University of Santa Catarina. Member of the Research Group on Nursing for Women's and Newborn Health. Researcher with CNPq. Florianópolis, SC, Brazil. firstname.lastname@example.org
IVPh.D. in Nursing. Coordinator of the Neonatal Unit Nursing Team of the University Hospital, Federal University of Santa Catarina. Member of the Study Group on Nursing and Health Knowledge History (Grupo de Estudos de História do Conhecimento de Enfermagem e Saúde - GEHCES). Florianópolis, SC, Brazil. email@example.com
This documental study analyzed the Brazilian production of stricto sensu nursing graduate programs related to gestational hypertension. The data source used was the Brazilian Nursing Association Theses and Dissertations Database. The survey located 14 studies produced between 1979-2008, produced mainly in the Southeast region between 1996 and 2008. The analytical process revealed a concern with the subjectivity of pregnant women and with aspects regarding nursing care. Furthermore, it showed that most studies used a qualitative methodology supported by nursing theories. The experience lived by pregnant women with hypertension is marked by negative feelings and socioeconomic problems, and is also affected by how the family is organized. The culture of pregnant women with hypertension is disregarded and they receive care in a context in which the disease is the priority. In conclusion, despite some scientific advancements, this topic has not raised the interest it deserves among nurses attending graduate study programs.
Descriptors: Hypertension, pregnancy-induced; Pregnancy; high-risk; Nursing research
Pregnancy is a phenomenon that is part of women's life cycle, characterized by alterations in their physiological, physical, emotional, social, and cultural aspects. Despite its universal character, it also involves specificity, as it is a unique experience, an event filled with subjectivities and representations, and, therefore, inserted in women's family life and sociocultural context. As it is part of the reproductive cycle, pregnancy should occur without any fear, but it is known that serious physical complications and social or economic disparities can occur, causing what is characterized as reproductive risk(1).
A risk pregnancy often results in maternal death, which is among the indicators of a country's human development. This finding, therefore, exposes the real socioeconomic situation of each country, and reflects the quality of life of the population, as well as the health measures being adopted by government policies. It is estimated that, worldwide, every day 1,000 women die because of complications related to pregnancy and childbirth. In 2008, 358,000 dies during or after pregnancy and childbirth, and most cases could have been avoided(1).
One of the most common causes of these deaths is Gestational Hypertension (GH). Despite the many forms of GH and the uncountable clinical denominations for high blood pressure during pregnancy(2-3), Pregnancy-induced Hypertension Syndrome (In Portuguese: Síndrome Hipertensiva Específica da Gestação - SHEG) is highlighted. Today in Brazil, SHEG is an expression that healthcare professionals and researchers have preferred over the expression Pregnancy-induced Hypertension (In Portuguese: Doença Hipertensiva Específica da Gestação - DHEG)(4).
This social situation directly points to the quality of healthcare that these women receive, and, particularly, to nursing practice, considering that these are the healthcare professionals most involved in the providing healthcare to pregnant women with hypertension, both at the primary healthcare level, as well as to hospital inpatients. Nurses, through their professional practice, have the unique chance to identify the signs and symptoms that characterize the evolution of this specific pathology, and, thus, make interventions even before the complications occur. This condition, however, is directly related to the improvement of the care provided to pregnant women with hypertension, which implies, among other strategies, not only to consume the knowledge produced in other areas, but also to produce nursing knowledge that answer this demand. The evolutions and changes in the care practice result from the advancements achieved by producing knowledge regarding that particular theme.
A considerable part of this production is strongly related to graduate courses and to the expressive number of Master's dissertations and Doctoral Thesis produced by Brazilian stricto sensu graduate studies programs(5-6). Nevertheless, in terms of this specific theme, this knowledge is not very evident or visible, as it is sparsely distributed, and there are no articles that present synthesized but thorough portray of this production. Hence, there is a gap of knowledge in this regard, which justified the preset study, which was performed with the objective to analyze the knowledge produced in Brazil regarding Gestational Hypertension in the theses and dissertations developed in the nursing graduate studies programs.
Taking into consideration that the electronic databases are tools consistently updated to disseminate knowledge among researcher, the authors chose, as the documental source, the Theses and Dissertations Database of the Center for Nursing Studies and Research (Centro de Estudos e Pesquisas em Enfermagem - CEPEn) of the Brazilian Nursing Association (Associação Brasileira de Enfermagem - ABEn) − the largest database of nursing theses and dissertations in Brazil.
