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The expectant father’s experience of high risk pregnancy and antenatal hospitalization Ross, Miguelle E. 1993

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THE EXPECTANT FATHER'S EXPERIENCE OF HIGH RISK PREGNANCYAND ANTENATAL HOSPITALIZATIONBYMiguelle E. RossB.S.N., The University of British Columbia, 1982A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIES(School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril, 1993© Miguelle E. Ross, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.Department of ^5 6.62416-c Sil—,icz( 6The University of British ColumbiaVancouver, Canada.../Y-3,Date ^t ?" DE-6 (2/88)iiAbstractDespite increasing interest in the role of the father in pregnancy,birth, and parenthood, little attention has been given to the expectantfather's experience of coping with a high risk pregnancy and thehospitalization of his partner. This study was undertaken to furtherunderstanding regarding the experience of the expectant father from hisown unique perspective. Using the grounded theory method, fathers'experience of the phenomenon of high risk pregnancy and antenatalhospitalization was explored, resulting in a descriptive analysis thatconveyed a common conceptualization of the experience.Participants were selected from the tertiary care facility serving theprovince of British Columbia. Nine fathers participated in the study; theycontributed a total of 16 interviews. The fathers' ages ranged from 29 to 40years. At the time of the first interview, pregnancy gestation ranged from24 weeks to 35 weeks. Pregnancy complications varied in nature reflectiveof a high risk population.Central to the fathers' descriptions were the roles they assumed inrelation to their participation in the phenomenon. The two predominantroles were providing emotional care to their partner and sustaining thefamily's functional responsibilities. The primary theme that evolved throughanalysis was a process of finding a balance between these two roles. Anumber of factors served to influence the balance, including the supportsystem available to the fathers, high risk condition factors, and geographicalcircumstance. Specific strategies were identified that contributed to thefathers' ability to cope with the experience. The findings indicated that the111experience had a significant personal impact on the fathers, affecting boththeir emotional and physical wellbeing.Based on the findings of the study, implications for nursing practice,education, and research were identified that promote recognition of theimportant and unique needs of expectant fathers in high risk pregnancy andantenatal hospitalization.ivTable of ContentsAbstract  ^iiTable of Contents ^  ivList of Figures  viiAcknowledgments  ^viiiCHAPTER ONE: INTRODUCTIONBackground to the Problem ^  1Theoretical Perspective of the Study  ^3Review of the Literature  4^Fatherhood in Normal Pregnancy ..   4Father's Experience in High Risk Pregnancy .   10Problem Statement ^  11Purpose ^  12Definition of Terms  12Assumptions  12Limitations ^  13Summary  14CHAPTER TWO: METHODOLOGYResearch Design ^  15Selection Criteria  16Selection Procedure  17Data Collection and Analysis ^  19Open Coding ^  21Axial Coding  21Selective Coding  22Reliability and Validity ^  23Ethical Considerations  24Summary ^  2 5CHAPTER THREE: FINDINGS FROM DATA ANALYSISDescription of Participants ^  26The Expectant Father's Experience: A Descriptive Analysis^27Role Behaviors ^  31The Role of Emotional Caregiver ^  31Maintaining a Physical Presence  33Providing Comfort and Compassion ^ 35Acting as a Psychological Coach  36Being an Advocate ^  3 8Providing Protection  38The Role of Family Sustainer  39Adjusting Work ^  40VProviding Childcare ^  42Taking on Domestic Responsibilities^43Balancing Factors ^  44Support System  44Partner  45Family ^  47Friends  48Church  49Health Care Providers^• 49High Risk Condition Factors . . .^ 51Anticipated Versus Unanticipated Risk .^51Perceived Severity of Risk . . . . 53Prior High Risk Experience .^ . 54Geographical Circumstance . . . 55Personal Impact of the Experience . . . .▪5 7Emotions Surrounding the High Risk Pregnancy^57Fear ^  57Uncertainty ^  61^Helplessness/Loss of Control . .   62Emotions Surrounding the Hospitalization^. ^ 63Loneliness/Loss of intimacy   63Security ^  64Feeling like an Outsider   66Belonging  68Physical Impact ^  70Diet  70Sleep  71Exercise/Leisure Activities ^  72Coping Strategies ^  72Positive Attitude  72One Day at a Time ^  7 4Faith  75Knowledge ^  76Finding a Balance  80Summary ^  84CHAPTER FOUR: DISCUSSION OF FINDINGSIntroduction ^  86Finding a Balance  8 7The Role of Emotional Caregiver ^  93The Role of Family Sustainer  96Balancing Factors ^  98Support System  98High Risk Condition Factors ^  102viGeographical Circumstance ^  103Personal Impact of the Experience  104Emotions Surrounding the High Risk Pregnancy^104Emotions Surrounding the Hospitalization . 109Physical Impact  ^112Coping Strategies  ^113Summary ^  114CHAPTER FIVE: SUMMARY, CONCLUSIONS, AND NURSINGIMPLICATIONSSummary ^  116Conclusions  ^118Nursing Implications^ 121Implications for Nursing Practice^ 121Implications for Nursing Education 130Implications for Nursing Research^...^131REFERENCES^ 135APPENDICESAppendix A: Introductory Letter^ ..^142Appendix B: Consent Form .. ..^146viiList of FiguresFigure^ Page1. Finding A Balance: A Substantive Experience .^. 29viiiAcknowledgementsMy sincere and overwhelming appreciation for the expert andgenerous guidance offered to me by my thesis committee, Professors ElaineCarty (chairperson), Linda Leonard, and Wendy Hall. Special gratitude goesto Professor Carty for her never ending support and mentorship throughoutmy graduate program. I will be forever in her debt for encouraging me everystep of the way with her calmness, understanding, and patience that was farabove and beyond the call of duty.I am eternally grateful for the support, encouragement (and neverending tolerance) of my partner, Andrew Hamilton, who is looking forwardto life post-thesis, and of my sister, Lani Wittmann, whose thoughts andideas guided me much of the way. Appreciation is also extended to mycolleagues at Grace Hospital, particularly Tina Tier and Sandy Anthony ,andmy friend, Deirdre Canty, for their ongoing flow of ideas, critiques, and mostof all, humor.I would like to acknowledge the University of British Columbia,School of Nursing, Sheena Davidson Nursing Research Fund for financialsupport of this study.Finally, I would like to thank the nine sensitive and articulatefathers who so willingly shared with me their experience.1CHAPTER ONEINTRODUCTIONBackground to the ProblemThe transition to parenthood is recognized as a critical developmentalevent in the lives of both men and women. While some argument existsregarding the degree of stress associated with this life experience - whetherthe process is determined to be one of crisis or transition - the significanceof the event in the lives of developing families is acknowledged by parentsand professionals alike (Cronenwett & Wilson, 1981; Duvall, 1977; Erikson,1950; Griffith, 1976; Hobbs, 1965; LeMasters, 1957; Rubin, 1975).Early attention to fatherhood was limited to anthropological andpsychoanalytic perspectives (Malinowski, 1966; Ross, 1979; Wainwright,1966). The natural childbirth movement in the 1950s triggered a small, butgrowing interest in the role of the father in pregnancy and childbirth (May& Perrin, 1985). Widespread and serious consideration of the importanceof the role has only been evident since the 1970s. This corresponds withthe immense social changes that have occurred in the western world duringthe same period, and which have led to a redefinition of sex roles and acloser examination of the man's role in the family (Hangsleben, 1980; May &Perrin, 1985).The body of knowledge about the experience of fatherhood has beengrowing over the past decade. Specifically, more is known about the father'srole transition during normal pregnancy, his participation in the birth2process, early patterns of father-infant interaction, challenges encounteredduring first time (and repeat) parenthood, and the role of the fatherthroughout a child's life (Jordan, 1990; Lemmer, 1987; May & Perrin,1985).There are, however, some aspects of fatherhood less well understood.Little consideration has been given to the impact of a high risk pregnancy onthe fatherhood experience. In the clinical setting of a high risk antepartumunit, the author has observed that, in high risk pregnancies, attention hasbeen very much directed to the mother-fetus diad. Whether intentionally orunintentionally, health care professionals have treated the father as animportant but subsidiary participant in the events. The result appears to bea father left to cope with a variety of complex emotions and additionalresponsibilities without substantial understanding or support from hispartner, family, friends, or members of the health care team.It has been suggested that a woman's experience of a high riskpregnancy may be altered significantly from the experience of a normalpregnancy (Kemp & Page, 1987; Penticuff, 1982). Hospitalizationcontributes additional dimensions to this phenomenon (Carty, Crawford &Ross, 1992; Curry, 1987; Loos & Julius, 1989; Merkatz, 1978; White &Ritchie, 1984). The question that remains unanswered is how do thesecircumstances change the experience for the expectant father? Once this iswell understood, intervention strategies designed to meet these men'sneeds can be developed.3Theoretical Perspective of the StudyThe grounded theory approach was the research method used for thisstudy. When using grounded theory, a frame of reference has a purposedifferent from that in traditional quantitative research. In quantitativestudies, a framework organizes the development of the study and provides acontext for interpretation of findings (Burns & Grove, 1987). In qualitativeresearch the emphasis is on theory building rather than on theory testing,therefore, a specific frame of reference was not explicated at the beginningof the study, but was developed through data collection and analysis. Abroad framework did, however, guide the study. The framework guidinggrounded theory is symbolic interactionism.The symbolic interaction theory of human behaviour was first advancedin 1934 by George Mead, a social psychologist, and further developed byHerbert Blumer (1969). Symbolic interaction is concerned with theparticular meaning of events to people in their natural environment. Howpeople define events from their own perspective and how they act inrelation to their beliefs is of primary concern. The concept of self is centralto the theory. It is believed that the concept of self, a quality held only byhumans, forms the basis of how humans create meaning and interpretexperience in the world. Meaning is created from experience. It is throughinteraction between self and objects, people, or events that individuals areable to define and attach meaning to experience (Chenitz & Swanson,1986). Grounded theory attempts to explicate that experience.4Review of the LiteratureThe purpose and timing of a literature review is also dependent on thechoice of research methodology. Grounded theory strategy dictates alimited overview of the subject initially, only to identify previously conductedstudies. There was no attempt to use the literature for the direction of datacollection, either to identify theoretical or conceptual frameworks, or toidentify variables and potential relationships for study (Strauss & Corbin,1991). Study findings can be jeopardized when there is an overemphasis onthe preliminary review of the literature. Strauss and Corbin (1991)explained that 'We do not want to be so steeped in the literature as to beconstrained and even stifled in terms of creative efforts by our knowledge ofit!" (p. 50).Later in the research process the literature was used for a differentpurpose. During advanced stages of data collection and analysis, theliterature became an important resource for furthering the refinement ofconcepts and verifying relationships in the developing theory (Burns &Grove, 1987). It was also used to validate the accuracy of findings and todemonstrate how the findings differed from previous work (Strauss &Corbin, 1991).This review includes an overview of the father's participation and rolein normal pregnancy, followed by literature that is relevant to the fatherhoodexperience in a high risk pregnancy.Fatherhood in Normal PregnancyAs mentioned previously, expectant fatherhood has only become of5wide interest since the 1970s. Before that, most literature could be dividedinto two categories, anthropological and psychoanalytic.The anthropological literature mostly involved studies exploring thephenomenon of ritual couvade (see Dawson, 1929). Ritual couvade has beendefined as the culturally sanctioned learned behaviours enacted by expectantfathers that usually involved such restrictions as special dress, socialconfinement, limitations on physical labour, sexual restraint, avoidance ofpolluting substances, mock labour, and postpartum seclusion (Clinton,1987). Ritual couvade is usually limited to preindustrial societies (Klein,1991). Interestingly, Heggenhougen (1980) proposes a similarity betweenthe contemporary western practice of