The study uses the documental research as the method to analyze the scientific production(7) of the Brazilian nursing stricto sensu graduate studies, regarding hypertensive disorders of pregnancy, listed in this base, in the period between 1979 and 2008, i.e., since it was established.
The first survey was performed, accessing the listed studies from reading their titles. Next, the abstracts, which titles were in some way associated with the chosen topic, were selected and read, because the keywords usually did not provide a clear indication of the contents of the studies. It was observed that the term most often used in the studies was related to the term Pregnancy-induced Hypertension (in Portuguese: Doença Hipertensiva Específica da Gestação - DHEG).
This first stage of the study resulted in a group of six dissertations and one thesis regarding gestational hypertension. However, considering that the set of selected studies had an insufficient quantitative relevance, and aiming to perform a more thorough screening to identify any production with unspecific indication, an addition selection was made, following the same methodology, of studies that had High-risk pregnancy as the theme. This decision was made by the researchers because it is understood that hypertensive syndromes have a high incidence within this gestational typology, and this was a way to find the theme of interest embedded in these other studies. Hence, seven additional studies were located: six dissertations and one thesis. Although the titles and descriptors of the studies did not present specific indicatives, it was realized that their objects were directly related with GH, as suggested in the abstracts.
Finally, the 14 studies - 12 master dissertations and 2 doctoral theses - comprising the corpus of this documental study were analyzed. The chosen technique for the collection, organization and classification(7) of the information regarding the referred corpus included the following steps: a) printing the 14 documents (dissertations and theses), in full; b) completing an instrument, which consisted of a scheme for a general identification of the variables to be analyzed, previously created by the study researchers, with the records made using Microsoft Excel™. The referred instrument addressed the following variables: Brazilian region where the study was produced, year of publication, participants, the adopted theoretical and methodological approaches, and the results; c) a careful reading of each document by the four researchers, individually, using as reference the indicatives that the dissertation or thesis would add to the production of knowledge on Gestational Hypertension; and d) a debate among the researchers with the purpose to compare their evaluations, in addition to negotiating the grounds for the analytical phase.
The variables related to the region where the studies were developed and their year of publication were analyzed by frequency distribution. The variables - participants, theoretical approach and methodological approach were organized into a chart. Next, thematic analysis was used to interpret the other characteristics of the studies, because the similarities between the results of these theses and dissertations revealed two thematic categories, which will be presented in the discussions section.
Because this is a documental study, it was not submitted to an ethics Committee. However, it should be noted that the researchers followed all the necessary ethic principles to analyze the study data.
The interpretation of the referred 14 stricto sensu studied regarding GH revealed aspects that provide a global characterization of the studied population. Chart 1 presents the distribution o f the studies, according to the dates of publication and the Brazilian region where they were performed. It is observed that the studies were published between 1996 and 2008, and most (eight studies) were performed in Southeast Brazil.
Regarding the characteristics of the studies, in nearly all of them, the participants were pregnant women (13) and most used a qualitative approach (9). In the referred qualitative studies, nursing theories were the prevalent framework (Chart 2).
The analysis also revealed two thematic categories that portray the type of knowledge produced by the nurses, in academic studies of this nature, i.e., the Meanings that the women assign to their surviving hypertension during pregnancy and Care to women with gestational hypertension.
It is not surprising that most studies were produced in Southeast Brazil, considering it is the region with the highest number of graduate programs in the country, currently with 19 of the 39 ongoing programs(8).
Regarding the methodology, the fact that most researchers used a qualitative approach is consistent with the nature of most nursing studies in Brazil, regardless of the field.
In terms of the theoretical-philosophical support, the fact that five of the analyzed studies used nursing theories reveals that these frameworks have been used to ground not only practice but also the scientific production of nursing in this area. In addition, regarding the characterization, it is highlighted that the studies have similar results, regardless of their methodology and the location where they were performed. This characteristic made it possible to group the findings into two thematic categories.
Meanings the women assign to their experiencing hypertension during pregnancy
Eight of the fourteen studies were classified within this category. Nearly all of them involved an interpretation founded on psychological and phenomenological perspectives and on the social representations theory. Only one study was analyzed founded on the anthropological framework.
The meanings attributed by the women involved the fear of death (their and their baby's), the social and economical difficulties that permeated their experience, as well as how they used their faith to deal with those difficulties. Considering all the studies in this first thematic category, the most common feeling revealed by the pregnant women with hypertension was fear. This feeling, however, appears to be associated with various situations, having different meanings for different women.
The authors of eight of the analyzed studies were unanimous in stating that these women experienced pregnancy in a negative way, because they felt threatened by the possibility of loosing a child or having to face preterm childbirth, because the child would have a higher chance of survival. Similarly, they evidenced that these women also feared for their own lives. Fear usually originates from one's lack of knowledge regarding the possible evolution of one's disease. When perceiving they are at risk, they also fear the possibility of their other children becoming orphans.
Fear increases as childbirth approaches, due to the fantasies regarding their own finitude, considering that their physical problems increase and, from a psychological perspective, women are within an emotional turmoil. Since they realize they are at risk, the study results denote complex feelings that make it difficult for the pregnant women to make decisions regarding their existential situation in the world, considering the current moment they are living as well as the life that is (or not) to come next.
After reading the studies, it was confirmed that in addition to the concern towards the disease per se, these women express feelings that extrapolate the negative effects that are observed in the maternal and fetal organisms, finding a resonance in the social and economical lives of their families. In 100% of the studies classified within this category, it was evident that uncountable concerns affect the modus vivendi of these pregnant women.
The results denote that their activities of daily living become restricted, such as eating, relating to others, managing the different social roles, besides the fact that the problems, in the social dimension, affect their global wellbeing, and this emerges as one of the main generators of stress. They deal with all types of difficulties, because of the low pay they receive in their jobs, or because they live far from work, from the hospital, or from their children's school. Furthermore, there is an intense accumulation of roles, responsibilities and appointments, which makes it extremely complicated to balance housework, maternity and profession when they have a disease that requires rest, dieting, and specific treatments, as recommended by healthcare professionals(9,15).
These representations show that these clients' needs surpass the physical domain, and interfere in their health care. The difficulties caused by their socioeconomic conditions, such as their low income and joblessness, contribute to making it difficult them to rest and obtain the necessary medication, leading to stress and increasing their exposure to the risk of complications and death(15).
One difficulty reported by the study participants is the need to be admitted(22) in any of the phases of their experience regarding hypertension. This issue appears in five of the analyzed studies as a generator of feelings of helplessness and hopelessness, because it removes women from their family environment and their children have to be looked after by relatives or neighbors, in addition to raising a sensation of dependence and strengthening the fear of the unknown, which is a result from the lack of information regarding the medical procedures.
Five studies demonstrated that the pregnant women, when facing the risk, seek some relief to all this suffering in religion. This perspective highlights the feelings that the religious belief can help deal with the difficulties caused by their condition of experiencing a high-risk pregnancy. On the other hand, this is also translated as a warning to healthcare professionals, who should consider the spiritual needs of pregnant women with hypertension, as a palliative that promotes comfort to their suffering and reduces their anxiety(18-19).
There is an urgent need to understand the logic behind some familiar health systems, which see religion as a source of therapeutic help. This representation, according to some authors, strengthens individuals to deal with the obstacles related to the health-disease process, providing answers to facts that are often unexplainable, such as the occurrence of some diseases, and even death. Faith is among the uncountable forms of self-care, which results from cultural and social processes, as a form of answering the health needs of a given social group, but healthcare professionals sometimes are not prepared to recognize and accept these cultural processes that are a part of the clients' lives.
The analyzed studies strongly indicate that healthcare professionals who treat these women must value them as a whole being, with spiritual demands that require respect and attentiveness, seeing religion as a cultural component that should inclusively, be used as an indispensible resource for care.
Nursing care to women with gestational hypertension
Six of the fourteen studies comprising the corpus of this documental study were grouped into this category. The main concerns of the master and doctorate students were the purpose of identifying the profile of these women, and their aim to improve the current healthcare, through the systematization of healthcare, in addition to the meanings that nursing care has to pregnant women with hypertension.
The master and doctorate students' concern with identifying the profile of the pregnant women with hypertension is formally related to the data collection stage or with the initial assessment of the nursing care methodology. The study results characterize the participants as white women, of ages between 20 and 35 years. Most are multipara and attended prenatal care. In average, 55% of the women underwent a cesarean section, while nearly 93% of all pregnant women had a live newborn(13,16).
Regarding their sociodemographic profile, we realized that the women are part of a deprived social group, which agrees with studies that affirm that the socioeconomic situation itself is a risk condition that also contributes with a higher incidence of gestational hypertension, as its rates are much higher in poor and developing countries. Most pregnant women have an incomplete primary or secondary education level. Regarding their occupation, most were housewives or had jobs as maids or clerks(10,16-17).
The limitations of the health team interventions to meet these women's needs emerge when, in the discourses, it is seen there are socioeconomic problems that undeniably contribute with making the pregnancy a complex event, emphasizing the nee for care that transcends the biomedical therapy that, in brief, focuses exclusively on controlling hypertension.