fathers' participation in childbirthand the accompanying rituals such as prenatal classes, and the couvadepractices associated with more primitive cultures.The influence of Freudian psychoanalytic thought on the understandingof fatherhood was limited to interest in the deviant behaviours sometimesexhibited by expectant fathers. May and Perrin (1985) identified a numberof disorders reported by psychoanalysts including depressive and psychoticreactions, impulsive behaviour, deviant sexual behaviour, suicidal behaviour,and fears of homosexuality. The authors noted that this particular approachto fatherhood contributed little to our understanding of the patterns ofthought and behaviour in the normal father, except to support the conceptthat a man's transition to fatherhood represents a period of vulnerability.More recent work on fatherhood has included studies ondevelopmental tasks in pregnancy (Valentine, 1982), couvade syndrome6(Clinton, 1987; Klein, 1991), paternal-fetal attachment (Weaver & Cranley,1983), and the experience of the expectant father from his own perspectiveusing grounded theory methodology (Jordan, 1990; May 1980, 1982a,1982b).When examining the developmental tasks of expectant fathers andmothers, Valentine (1982) noted that the processes were remarkablysimilar. She went on to suggest that despite our culture's lack ofrecognition of fatherhood, fathering is "probably as involving and as varied anexperience as mothering" (Valentine, 1982, p. 246).Four developmental tasks were identified by Valentine (1982):1. acceptance of the pregnancy and development of an attachment tothe fetus2. concern with practical issues such as finance, accommodation, anddeveloping a sense of being a good provider3. resolution of dependency issues4. coming to terms with his relationship with his fatherCongruent with developmental theory is an assumption that unless afather can successfully complete the required tasks of pregnancy he willhave difficulty in his adjustment to his new role as father.A surprising amount of attention has been given in the literature to aphenomenon labelled couvade syndrome. Couvade syndrome is a separateentity from ritual couvade discussed earlier. It is a constellation of physicaland emotional symptoms that occurs among expectant fathers. Theincidence of couvade symptoms is estimated to be anywhere between 22 and779 percent (Klein,1991).Clinton (1987) examined the physical and emotional health ofexpectant fathers compared with that of non-expectant men. The findingsrevealed that in general, expectant fathers and non-expectant menexperienced similar patterns of physical and emotional symptoms.However, expectant fathers had a higher incidence of colds, unintentionalweight gain, insomnia, and restlessness. These findings were congruentwith previous studies except that others found a higher incidence ofdepression in expectant fathers (Brown, 1983; Davis, 1978). In the earlypostpartum period, there was a more significant difference between the newfathers' health and men who were not fathers, with a higher incidence ofnervousness, irritability, inability to concentrate, headaches, restlessness,fatigue and insomnia. Clinton (1987) concluded that the psychologicaltransition to parenthood is as dramatic for the father as it is for the mother,and that the father deserves considerably more attention than healthprofessionals have been providing.Another area that has only begun to receive attention is paternal-fetalattachment behaviour. Weaver and Cranley (1983) conducted a study toexplore this relationship. The findings supported the hypotheses thatexpectant fathers demonstrate attachment behaviours towards the fetus, andthat there is an association between attachment behaviours and the strengthof the marital relationship as perceived by the father. The presence ofcouvade symptoms were found to be weakly related. This study, andsubsequent research, supports the notion that fathers, like mothers, begin8to develop a relationship with the baby prior to birth.The last area of research to be described in this section is that whichexplores the experience of expectant fatherhood from the perspective of theman himself. May (1980), examined the different types of fatherparticipation in a pregnancy. Three separate styles were identified, witheach style differing in the degree of attachment to the pregnancy. Theobserver style was the most prevalent, and described the father who wasleast likely to be involved with the pregnancy. This type of man wasdescribed as a "bystander" or "onlooker" and did not contribute to much ofthe decision making that occurred during the pregnancy. Men who fell intothis category varied in their degree of desire for the pregnancy, frompleased to very unhappy.The second type of father participation, and second most common,was the expressive style. This man was more involved in the pregnancythan those in the other two categories. He had intense emotional responsesto the pregnancy and strove to be in touch with the experience. Hisrelationship with his partner was likely to be one of equality. These fathersnot only experienced the emotional highs of the pregnancy with greaterfeeling, but exhibited equally intense reactions to negative events such asthreatened loss of the baby.The instrumental style was the third and the least commonly occurringstyle identified. May (1980) noted that men in this category were likely tobe of an ethnic minority, possibly reflecting different cultural values. Thesemen were organizers and prided themselves on their efficiency in managingthe practical aspects of the pregnancy. Their emotional participation was9less evident, however, placing their involvement into the middle range ofthe continuum. May (1980) noted that a primary factor that seemed todetermine involvement style was the father's degree of readiness for thepregnancy. Other possible factors included the man's age, developmentalstatus, and the distribution of power in the marital relationship.Another study by May (1982a) explored the father's involvement in thepregnancy, but focused on the progressive aspect of involvement over time.May (1982a) identified three phases of involvement: the announcementphase, the moratorium, and the focusing phase. Each of the phases wascharacterized by certain activities and emotions. It was the moratoriumphase that distinguished fathers' readiness for a pregnancy. Fathers whorequired more time to work through their ambivalence and to adjust to thereality of the pregnancy required more time in this phase.Most recently, Jordan (1990) reported a grounded theory study thatbuilt on May's work. Jordan conducted more than 180 interviews on 56expectant fathers at selected intervals in the pregnancy. The theme of thefather's experience was "labouring for relevance" which described a father'sattempts to integrate the new father role into his own and others' conceptof himself. Three developmental subprocesses were explicated: grapplingwith reality, struggling for recognition as a parent, and the role-making ofinvolved fatherhood. Important findings included the lack of recognitionaccorded the fatherhood role, the continued exclusion of fathers from thechildbearing experience, and the lack of effective role models.10Father's Experience in High Risk PregnancyEstimates of the incidence of high risk pregnancy vary by definitionand population, but range from 10 to 20 percent (Kemp & Page, 1986).High risk is defined as any pregnancy in which there is significant possibilityof fetal demise, anomaly, life threatening illness to the newborn infant(Penticuff, 1982, p. 69), or threat to the health or life of the mother. Anumber of authors have suggested evidence of the psychosocial impact of ahigh risk pregnancy on the woman (Snyder, 1979), and the family (Kemp &Page, 1986; Mercer, May, Ferketich, & deJoseph, 1986; Penticuff, 1982).In the past twenty years, a number of advances in perinatal care haveresulted in improved outcomes for both mothers and babies. One of theseadvances has been the creation of high risk antepartum units in tertiary levelhospitals that specialize in the care of the high risk mother and fetus.Hospitalization is recognized as a significantly stressful event for anyindividual and family (Williams, 1974). Hospitalization during a pregnancycontributes to the degree and range of complex experiences that must benegotiated by a family in transition.A number of authors have begun exploring the experience ofhospitalization from the woman's perspective. The findings indicate thatwomen hospitalized for a high risk pregnancy undergo varying degrees ofstress which can lead to feelings of boredom, loneliness, and powerlessness(Loos, 1989). This stress can impair maternal-fetal attachment (Curry,1987), and impede successful accomplishment of the developmental tasksof pregnancy (Merkatz, 1978; White, 1984).11Little is known about the experience of high risk pregnancy andhospitalization from the perspective of the expectant father. Penticuff(1982) explored the potential impact of the stress of a high risk pregnancyon both expectant parents. It was suggested that the effect of the high riskpregnancy could alter a father's progression through the developmentalprocess of fatherhood. In applying theories of stress/adaptation and learnedhelplessness, Penticuff concluded that ultimately what determined both amother's and a father's ability to cope with the uncertainties and fearsinherent in a high risk pregnancy was their ability to develop a realisticappraisal of the problem, and to adapt their behaviours and environment insuch a way that either a solution was found or the stress was minimized.Conner and Denson (1990) reviewed the literature on expectantfathers' response to pregnancy and the implications for research in highrisk pregnancy. A number of areas for research were identified andsuggested a need to better understand this experience from the perspectiveof the expectant father.Problem StatementDespite increasing interest in the role of the father in pregnancy,birth, and parenthood, little attention has been given to the expectantfather's experience of coping with a high risk pregnancy and thehospitalization of their partner. The research that is available on fathers'experience of high risk pregnancy suggests that this is a stressful event thatrequires coping behaviours beyond what is normally required for a12pregnancy with an expected healthy outcome.PurposeThe purpose of this study was to understand the experience of highrisk pregnancy and hospitalization from the perspective of the expectantfather. This purpose resulted in the formulation of the following question:"What is the experience of an expectant father when his partner ishospitalized with a high risk pregnancy?".Definition of TermsHigh risk pregnancy: A pregnancy in which there is significantpossibility of fetal demise, anomaly, life threatening illness to the newborninfant, or threat to the life or health of the mother.Hospitalization: Inpatient hospitalization on an antepartum unit.Expectant father: The father of the baby.AssumptionsThis study was undertaken on the assumption that expectant fatherswhose partners were diagnosed with a high risk pregnancy and hospitalized,were subject to a unique experience. As a result, their specific needs andconcerns differed from the experience of the expectant father whoanticipated a normal pregnancy and healthy outcome for both mother andbaby. Furthermore, it was assumed that the most accurate and richestsource of information was the expectant fathers' own description of their13experience, and that fathers would be willing to share their experienceswith the investigator in an open and honest manner.LimitationsInitial data collection took place while the man's partner washospitalized on an antepartum unit. This created a concern regarding thepotential influence of the hospital environment on the expectant fathers'responses. It is possible that they may have felt unable to verbalize certainfeelings for fear of alienating their partners' caregivers. However, it was feltthat the advantage of interviewing the fathers as the experience was beinglived outweighed the disadvantage of the above concern. Furthermore,interviewing fathers after the birth of the baby could have introducedconfounding variables that could have influenced their perception of theexperience under study. For example, a father's perception of hisexperience might have been quite different if the outcome of the pregnancyhad been a fetal or neonatal loss instead of a healthy baby.Given the nature of the chosen method, specific limitations existregarding the generalizability of the study findings. The participants in thestudy were selected from two antepartum units in one hospital and thenumbers were small. The data that emerged from the experiences of thesefathers are, however, relevant in so far as anyone's experience, if welldescribed, represents a piece of life (Denzin, cited in Sandelowski, 1986,p.32).14SummaryThis chapter has identified the background to the problem that led tothe study. The purpose, definition of terms, assumptions,and limitationshave also been explicated. Chapter two outlines the study methodology andreviews the selection criteria, selection procedure, the process of datacollection and analysis, reliability and validity, and ethical considerations.15CHAPTER