Two studies aimed at identifying nursing diagnoses in women who had received a medical diagnosis of gestational hypertension. Both highlighted the importance of this methodological step of the nursing process in providing care to women experiencing a high-risk pregnancy. One of them identified the nursing diagnosis fear and anxiety in 46.6% of the pregnant women with hypertension, and fear, alone, in 90% of the participants(14), which reinforces the meanings found in the results pointed out in the first category. The other study obtained similar results and also identified, as a defining characteristics of fear, the identified lack of knowledge and their difficulty to follow instructions(10). In both studies, the nursing diagnosis deficient knowledge was highlighted(10,14). This identification invigorates the importance that the educational aspects have on nursing care(12,21).
Only one study addressed the purpose to test a new therapy for nursing action/intervention. Quantitative methods were used to determine the physical benefits of reflexology for pregnant women with hypertension. The results showed that the therapy reduced the blood pressure levels, besides relieving the level of edema(10). This care reveals new strategies that can be extremely useful for nurses that take care of pregnant women with these clinical conditions.
The only study that aimed to understand how nursing care was delivered to this specific population, and that investigated the nurses' perception about the care to this group of pregnant women, shows that although most nurses develop their work non-systematically, they seek professional and personal qualification, show interest and concern towards the patients' feelings, perform an intuitive assessment of the patients, are committed to developing humanized care, and are open to making changes to improve the quality of the care being provided(11).
This perspective of the representation of the women who experience GH is an indicator of the fragility, distance and lack of interest that take place in their relationships with nurses, particularly in the hospital environment. This denotes a care model guided by the immobilization of the professional health system, showing their lack of knowledge regarding the women's reality, and their avoidance of a sincere and genuine listening(18), concern aimed at curing the body of the mother and fetus, and care centered on ethnocentric, centralizing and medicalizing perspectives, which are particular of biomedical care.
The analysis of the production of Brazilian stricto sensu nursing graduate programs regarding gestational hypertension found that the theme has risen little interest among nursing academics, and that the Brazilian production, in quantitative terms, is not very significant considering the severity of the risk of hypertension during pregnancy. It is noted that the production on this theme concentrates in the period between 1996 and 2008, with a prevalence of dissertations, which, geographically, concentrate in the southeast region.
Regarding the theme, the importance of understanding the subjectivity of the pregnant women with hypertension and elaborating healthcare proposals to this specific population are highlighted. It is also emphasized that nursing theories were the most common framework used to interpret the data. The results of these studies reveal that the experience that these pregnant women live is marked by negative feelings, particularly those related to their own death and that of their baby. It is also identified that the identified problems are worsened by the socioeconomic conditions and by how the family is organized, which increases their difficulty regarding self-care, generating stress and increases their exposure to the possibilities of physical complications and also to the risk of death while generating a new life. The studies also show that these women's culture is disregarded in the nursing care process; a fact that can help reduce the understating of the subjectivities involved in experiencing GH. The pregnant women with hypertension are treated in a context in which the disease, itself, is the priority, although the phenomenon is addressed, in some way, from the phenomenological and psychological perspectives. On the other hand, studies reveal that the nurses' concern to consolidated nursing as a science and also their availability to understand and talk to these clients, thus being closer to their personal experiences.
It is also emphasized that the nurses constantly search to improve the quality of healthcare to this specific population, although the care remains focused on perspectives aimed at the knowledge that is required by the professional healthcare system, with a strong medicalizing cover.
The analysis of the study results implies that the context in which these pregnant women have been treated is filled with gaps. The lack of information that permeates this experience is a consequence of the healthcare that is offered, centered on the disease and on treating the symptoms, disregarding the emotional and socioeconomic causes, and, mainly, the cultural meanings associated with the condition of heaving a pregnancy-induced disease. Nursing care, following the biomedical model, reduced the perspective of comprehensiveness in the healthcare to pregnant women.
Despite the limitations of this study, such as the fact that it systemizes the knowledge produced exclusively by nurses, and from the circumscribed angle of stricto sensu productions, nevertheless, it reveals an important part of this knowledge and may serve to stimulate the analysis of other bibliographic sources, further studies that include the production on international graduate studies, as well as the production performed by nurses, in domains other than graduate studies.
It is believed that the results presented herein can bring nurses and pregnant women with hypertension closer, so that the nursing care that is provided is more consistent with the reality that these women experience, and, this way, help reduce the rates of maternal death caused by hypertensive syndromes of pregnancy.
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