TWOMETHODOLOGYResearch DesignA qualitative research approach using the grounded theory method waschosen for this study. Qualitative research "seeks to gain insight throughdiscovering the meaning attached to a given phenomenon" (Burns & Grove,1987, p. 75). A number of different methods fall into the category ofqualitative research; grounded theory is one approach.Grounded theory is both an inductive and deductive research methodoriginally developed by Glaser and Strauss (1967). it is a systematicresearch approach for the collection and analysis of qualitative data for thepurpose of generating explanatory theory that contributes to theunderstanding of social and psychological phenomena (Chenitz & Swanson.1986). Grounded theory is directed towards developing an understandingof how groups of people define their reality via social interactions (Stern,1980). By systematic study of human behaviour in specific situations, theinvestigator develops abstract. concepts and propositions about therelationships between them. This inductive/deductive approach to theorygeneration is in contrast to the deductive process most commonly appliedto quantitative research whereby variables relevant to concepts in alreadyestablished theories are tested. For this reason, grounded theory is mostcommonly applied when an area under examination has had limitedresearch and for which a greater understanding of the phenomenon is16required (Hutchinson, 1986).Selection CriteriaNine participants were selected from those expectant fathers' whosepartners were admitted to either of two antepartum units in Grace Hospital,Vancouver. The Grace Hospital was chosen because it is the only tertiarylevel obstetric center in British Columbia and therefore provides care to themajority of high risk women and their families in this province. Womenwho were admitted to an antepartum unit and who were diagnosed with ahigh risk pregnancy requiring inpatient assessment and treatment wereused to gain access to the population of interest. The following criteriaprovided direction for initial selection of potential study participants.Rationale is provided to substantiate the criteria.Selection Criteria:1. Expectant fathers whose partners were hospitalized for a high riskpregnancy condition as defined under definition of terms.Rationale: This is the target population.2. Singleton pregnancy.Rationale: A multiple pregnancy may present additional stressorsthat could confound the experience.3. Married or living with their partners.Rationale: An uncommitted relationship may confound theexperience.4. No plans to relinquish the baby for adoption.17Rationale: Plans to give the baby up for adoption may confound theexperience.5. English speaking.Rationale: To facilitate communication.6. Age 19 or older.Rationale: The concerns of teenage fatherhood may confound theexperience.Selection ProcedureExpectant fathers who met the criteria for participation in the studywere determined by the investigator in conjunction with the NurseManagers and primary nurses on the antepartum units. The nursing kardexthat details the basic medical and nursing information for each patient wasreviewed regularly to identify potentially suitable participants. Thesecandidates were approached by the investigator and given an introductoryletter (appendix A) outlining the study as well as a verbal explanation of thestudy's purpose and the requirements for participant involvement. Wherepossible, initial contact was made with the expectant father himself when hewas visiting on the unit. If this was not feasible, the partners of potentialparticipants were approached with the information and a request that theintroductory letter be given to the expectant fathers for consideration. Ifthey were interested in participating or desired more information, theywere directed to complete the form attached to the introductory letter(Appendix A) and return it to a designated box at the nursing station. The18investigator regularly collected the completed forms from this box.In qualitative research, representativeness of experience is theprimary sampling consideration rather than representativeness of thepopulation - a concept relevant to quantitative research. In qualitative work,depth rather than breadth of experience is desirable.Integral to the grounded theory method is the principle of theoreticalsampling. Theoretical sampling is "sampling on the basis of concepts thathave proven theoretical relevance to the evolving theory" (Strauss & Corbin,1991, p. 176). This sampling technique is dependent on the need toexplore fully all identified categories and their relationships and to ensurethat representativeness of each has been achieved. For example, when thecategory "providing childcare" was identified, an attempt was made to seekout fathers who were caring for children at home. These fathers were thenasked questions designed to explore the implications of this component oftheir role in the context of the overall experience.Sampling and data analysis are simultaneous processes, with dataanalysis providing direction for further data collection. Every categoryrequires testing against new data to develop the category to its fullest.Decisions regarding sampling are based on the need to test, elaborate andrefine categories, to develop relationships between categories, and todevelop fully the core concept. Sampling continues until theoreticalsaturation is reached. Saturation has been achieved when categories andrelationships between categories are fully developed and validated. This19process is viewed as one of the most important aspects of grounded theory(Strauss & Corbin, 1991).Data Collection and AnalysisData collection in grounded theory may consist of formal or informalinterviews, participant observation, and technical and nontechnicalliterature, depending on the phenomenon of interest. When in-depthinformation that is best obtained from subjects in private settings and frompredetermined sites is desired, then a formal interview is the tool of choice(Swanson, 1986). This was the principal source of data for this study.Data gathered from formal interviews was supplemented withinformation obtained from technical and nontechnical literature. Theliterature became a secondary source of data. Published research reportsthat included quotations from expectant fathers or descriptions of theexpectant fathers' perspective were analyzed along with interview data.Informal interviews and participant observation are two methods thatwere not used for data collection. The investigator did, however, during thelater stages of this study, return to her role as nurse manager of one of theantepartum units designated for the study. It was valuable (and evenunavoidable) for the author to observe, with heightened sensitivity, theexperiences of expectant fathers on the unit. This opportunity lent validityto observations drawn from formal interviews alone.Initial data collection consisted of unstructured in depth audiotapedinterviews of nine men. Five men were interviewed a second time in20person. Two men had returned to their home towns at the time of thesecond interview and, because of the distances involved, were interviewedby telephone. Of the two fathers not interviewed a second time, onedeclined a second interview, and the other was not contacted, despiteseveral attempts.The setting for the first interview was a private office on one of theantepartum units. Since all the women had been discharged from thehospital at the time of the second interview, this interview took place in theparticipants' homes. The length of the interviews varied, with most lastingapproximately one hour.Each initial interview began with the question, "What is it like for youto have your wife/partner hospitalized for a high risk pregnancy?" Theinterviewer then encouraged the subject to elaborate on the concepts thatemerged from the data. In accordance with the methodological principles,loosely structured questions that guided initial interviews were modified insubsequent interviews as concepts and categories emerged and requiredclarification and/or elaboration. Data analysis of verbatim transcriptsoccurred simultaneously with data collection to meet the requirements oftheoretical sampling.The constant comparative method of analysis was fundamental to thedata collection and analysis process. The focus of this method is "thegeneration of theoretical constructs that, along with substantiative codes andcategories and their properties, form a theory that encompasses as muchbehavioural variation as possible" (Hutchinson, 1986, p. 122). Data from21verbatim transcripts were first broken down into discrete parts, closelyexamined, compared for similarities and differences, conceptualized, andcategorized. The data was then reconstructed in new ways by makingconnections between categories. Finally, a core category was identified, themajor categories were related to it and each other, relationships werevalidated, and categories requiring further development were refined.Data collection continued until a point of saturation was reached whereno new conceptual information was emerging. The outcome of such aprocess resulted in a substantive theory that was grounded in theexperience of the phenomenon under study (Strauss & Corbin, 1991).The above analysis was carried out using the three steps of codingdescribed by Strauss and Corbin (1991).1. Open CodingOpen coding involves the "process of breaking down, examining,comparing, conceptualizing and categorizing data" (Strauss & Corbin, 1991,p. 61). The transcript was read and each discrete incident, idea, or eventwas given a conceptual label. Concepts that appeared to relate to the samephenomenon were then categorized, and the category was named. Acategory was then developed by identifying its characteristics, known asproperties and dimensions.2. Axial CodingAxial coding includes a series of steps whereby data are reassembled innew ways by making connections between categories (Strauss & Corbin,1991, p. 96). A category was specified by its related conditions, context,22action/interaction strategies, and consequences. It was a complex process,involving several steps that required both inductive and deductive thinking.3. Selective CodingSelective coding encompasses the process of selecting the corecategory, relating it to other categories in a systematic fashion, validatingthose relationships, and refining categories that need further development(Strauss & Corbin, 1991, p. 116). This process of integrating categories ledto the development of a grounded theory. Selective coding is similar to axialcoding except it demands greater abstract analysis.Thus, conceptual labels such as "being there", "staying overnight", and"visiting" were identified as being related to the same phenomenon, werecategorized together, and named "maintaining a physical presence". Thiscategory was then related to other apparently similar categories including"comfort and compassion", "psychological coach", "advocate", and"protector". These categories were identified as subcategories of the"emotional caregiver role". This role became a major concept, along withthe "family sustainer role".The core category evolved from analysis of the relationships betweenthese two major concepts and related conditions which included "socialsupport", "high risk condition factors", and "geographical circumstance".The category of coping strategies with its' subcategories of "positiveattitude", "one day at a time", "faith", and "knowledge", were identified asaction/interaction strategies. The subcategories under "personal impact"were the consequences of the fathers responses to the central phenomenon.23Finally, a process of "finding a balance between roles" emerged as thecentral phenomenon of the study, and became the core category aroundwhich the other categories were systematically related.Throughout the process of data collection and analysis an essential skillcalled theoretical sensitivity was required. Strauss and Corbin (1991)described theoretical sensitivity as "the attribute of having insight, the abilityto give meaning to data, the capacity to understand, and capability toseparate the pertinent from that which isn't. All this is done in conceptualrather than concrete terms" (p. 42). Theoretical sensitivity required abalance between creativity and science and was cultivated from a number ofsources including literature, professional and personal experience, and theanalytic process itself.Reliability and ValidityRigor in qualitative research is equally as important as researchemploying quantitative methodology. In qualitative research, however, thetraditional methods to determine reliability and validity are not applicable,therefore, alternative methods have been developed.Sandelowski (1986) identified auditability as a key strategy in ensuringrigor in qualitative research. Auditability is achieved when the researcherleaves a clear decision trail that allows any reader to follow the study frombeginning to end and understand the logic of what was done and why.Sandelowski (1986) identified four additional tests of rigor that can beapplied to qualitative research. They are: 1) truth value, 2) applicability, 3)24consistency, and 4) neutrality. Throughout this study a concern for rigor indata collection, analysis, and reporting was applied to optimize the reliabilityand validity of the findings.Ethical ConsiderationsPermission to conduct this study was received from the ResearchCoordinating Committee of Grace Hospital, Vancouver, British Columbia, andfrom the Behavioural Sciences Screening Committee for Research andOther Studies Involving Human Subjects of the University of BritishColumbia.At the beginning of the first meeting, the investigator reviewed theconsent form (Appendix B) with the participants. It was not anticipatedthat there would be any harmful consequences for the participants. In factthe opportunity to discuss their individual experience with an attentive andaccepting listener could be seen as a benefit. However, it was recognizedthat as with any study requiring discussion of potentially emotional material,there was a risk of feelings arising that might be distressing to theparticipants. Qualitative research methodology allows for interactionbetween interviewer and subject, therefore emotional responses could havebeen addressed directly by the investigator during the course of theinterview or, if appropriate and agreeable to the subject, referred to thehospital social worker, physician, clergy, or to an outside agency. Asdiscussed in the findings, many men expressed feelings of helplessness,fear, worry, and emotional stress. None of these men requested any25intervention beyond the understanding and supportive acceptance by theinterviewer.SummaryThis chapter has reviewed the grounded theory method used in thestudy. The selection criteria, selection procedure, process of datacollection and analysis, reliability and validity, and ethical considerations,were also discussed. Chapter three presents a detailed description of thefindings from data analysis with supportive quotes from interviewtranscripts that illustrate and substantiate the interpretations.26CHAPTER THREEFINDINGS FROM DATA ANALYSISIn this chapter the outcome of data analysis is described. The chapterbegins with a description of the participants followed by a theoreticalportrait of the experience under study that evolved through grounded theorymethodology. Interspersed throughout this chapter are quotes fromparticipants that serve to illustrate and substantiate the interpretations.Description of the ParticipantsNine expectant fathers volunteered to participate in the study. Theirages ranged from 29 to 40 years. Their partners' ages ranged from 23 to 40years. All the couples were married except one; this couple had been livingtogether for one year.Six of the nine pregnancies had been planned. Three pregnancies hadbeen unplanned, two by couples who were unmarried at the time, and oneby a couple with a two year old child. None of the unplanned pregnancieswas unwelcome, though each had necessitated psychological and practicaladjustments for both partners. This was a first pregnancy for four of thecouples (One father had a child by a previous marriage. This child hadsurvived without handicap after being delivered at 26 weeks). Two of thecouples had a small child at home. Three couples had experienced previouspregnancies resulting in loss. These included multiple spontaneousabortions, two stillbirths (at 28 weeks gestation and term), and a pregnancy27terminated due to a diagnosis of Down's syndrome.The reason for admission to the hospital varied. Obstetrical problemsincluded premature rupture of the membranes, preterm labour, abruptioplacenta, pregnancy induced hypertension, premature dilatation of thecervix, and gestational diabetes. At the time of the first interview, thepregnancy gestation ranged from 24 weeks to 35 weeks, with five of thepregnancies below 32 weeks. The first interview was conducted from threedays to three weeks after a partner's hospitalization. The second interviewstook place within two weeks to three months of the birth. Some of thebabies were delivered prematurely and required care in a special carenursery for a few days to a few weeks. However, all of the newborns werehealthy and at home with the parents at the time of the second interview.The occupations of the participants included a teacher, nurse,photojournalist, actor, union representative, automotive mechanic, plumbingcontractor, owner of a waterproofing company, and a restaurant manager.Education ranged from high school to university. Six of the expectantfathers described their cultural origin as Canadian, with the remaining threeof German/Italian, Caribbean, and Native/German extraction. All of the menidentified English as their first language.The Expectant Father's Experience: A Descriptive AnalysisGrounded theory analysis of expectant fathers' collective descriptionsof their experience when their partners were hospitalized with a high riskpregnancy resulted in the following descriptive account.28The fathers' descriptions indicated that their participation in thepregnancy and hospitalization was substantive in nature. Substantive isdefined as "having separate and independent existence, not merelysubservient" (Concise Oxford Dictionary, 1982).Central to the expectant fathers' descriptions of their experience werethe roles they assumed in relation to their participation in the phenomenonof high risk pregnancy and hospitalization. The two predominant roles wereproviding emotional support for their partner and sustaining the family'sfunctional responsibilities. The predominant theme that evolved throughanalysis was a process of finding a balance between these two roles. Thisconceptualization is illustrated by Figure 1.The fathers' descriptions portrayed an experience that revolved aroundtheir enactment of these two roles. The first role, providing emotionalsupport to their partner, will be referred to as the emotional caregiver role.This role was of primary importance for many of the fathers. It involvedactions that were intended to provide support through physical presence,comfort and compassion, psychological coaching, advocacy, and protection.This role was mostly enacted within the environment of the hospital.The other role, sustaining the family's functional responsibilities, willbe referred to as the family sustainer role. This role involved maintainingthe family's life in the world outside of the hospital, including work,childcare, and domestic responsibilities.Each of the fathers was required to determine the amount of attentionthese two roles deserved. Since fathers possessed only a finite amount ofFigure 1. Finding a Balance: A Substantive Experience30energy, a process of determining how much weight they would give each ofthe roles was necessary. The resulting balance was dependent not only onthe emphasis placed on each of the two roles, but also on contributingvariables that shall be called balancing factors. The nature of these factorsdetermined the amount of time and physical and emotional energy that wasallocated to either of the two roles. They included the support systemavailable to the father, high risk condition factors, and geographicalcircumstance.Based on the above factors, the fathers varied in their valuing andaccomplishment of the two roles. Some fathers placed enormous emphasison their emotional caregiving role, some on their family sustainer role, andothers found an intermediate balance between the two roles. Every fatherfound his own personal balance that was congruent with his individualcircumstance and interpretation of the experience. Most of the fatherswere relatively content with the balance they found for themselves. Therewere some, however, that expressed significant dissatisfaction with theirposition but were unable, under the present circumstances to influence achange in the balance.A critical component to the description of their experience, whichencompassed all of their discussions to some degree, was the personalimpact of the phenomenon on their own emotional and physical wellbeing.Though the focus of their descriptions was on the enacted roles, both thephenomenon of high risk pregnancy and hospitalization, and the process ofrole balance had a significant impact on themselves as individuals. In turn,31the emotional and physical components of the fathers' experienceinfluenced their ability to carry out the roles.Each of the fathers identified a number of personal strategies that hebelieved contributed to his ability to cope with the experience. Thesecoping strategies included maintaining a positive attitude, taking one day ata time, having faith in a higher being, and seeking knowledge. Thestrategies influenced both the fathers' ability to carry out the two roles andthe nature of the personal impact.Role Behaviors The central theme in the fathers' descriptions was their assumption oftwo very different roles, that of emotional caregiver, and family sustainer.Most of the fathers enacted each of the roles to a certain extent but theemphasis placed on each varied depending on individual circumstances.The role of emotional caregiver was performed by and large within thehospital setting, while the family sustainer role was carried out in the worldoutside of the hospital. These two different settings contribute to theconverse nature of the performance of the roles.The Role of Emotional CaregiverThe fathers spent a considerable amount of time describing their roleas an emotional caregiver. The fathers clearly articulated a belief that thiswas one of their fundamental roles. The men believed that as expectantfathers, they too were in need of emotional support. However, they believedtheir partners' needs were even greater.Fathers offered three explanations to justify this belief. The first was32the physical reality of the pregnancy. Although they were involved in thepregnancy, and described themselves as undergoing an experience that wasunique and legitimate in their own right, they acknowledged a very obviousfact of life; no matter how involved they were with their partner and thepregnancy, the reality was that they themselves were not physicallypregnant, nor could they hope to fully appreciate the experience from thefirst hand perspective of their partner.Cause she's the one that carried the child and the bond between them,a mother and a child, ...yeah there is the father also, but not such a degreeat that stage....because she's carrying this child that, that, it's going to be, that itwould be more devastating, the loss would be...have a greater impact on her,now that's not to say that it wouldn't be devastating for me...I don't have allthe aches and pains and the body image distortions...I didn't need any support myself. It wasn't me going through it, it washer...first of all she, as most women are, would be more emotional in thecouple so she needs it more...even if the woman was less emotional than theman, she would still need more anyway because she's going through it.The second reason given is also identified by the above father. This isthe belief that women are inherently more emotional than men so willrequire the additional emotional attention. The next father elaborates byexplaining his belief that it is also normal for pregnant women to worry....being pregnant and just having everything, you think of anything, atwo headed baby on the ultrasound, or whatever so it's just sort of normal fora pregnant person to think things like that.The third explanation given for the partner requiring additionalsupport, was that she was confined to bed in the hospital with little to33occupy her time and distract her from worry. The fathers maintained theirfreedom to some degree and did not experience the physical restrictionsand isolation from the outside world. Two fathers explained:...it's a lot tougher on her because I've got stuff to do, and it's just like Ican be distracted, she just lays here and thinks and, uh, and her thoughts gofrom sort of, uh, bad to worse....When she first got here she was just, well she was devastated, ...wewere both devastated but she had more time to think about it...I was lucky tohave [son] to look after...it kept my mind from wondering about thepossibilities, you know, how things were going. [Partner] didn't have that,she was sleeping all the time thinking about that over and over...The emotional support that fathers provided to their partners includedmaintaining a physical presence, providing comfort and compassion, actingas a psychological coach, being an advocate, and providing protection.Maintaining a physical presence. All of the fathers held a strong beliefthat an important facet of being an emotional caregiver to their partners wasthe act of being physically present. Fathers demonstrated this by, almostwithout exception (and this was because of geographic separation), spendingtime with their partners virtually every day. The amount of time spentvaried. Some fathers visited for periods of one to two hours after they hadworked a full day. Other fathers spent time with their partners forextended periods during the day but returned home at night. One fatherstayed in the private room with his partner for her entire three week stay.Fathers gave several explanations for the importance of their presenceincluding emotional and physical benefit for their partners, emotionalbenefit for themselves, companionship, and a sense of fairness and34obligation.She needs me to be there, to be right there, and supporting her onehundred percent, and I feel like that's the contribution that I can make tohaving this be a successful pregnancy. Just by that, removing that aspect ofanxiety like will I be there of won't I.When questioned further, this father acknowledged that being presentwas so important to him because he felt he had very few other optionsavailable to "do something for her and to help this pregnancy".Well, we're very used to seeing each other every day and so, how do Idescribe this, I feel like she doesn't get a day off, so as her partner I don'tthink it's fair that I get a day off. I mean, I get a change of scenery, she getssome striped curtains....it means a lot to her too. Like, like if I wasn't there, she'd be kind ofprobably twice as bad cause she'd be really scared and tense, you know.For one father, the need to be present was particularly evident. Thisfather lived in a distant community and had taken time off work and flown tothe city in order to be close to his partner. When offered nearby hostelaccommodation that was available for families he adamantly refused to beseparated from his partner even during the night. In fact, when the hospitalstaff had perceived that he had 'overstayed his welcome' and told him so, hemet with hospital administration to argue his point, and declared he wasprepared to take the issue to the local paper. He explained his position thisway:...it makes her feel secure that I'm there beside her if she wakes upand needs something I can get it for her right away. I want to stay at herside now cause it makes her feel better and even that little bit, if that helpsextend the pregnancy by a week, that's going to be helpful to the baby. And Ihonestly think that it's necessary at this point for me to stay with her...I'mmaking sure that I stay out of peoples way...I'm trying to be as helpful as Ican...it's a single room so I'm not bothering anybody else...35This father's opinion regarding the reason for the resistance on thepart of the hospital staff was the following:...my personal opinion is that some of the older, perhaps nursing staffin the tradition of nursing where, you know, in the olden days husbandswere supposed to wait outside in the waiting room. I think it goes back tothat, and they feel uncomfortable with having the husbands around.While this father was very outspoken and assertive regarding his needto be present 24 hours a day, several of the other fathers stated that theywould have chosen, if given the option, to stay overnight at least on anintermittent basis. One father admitted:..if you did it every once in a while you'd want to do it all the time, Iknow I would, I would want to stay all the time and I think [partner] wouldwant me to...she gets up so many times in the night going to the washroom,she's waking up constantly so it would be probably be more comfortable togo back to sleep if I was there or if we were together.Providing comfort and compassion. Most of the fathers identified arole of providing comfort and compassion to their partners as a componentof their emotional caregiving. Comfort was demonstrated primarily throughphysical gestures and resulted in emotional benefit. Compassion describesthe sympathetic care and understanding that was provided.Fathers offered comfort to their partners in many ways. Some fathers,by virtue of their regular presence, were able to give much physical care totheir partner. Activities such as back massages, assisting with bathing,tidying the bed, bringing in food and other treats and surprises from theoutside contributed to their partners' sense of well being. Comforting was ameasure that one father described as palliative care. This alluded to the fact36that these actions did not have direct impact on his partner's condition butserved to make her life a little more tolerable....I feel like it's my role to, to do everything I can to make her morecomfortable...bringing her little surprises every once in a while, somespecialty food, music to listen to, comforts... palliative care...Compassion was displayed by every father as a means of support. Byvirtue of his focus on how she was coping with the experience, and bywithholding sharing his own emotions, attention was directed towards herthoughts and feelings. Each father described listening to his partner'sworries and fears and responding to them by acting as a 'psychologicalcoach'.Acting as a psychological coach. Psychological coaching refers to theactive role fathers played in influencing their partners' emotional status.The strategies used by fathers could variously be referred to as providingreassurance, reinforcing reality, encouraging a positive outlook, and takingone day at a time.Reassurance was given in an effort to dispel their partners' realisticand unrealistic apprehensions. This father explained:I tried to reassure her that, we just had to do basically what the doctortold us to do and, you know, that she was very, she's very healthy, she's avery active and healthy person...Another strategy for psychological coaching was reinforcing reality byreminding their partners of the probability of a positive outcome given thefacts of their situation. Partners often required ongoing reminders.37Well you know the baby's heart is fine, the baby is fine, you're fine andit's a matter of how long the baby is going to have to spend in the hospital.I've tried to talk to her and she says that even just the fact that I keepreminding her that this is not necessarily going to happen to us helps...and Iguess I have to keep reminding her continuously too...One father clarified that his attempts to reassure his partner were notcarried out with the intention of minimizing what she was experiencing. Heacknowledged her fears and worries but tried not to elaborate on them.Rather, his desire was to encourage his partner to have a positive outlook.He admitted however, that his partner did not always perceive thisdistinction.I would say, be trying to look on the bright side but she didn't want toright then because this is a worry, and she didn't want me minimizing itexactly, and it would cause some friction because I would be thinking, well,I'm just trying to maintain a positive attitude.Taking one day at a time was another approach encouraged by thesefathers. They attempted to focus their partner's attention on the here andnow rather than waste valuable emotional energy on negative possibilities.We've had a tour of the observation nursery, all the specializedequipment basically has been explained to us...my wife gets a littleuncomfortable with all that stuff but at this point I'm trying to convince hernot to really worry about that stuff yet cause we're not at that point yet.Worry about the stage now at the time. Just keep the blood pressure downas long as possible and we'll worry about that stuff when we get to it.As will be seen later in the discussion, fathers themselves relied ontheir ability to maintain a positive attitude and to take one day at a time ascoping strategies.38Being an advocate. Fathers acted as advocates for their partners whenthey perceived that the partners needed someone to act for them becausethey were either too shy or too vulnerable to act for themselves. At timestheir partners shared with them feelings or needs that the fathers feltrequired action on the part of others in order to ensure the partners', or thefetuses' well being. Advocacy was demonstrated by these fathers in severalsituations including the following:I try to kind of insulate her from other problems...so, I'll pull thecurtain, she doesn't want to pull the curtain because she feels like it's rudeto her neighbour. Well I said it's not really, she's got to be, you know, you'vegot to look after yourself and that's the most important....when she called on the phone, I said, buzz, you know that's what thebuzzer is there for and get somebody and she was upset because she didn'twant to...so I just tried to get her to understand that everybody is therebecause there are women in there that need, that need attention and askingfor attention is not wrong, I said you have to keep asking sometimes becauseeverybody is human.Providing protection. Fathers protected their partners from a numberof real and potential psychological and physical threats. One of theprotective actions the fathers all participated in was ensuring their partnerswere in the hospital receiving the best care that was possible. This will beexplored further in the discussion regarding their feelings of securityrelated to hospitalization. By ensuring their partners' and babies' security,they were able to partially fulfill their protector role.A particularly significant strategy the fathers used to protect theirpartners from unnecessary worry was to withhold sharing all of theirfeelings. Most of the fathers felt that their partners were experiencingtremendous self-induced worry. They believed that as supporters, they39should not contribute to their partners' anxieties by verbalizing their ownfears and concerns.I've tried I guess to not, to not burden her at all with my worriesbecause I feel like she's already worrying enough, probably for both of us,and that sharing my worries won't do anything more but, that, I guess, Iguess I feel like I'd be asking her to help me deal with my worries, when Ifeel like probably, I, I'd be better helping with hers.This father described the potential problem of legitimizing hispartner's worries 'by sharing his own.I wouldn't want to worry her. I might be worrying about somethingthat... if she hasn't thought of it, why bother, why tell her...and if she isworrying about it herself maybe she needs someone to legitimize it then if Isay something, then she'll think maybe it will happen.During a second interview, a father's partner was present for part ofthe discussion. He acknowledged that he had intentionally not shared manyof his fears and concerns with her with the belief that he would have then"validated her own fears". Of interest is that his partner confirmed that shehad needed him to act as a supporter. She believed that if he had verbalizedall of his fears it would have served to escalate her own anxieties.The Role of Family SustainerThe other role the fathers identified as significant was the role offamily sustainer. The role behaviors include adjusting work demands,providing childcare, and taking on the sundry domestic activities of dailyliving. These activities were all directed towards the reality of sustainingthe life of the father and his partner in the real world. Despite the fact thatthe couples were experiencing a significant crisis resulting in a major40disruption of their lives, most were unable to abandon all their practicalresponsibilities and focus exclusively on life inside the hospital. Someonewas required to fulfill the role of maintaining this outside life, so that thecouple had something to return to on resolution of the crisis. This role was,of necessity, assumed by the father.Adjusting work. For all of the fathers, the impact of the high riskpregnancy and the hospitalization of their partners required adjustment intheir usual work routine. It was necessary for the majority of fathers tocontinue working in order to maintain financial security for the couple. Mostof these fathers, however, were able to manipulate their schedules andcommitments so that they had greater time to attend to the other demands,both inside and outside the hospital. Two fathers stopped working duringtheir partners' hospitalization.Fathers were able to adjust their work commitments by a variety ofstrategies. Some were self employed and chose to either reduce their workcommitments or to delegate work to employees. Others negotiated withunderstanding employers for greater flexibility in their schedules andreduced hours. None of the fathers described having to maintain inflexiblework obligations in order to keep his job.The two fathers who temporarily gave up work did so for differentreasons. The first father left work because of the overwhelming nature ofthe circumstances. He had experienced past pregnancy losses and wasunable to function at work due to the amount of stress he was experiencing.He had requested, and been granted stress leave for the past month.41The second father lived with his partner in a community 500kilometers from the hospital. This father stated that he was able to taketime off work to be with his partner in the hospital. He explained that if shehad been hospitalized in their community hospital he would not have beenrequired to abandon work altogether as it would have been possible tocontinue to work part time. The geographic separation however, forcedhim to leave his work in order to be with his partner. He explained that hadhis employer refused to grant him the leave, he would have taken the timeoff regardless because of the priority he gave to his emotional caregiver role....if it was required I would say hey, you know, I'm sorry but I have togo and that's that...cause there's no question about that, she needs me andthat's , that's a priority, that's what you have to do.Fathers reported that financial security was a significant worry forthemselves and their partners, and that this was the principal reason fortheir continued commitment to work. Factors that contributed to theirfinancial concerns over and above those of couples experiencing a normalpregnancy were the unexpected loss of the woman's income earlier in thepregnancy than was originally anticipated, the loss of income the fathersexperienced due to adjustments in their work schedule, and the costsassociated with hospitalization. A father, who took time off work to be withhis wife, explained his situation:...there's always the problem of funds as well. I mean, I consider myselffortunate that I'm in a position that I can take all this time off to stay withmy wife but at the same time I paid for a commercial air fare for both of usfor the return...I'm taking time off work, I still have to pay rent and hydroand telephone and all that stuff at home. The financial end of things, even42like staying at a place that is forty dollars a night, but, you know, to look atsomething like that for one or two nights is not unreasonable but you starttalking three weeks, maybe a month, that's a lot of money. I mean I'm notmade of money.Providing childcare. Whether or not a father had a child at home tocare for determined, to a great extent, the amount of emphasis placed onthe sustainer role, and therefore the resulting balance of roles. Only twofathers were required to be responsible for another child at home. For bothmen, this new role represented a departure from their usual involvementwith their children. Although the fathers described different degrees ofinvolvement with their children prior to the hospitalization, bothexperienced a significant challenge associated with the additionalresponsibilities of assuming their new role as a 'single father'.Each father described the stress of suddenly being left with soleresponsibility for the physical and emotional welfare of his child....it's tough, you know, in more ways that one. In, in the physical senseit's tough cause you're running after him all the time and he looks for you allthe time Any time he thinks I'm gone, he's 'daddy, daddy'...in an emotionalsense too of constantly trying to keep track of what's going on and knowingyou're it. You know, you're responsible for everything.You've got so much responsibility, if anything happens it's you that's gotto deal with that. You're totally responsible for him...I think the big thingabout having two parents around and being a single parent, there's someoneelse to share the responsibility and that's a really big part of itDespite the disadvantage of being, at least temporarily, a single parent,the fathers recognized the advantage the opportunity gave them to develop acloser relationship with their child. Both fathers continued to work fulltime, but on return from work they spent undivided time with their child43that they might otherwise not have experienced. This was identified as aunique opportunity to explore their father-child relationship and to perhapsinfluence it positively in the future....we are spending a lot of time together and I'm starting to understandwhere he's coming from...I have a much better relationship with him,though I spent a lot of time with him before, I think now I'm spendingmore, just that much better time with him and understanding him thatmuch better.In order to continue to work, as these two fathers did, child carearrangements were necessary. Neither of these men's partners workedoutside the home, so the full-time childcare support they required wasfound as a result of scrambling on short notice. One father had great familysupport from a mother who took on the care of his child during the day.The other father had no family support, but found a reliable babysitter whomhe trusted and who was able to meet his needs. While both these fathersfound workable solutions relatively easily, they considered themselvesfortunate.Taking on domestic responsibilities. Whether the fathers had childrento care for or were on their own, they were left with the responsibility ofensuring the ongoing activities of family life were attended to. Theseincluded doing housework, shopping, preparing meals, budgeting andpaying bills, and running errands. Two fathers were also in the process ofselling and purchasing a home. Some of these activities they would havecarried out even if their partners were at home, but they would not have hadsole responsibility for them. Some chores were completely foreign to them.44Regardless of their familiarity, the fathers took on these responsibilities anddescribed varying degrees of success. 'Hectic' was the term most often usedto describe their daily schedule....we've got to get that and we've got to get that, and I've got to get thisand I rush off to the store and I run to the bank and get some money and Ilook at the account and I got, [gasp] not much left, and I run off over hereand then I go, well, geez, did I pay that bill, oh, got to go back to the bankand put the hydro bill in, you know, it really is hectic and, uh, you don't havean awful lot of time to yourself.There's periods I hit like today I was, it was a real hectic day, lots ofthings...had to do laundry at home, [partner] wanted clothes down here fortonight. So I had to go home last night and do laundry, got to go to bed aboutmaybe twelve thirty, quarter to one, okay, I'm up at six. And then you start,you go again.And so I leave him with her and I go to work and I just work likecrazy...so about quarter to four I say I start, oh, supper, geez, I have to dosomething, wow, the store is closed, I phone [babysitter] and tell her thatI'm going to be late cause I've got to go to the store and get something and,oh, I've got to get some money so I can pay her too...Balancing Factors In order for the fathers to determine the amount of energy andattention either of the above competing roles deserved, as well as theamount of energy personally available, he was required to acknowledge,either consciously or unconsciously, a number of balancing factors that hadinfluence upon the decision. They included the support system available tothe father, high risk condition factors, and geographical circumstance.Support SystemFathers described receiving emotional, practical, and informationalsupport from a number of sources, including their partners, families,45friends, churches, and health care providers. Fathers varied in theirassessments of their need for external support from these sources and theextent to which they received it. Some fathers explained that they had littleneed for outside support since they were coping adequately on their own.Others spoke of an acute awareness of their lack of support and the desirefor better recognition of their needs from others. It was obvious that thereality of their involvement created a substantial need for support in theirown right that was not being met.The type and degree of support provided to the fathers contributed totheir ability to carry out the two roles, and to the relative balance betweenthe roles. Fathers who themselves received support were assisted in theirrole of providing emotional caregiving to their partners, and in fulfilling theresponsibilities of sustaining the family. It was evident that fathers whoreceived inadequate support from others were likely to encounter increaseddifficulty in fulfilling the roles. This situation invariably required somecompromise in at least one of the two roles. For example, a father receivinglittle in the way of practical support was required, by necessity, to devotemuch of his time and attention towards this role, and relatively less on hisrole as emotional caregiver.Partner. The fathers believed that they should protect their partnersfrom their own emotional distress. They thereby effectively preventedthemselves from seeking support from the very person who was closest tothem. The physical separation served to compound the resulting emotionalisolation. The fathers' descriptions of their experiences in these two areashave been discussed previously but will be elaborated upon.46This father explains his reluctance to share his worries with hispartner (and others)....I didn't want to share it with other people and the only, but I didn'twant to share it with [partner] either because I didn't want her to worry...atnight especially going to sleep I would really worry and I didn't want to talkto [partner] about it particularly because I didn't want her to worry anymorethan she was.When asked what he needed from his partner, this father explained:...if I do everything I can to help her deal with it, all she can do is doher best to deal with it, and that is looking after herself as best she can. Iguess I feel like it's not a time where she's really got anything to give to meor to anybody else.The above discussions might suggest that the fathers received littlesupport from their partners. This is not the case. Regardless of the desireto protect their partners from the full impact of their own worry, in theend, the fathers inevitably received most of their emotional support fromtheir partners. This would be logical since their partners were consideredto be their major support in the rest of their lives. One father explainedthat he and his partner were mutually supportive, though he went on toacknowledge that he was the one to give additional support because she wasmore "vulnerable"....the worry is there and it's just, it's such a state that, um, like there'snot denying it. So we sort of take turns picking one another up, you know,like she'll, she'll just see the look on my face and, uh, don't give up. We keepon telling each other that it's going to be okay.47This father also described the situation of limiting expectationsregarding fully mutual support:I think I share concern, when she's concerned I'll share concern withher but, but only so that, because if I pretend there was no problem at allshe'd be thinking well, don't you care?...I'm concerned but I am trying tohide worry, or not share worry, not so much hide it, I guess, but just notlook for support from her, because I feel like I'm, we're sort of supportingeach other, I guess, but I think she probably needs more support becauseshe's the one doing it.When emotional support was received from people other than theirpartner, which was rare, it by and large came from family and the church,rather than from friends.Family. For some fathers, family members were also sources ofemotional support.Not in so much a counselling kind of way, just, my brother forone...he's been very what am I saying, untypical...I know he's being moresupportive than he normally would be Same with my Mum and Dad, theycall...to talk to me about how things are going and, urn, then I get a chanceto tell them and I guess in that way I share my concern with them, I sharemy worries with them.Most fathers, however, emphasized the practical support receivedfrom family. Assisting with childcare, providing home cooked meals,helping with household chores, and providing a place to stay were some ofthe supportive actions that were described....my mother and sister were great...I didn't need to cook much, theyhad me over to dinner most of the time or sent home, you know, uh, frozencare packages to eat...my mother, she doesn't live far from where, on myway to work, so I dropped [child] off with her...it worked out well but it wasa bit of a hassle...48Not all fathers described receiving beneficial family support. Severalfathers gave examples of inadequate or nonexistent support from family....my problem is because I've had both, my Mum dying and my Daddying, and, my sister, I was always the one that looked, was the supportperson...that's the kind of position I have is, a position I probably mademyself have...and, it's really good until I need the support and then I'm,when I stop that's were the, it gets real hard.One of the hard things for me is coming to the, abandoning the illusionthat we're a close family, that we're close in superficial ways...like if youneed anything, just don't be afraid to call us which is the biggest cop out, I'mnot going to be calling them all the time saying, you know, I need you, orwhatever, can you cook me a meal...Friends. Friends were mainly seen as sources of support for theirpartner. Several fathers commented on their relief when friends were ableto provide emotional support and entertainment for their partner. Whensupport was received directly by the father, and this was mentionedinfrequently, it was most often of a practical nature.We've been getting along pretty good I think, we've been making out.But, yeah, people are there if we need it, someone is always there to help usout...The majority of fathers, however, described little support from friends- either of a practical, or emotional nature. This was mostly attributed to thefact that friends, particularly male friends, had no understanding of what thefather was experiencing.If I have one thing that is eating me up right now is that fact that I dofeel rather alone like, you know, like I don't feel like, uh, that most of my,my friends don't understand what I'm going through, or they haven't putthemselves on the line to help take the pressure off.49When one father was asked whether he received any support from hismale friends he replied:No, no, not really. They're, uh, they're just sort of "what's going on?",you know, uh, "oh yeah, so when's the baby due?" You know, the same sort ofquestions regularly...I guess I suppose they're not exactly sure how to , howto exactly to react...I 'm not going to cry on their shoulders or anything andit's sort of a weird thing because it's..a weird thing to describe to somebodyelse...I don't think they really understand what it's about...I think they seemto comprehend either you go into labour and you have a baby or you mighthave a slight complication and go home, they don't understand, they don'task too many questions...Church. One father specifically described his church as a significantsource of support for both himself and his partner. This father describedreligion as a major part of his life and was very involved in the activities ofthe church.We take our council from the Lord and our family, and yeah, we've beenwell comforted like I say by many people in the church...Health care providers. Of the three types of support described by thefathers, health care providers were mostly identified as a source ofinformational support. Informational support was received either directlyfrom the health care providers or, most commonly, second hand via theirpartner. This form of support will be discussed further in relation to thefathers' coping strategy of seeking knowledge. It is of interest that only twofathers mentioned the fact that they received some of their informationfrom a nurse....one nurse offered to since you missed the prenatal stuff do you sortof want to, uh...and giving sort of [on] the spot prenatal class here if youwant, so that was pretty good.50Not all fathers expressed a need for support. This father stated:Urn, I would say for me it doesn't make as much of a difference. I'm, Itend to be a very self sufficient person I think.One father described a feeling that he had no right to seek supportfrom others; that it was somehow illegitimate.See, but it's the kind of stress where you don't tell anybody because ifyou complain it's, what have you got to complain, you're not goingthrough...that's the problem with the father, you always feel you have noright to complain because it's not physically happening to you. You don'thave to carry the baby, you know, you should be happy, you should be this,and that's the problem.This same father went on to suggest that an opportunity for fathers toshare their feelings with others either individually or in a group would bevaluable....I think the best thing would be, I think if every father or somethingcould go through something like this [referring to the interview] I thinkthat's a pretty good idea...I guess I, you almost wish there was a, in asituation like this, you wish there was a group, a men's, fathers' group thatyou could come once a week and talk to all the other fathers...When another father was asked how fathers could be better supportedthan they are at present he suggested that an ideal system would bemodelled after how he understood the Japanese supported those copingwith a death of a family member. His description vividly portrays thedifficulty some fathers encounter when attempting to balance both roleswith inadequate support.[In] Japan when, when a person dies...you have a lottery system orsomething so that some other family has to take care of all the funeralarrangements so it allows all the people the time to grieve, you don't have togo out and look after and arrange the funeral...you almost wish there was a51set up like that, you as a husband...you could drop everything and your timecould then be devoted to, you know, being there...but you can't, becausethere is this whole life set up...Yet another father explained why some fathers do not express the needfor emotional support for themselves.Guys don't tend to open up to people trying to help them...lots of timesI don't want to talk about it...I can handle it...men don't want to allow thebarrier they have put up around them down in case, they won't gamble...ifthe bubble breaks, they may be defenseless.He suggested that the biggest support to the father was knowing thathis partner was receiving the best physical and emotional care, and that hehad "around the clock access" to his partner whenever he wished to be withher. Other fathers reiterated these thoughts, and added the request formore practical support. This father responded to the question of whetherthere was anything more that could be done for him with the reply...Oh God, come and clean the house!High Risk Condition Factors Another category that influenced the balance of the roles was thecollection of factors directly related to the high risk condition. Thesefactors included anticipated versus unanticipated risk, perceived severity ofrisk, and prior high risk experience.Anticipated versus unanticipated risk. Whether the high riskcondition and hospitalization was anticipated or not appeared to influence,for some fathers, the emphasis placed on either the emotional caregiver roleor the family sustainer role. Fathers who had the opportunity to anticipate52risk either because of past high risk experience or because the developmentof the current high risk condition was gradual were able to preparethemselves for the experience. For one father, this meant releasing himselfof all other responsibilities so that he would be free to focus himself on theemotional caregiving role. This father had already anticipated risk to thepregnancy based on his past pregnancy experiences:...its been like walking on eggshells this whole pregnancy and she'sbeen on sick leave from the moment we found out she was pregnant...weexpected that it would be difficult.Others were completely unprepared for the change in events.I was actually quite surprised when she phoned me at work...I knewshe had gone to the doctor's and she didn't tell me what was wrong at first,she just said come down and get me right away and all kinds of things weregoing through my mind...Fathers who were unprepared for the experience were left to scrambleto organize their resources, resulting in less opportunity for choiceregarding their role emphasis. When risk to the pregnancy was alreadyacknowledged, fathers were prepared for the uncertainty accompanying ahigh risk diagnosis. Fathers who had no prior knowledge of pregnancy riskwere surprised by an unexpected diagnosis that instantly changed theanticipated normal course of pregnancy to a pathway of uncertainty.When the diagnosis of a high risk pregnancy was made, the resultingmedical interventions were either progressive in nature, allowing for somedegree of acclimatization, or abrupt, requiring immediate and sometimesdrastic adaptation by both partners. Medical interventions that were53initially relatively minor provided fathers with the time needed to acceptthe developing reality of the potential risk. Interventions such as bedrest athome, oral medication, and increased monitoring of the pregnancy,frequently preceded the more drastic intervention of hospitalization.In some cases, however, there was very little time between initialdiagnosis of a problem and hospitalization. Another father lived with hispartner in a community 600 kilometers from the tertiary hospital. Whenhigh risk problems were diagnosed she required immediate medivac,leaving a shocked and unprepared father with a two-year-old son behind.Yeah, we didn't have time to react really, basically it was just like, okay,if you have to be in the hospital in Vancouver then you have to be in thehospital in Vancouver, let's just get you there now.Perceived severity of risk. Another important weighting factor is thedegree of threat to the pregnancy that the father believes to be present.This awareness may be influenced by a subjective as well as objectiveassessment of the situation. In other words, the father's perceived severityof risk may be quite different than the actual risk associated with the highrisk condition. When a higher degree of risk was perceived, fathersappeared to place a greater emphasis on the emotional caregiving role. Thiswas demonstrated by the father who gave up work to remain with hispartner 24 hours a day. This woman's pregnancy was complicated byhypertension, which was relatively minor given her advanced gestationalage, however, the father perceived a significant risk and acted accordingly.Another father described minimal perceived risk to a partner's54pregnancy that was complicated by chronic abruptio placenta and severeoligohydramnios in a 29 week fetus. This condition does, in fact, place thefetus at a relatively high risk and warranted greater concern than wasdemonstrated by the father. This father's assessment of risk appeared toinfluence the role balance resulting in relatively less emphasis on theemotional caregiving role. He described his assessment of the risk byexplaining:Even though she was on the high risk ward she was the lower of thehigh risks, that's the way I perceived it.Prior high risk experience. Prior high risk experience appeared toinfluence role balance in a similar fashion. Four of the participants hadprevious experience with a high risk pregnancy or a pregnancy loss. Threeof the fathers had experienced losses ranging from spontaneous miscarriage,elective termination due to Down's syndrome, a stillbirth at 28 weeks, and astillbirth at term. One father had experienced a positive outcome when his26 week baby survived and had no neurologic sequela.Those fathers who had negative past experiences tended to express agreater sense of distress at the diagnosis of the current high risk problemand appeared to place a greater emphasis on their emotional caregiving role.One father expressed a tremendous amount of anxiety related to the beliefthat this was their last chance to achieve a healthy baby. They hadexperienced a number of previous losses and the negative impact on each oftheir lives and on their relationship had taken its toll. He explained:We more or less said that this was our last attempt. So it feels thatthere's, there's a hell of a lot riding on it, both her and I....we're getting too55old to have a baby...It's just, I guess it's, uh, if it goes wrong, what do we do,like there's, we can't really do this again.Another father explained that he would not rest easy until the baby wasdelivered.Well, I think because of our past problems that we just were alwaysworried...there's always that, even now your worried, even if she's at 36weeks there will always be, just because of our past, once you've been in ahouse fire you're always worried...I think until the baby's out, when thebaby's out and healthy, I think alot of that will just [go]...Another father who had experienced a previous pregnancy (withanother partner) that resulted in the delivery of a 26 week infant who washealthy applied that knowledge to his current situation and explained:I wasn't too worried, mainly because of [name of 26 week child[...froma life threatening point of view...I felt pretty competent that everythingwould be O.K.As a result, this father seemed comfortable with the high risk processas it was unfolding and attempted to convey this expectation to his partner.It is significant to note, however, that because his partner had not hadexperience with a previous high risk pregnancy herself, more energy wasdirected to the emotional caregiving role that what might have beenexpected had she also experienced a previous positive outcome.Geographical Circumstance When the couple's residence was remote from the hospital, asfrequently occurred in a tertiary level hospital that provided service for anentire province, the impact of the geographic distance had a profoundinfluence on the father's role balance.56Fathers who live a great distance from the hospital are faced with avariety of obstacles and decisions not experienced by the father whosepartner is closer to home. The primary problem is an inability to find aneasy compromise between the two roles. The fathers were forced to make adifficult choice. Either remain in their home community, meet theobligations of sustaining the family, and neglect their partner hundreds ofmiles away at a time of crisis...I'm finding that's possibly the toughest, toughest part right now, it's,like we're separated by, 1000 kilometers, and, you can't just turn to yourpartner and say, you know, I'm having a problem, or I've got an idea this isn'tgoing to be so bad, but you need to handle it this way and get it all workedout, and the economics of the situation how is that I just can't phone heranytime I feel like it...Or alternatively,abandon their responsibilities at home and devotethemselves to the unfolding events in the hospital, and to their support rolefor their partner. This father, who had left taken time from work andjoined his partner in the hospital commented on how the situation wouldhave been different had she been hospitalized in their home community....[had partner been hospitalized in home town], I would have probablyhave continued working and then just in between shifts and lunchtime andeverything, go in and see her.Fathers who choose to join their partners are faced with the need tonegotiate time off from work, organize their transportation to the city, findappropriate accommodation, and discover their way around a foreign city.Fortunately the hospital where the study was conducted has hostelaccommodation available nearby for families.57Personal Impact of the Experience The personal impact of the experience included two components:emotional and physical impact. Fathers' descriptions of their emotional andphysical responses convey the impression that theirs is a highly individualexperience with significant meaning. Though the content and intensity ofthe emotions varied to some degree from father to father, it was uniformlyevident that every father was substantially affected by the high riskpregnancy and hospitalization. What follows is a description of theemotional and physical responses that were most commonly discussed bythe fathers.Emotions Surrounding the High Risk PregnancyThe realization that the pregnancy was at risk resulted in a range ofemotions that began at the time of discovery, and continued with varyingdegrees of intensity for the remainder of the pregnancy. The predominantfeeling described by the fathers was fear. Other emotions includeduncertainty, helplessness, and loss of control.Fear.I was really worried that something would happen to the baby becausewe were so excited and this was only, this was at twenty weeks that wefound this out, so we weren't very far anyway... I started to think, oh God,what happens if we don't have this baby and then that, that got worsebecause then I started to think well, if the baby is in danger, what about[partner], like is she in danger too? ...It worried me enough to think we'dlose the baby, but then to start thinking, you know, something might happento [partner], that was even scarier for me...Fathers' fears, anxieties, or concerns (the terms will be usedinterchangeably), were divided into three basic categories: concern for the58baby and for their partner, concern regarding the potential impact on theirrelationship, and concern regarding their performance as a supportivepartner. Financial concern, which was also expressed, was addressedearlier in the discussion as it related to the family sustainer role.All of the fathers described at least some degree of concern for thebaby, though some of the fathers' fears were more profound than others.Yeah, one of the fears (is) that the baby will be born today... the baby atthis point could suffer serious brain damage... serious brain damage orphysical damage... those are the fears instantly, that the baby won't survive atall or won't survive properly.One father was more confident that the baby's life was not threatened.I was worried because we know it is a boy and, uh, boys tend to not fareas well as girls so it's just, I was, I was concerned that it was a boy and itmight be premature delivery. But I also felt that because it was about 32weeks at the time that he had a pretty good chance...just from a lifethreatening point of view I felt pretty competent that everything would beokay.One father, when asked if he feared the baby surviving with ahandicap more than the possibility of it dying, replied:Yeah, I have a huge fear of that, it's my greatest fear. Absolutely, I'mterrified that I, I feel like I could cope if we were childless...we would justre-evaluate what, you know, our goals and the direction our life is going togo. But I don't know what it would be like to have a special needs kid...Itscares me.Other fathers shared his feeling that fear of a mentally or physicallyhandicapped child was greater than the fear of death. They described thepotential for lasting impact on them and on other family members' lives, andwondered about the quality of life for a severely handicapped child. One59father elaborated by describing the uncertainty that he and his partnerwould be able to deal with such a challenge.You know the fear that if the baby is handicapped will you be ready tomeet the challenge, because, I know, I've seen people deal with handicaps,it's tough, really tough, it has to be done for the rest of your whole life havinga handicapped child...if the baby didn't survive, I'd think well, okay, we canstart again.Most couples had, at one time or another discussed this possibility.Some had decided together that they would request 'no heroics' if thenewborn's chances of intact survival was remote.Not all fathers feared potential handicap more than death. One father,who had worked with handicapped children as a teacher, explained that thisknowledge helped him understand the challenges and rewards of life withthese children. While this allowed him to be even more cognizant of thegreat difficulties encountered by the children themselves and their families,it reassured him to know that families could survive this kind of tragedy.This father believed he was more worried about losing the baby altogether.Many of the fathers said they feared that their partners' lives were indanger. They acknowledged the fact that this possibility, in reality, was veryunlikely. Nevertheless, they described a deep unsettling fear that theymight lose their partner as a result of the problems they were experiencing.There was an underlying awareness that women throughout the ages andaround the world have died in childbirth, and that their partners, despitemodern advances in heath care, may not be immune to this phenomenon.I had a dream the other night that the baby had survived and (partner)hadn't and, uh, that's just life, because suddenly sure you have another baby,you have your daughter or son, but you don't have the mother, you don't have60your wife...it really made me think that, its childbirth right, having babies,but childbirth is dangerous too.One father explained the unpredictability of such tragedies:Oh yeah, because of life, even the most minute things, I have a friendwho had a gall bladder operation, she went in, its a normal thing but shedied, its just a strange thing, you know, there's always the chance thatunbeknown, something will go wrong.Some fathers feared the impact of a potentially negative outcome ontheir relationship. They were aware that the stress of coping with theresulting emotional upheaval would create difficult challenges in therelationship. This awareness did not necessarily reflect current difficultiesin their relationship, but more an understanding of the process required ofcouples following a loss. One father's misgiving about the potential impacton their relationship was based on past experience with a perinatal loss.I mean, that's central to my emotions right now because I saw, it took agood couple of years for her to pick up the pieces of that...I mean, humanbeings being what they are I suppose we will survive...I just hate to imaginewhat this one would be like if she lost it and how long, cause it was reallyhard on our, on our relationship because of the, the different stages we wentthrough the grieving process.Some fathers verbalized anxiety related to their role as a support totheir partner. They perceived that their actions were being judged by thehealth care providers, their partner, and others. Were they being as helpfuland understanding towards their partner as they should be? Or as much asthe husband of the woman in the next bed?Am I seeing her enough, or do they think that I'm a, do the nurses thatare around think that I'm not...that husband does so much, you know, she's61talking with somebody else, "Oh, I love your husband, he's so lovely...what hedoes for her"...am I doing enough, is that what she's saying?One father elaborated on this feeling and related it to his generalperception of fatherhood. He felt that society was encouraging fathers toenact the "new father" role but was doing very little to support him in theprocess. This led to anxiety regarding his ability to carry out this desiredrole, particularly as it related to his involvement with the pregnancy, and hissupport for his partner.Society is saying we want the father up there, we want the father upthere, but at the same time they're pushing him back to the side so it's,that's the quandary.While fear, or anxiety and concern, were the predominant emotions formost of the fathers, other feelings were also expressed. These includeduncertainty and helplessness.Uncertainty. Feelings of uncertainty were expressed by most of thefathers at some point in their experience. Uncertainty existed in multipleareas, but primarily concerned the health of the baby and their partner, andthe ability of the medical profession to intervene.I think the thing that was sort of the biggest worry, was that nobodycould exactly say do this or take this medication and everything will befine...that element of not really sure exactly what's going to happen, nobodycan really say, don't worry, this will happen or at least expect this to happenbut there's not any boundaries.I feel like obstetrics is 'smoke and mirrors' because nobody really has aclue of what's, you know, why it works or when it works.62Helplessness/loss of control. While helplessness would be a logicalfeeling for these fathers, it was voluntarily expressed in surprisingly fewmen. One father alluded to helplessness when he described the things thathe was doing for his partner and explained:But, I still feel like I wonder if there's something more that I could dofor her to put her more at ease.Two fathers explained the feeling of helplessness when their partnerswere abruptly transferred to Vancouver from their remote community.I was in [name of community] going, you know, "what can I do", I stayhome and look after [my son].You know, it was pretty frustrating to be at the other end of the phonea thousand miles away trying to calm her down and not being able to doanything about it.Other fathers, admitted to some degree of helplessness only in thesecond interview when questioned directly about this feeling. One fatheracknowledged some helplessness but explained:I probably didn't think about it much...when she first came in I just satthere and the doctors were talking to her and examining her and I didn'tfeel like I could do anything.Another father, during the second interview only acknowledged asense of helplessness because he was unable to convince his partner thateverything was going to be 0.K, "a piece of cake". His partner continued toworry despite his attempts to reassure her which left him feeling helpless.Helplessness is an emotion that is associated with a loss of control.When questioned about a sense of loss of control, fathers denied this feeling.63They believed that pregnancy was not an event that was within their controlat the best of times, and particularly not since high risk problems haddeveloped. They saw themselves as supporters to the process and notcontrollers. Fathers offered the following explanations:I didn't feel like it was something I guess, it wasn't anything I expectedto control...I don't think I ever felt like I was going to be in control that Iwas sort of, watching in amazement, so I didn't feel like I lost anything bynot being in control.I couldn't even imagine what she was going through, so I had no rightto take control...not forcing my way on someone else in a situation I couldn'teven comprehend...pregnancy is an experience I could never experience orcomprehend so it wouldn't be right for me to take control.It is perhaps revealing that while fathers denied feeling a loss ofcontrol when questioned directly about this feeling, they gave numerousexamples in the rest of their discussions suggesting feelings related to lossof control. Loss of control particularly related to their role behaviors,discussed previously, and coping strategies which will be discussed later inthis chapter.Emotions Surrounding the Hospitalization Feelings surrounding the hospitalization of their partner wereconflicting. They included loneliness and loss of intimacy, security, feelinglike an outsider, and belonging.Loneliness / loss of intimacy. Hospitalization inevitably led to somedegree of separation from their partners. Being apart under such stressfulcircumstances created feelings of loneliness and loss of intimacy. Loss oftheir best friend on a day-to-day basis was significant for most of the fathers.64Several of the couples shared remarkably close relationships, so for thesefathers the separation was particularly disturbing. The loss of intimacy wasalso a significant issue for most fathers.Its definitely been harder on both of us having her in here...it's a bigstrain being apart...that's a big deal, for her and in fact for myself, I think, tobe apart...it is a big difference not sleeping together because we really lookforward to that, and it's nice, you miss that kind of intimate time when yournot sleeping together and waking up together in the morning. You talk aboutthings when you're going to sleep or when you wake up that are importantbecause you've got time to lay and think about them, you know, kind ofrelaxing.One father, who was separated from his partner by 600 kilometers andwas kept busy caring for his small son explained:I'm so busy trying to keep things going anyhow, that, it's only late atnight when you're kind of sitting back and going okay, you know, like I guessI should go to bed, oh, right, bed, yeah, empty bed, you know, its just like,that's the only real time when you start to think you know, there's no onearound...and I find I don't go near the bedroom too much, cause its just a,there's no one there.This father found ways to make up for this loss of intimacy with hispartner by spending more time cuddling with his son.It's nice (my son) is a cuddler too, so...instead of spending my time ,you know, thinking about wow, I wish [my partner] was here, I spend mytime doing things with [my son].Security. Despite describing feelings of loneliness and loss of intimacy,a predominant emotion related to hospitalization was a feeling of security.The hospital and its caregivers offered a haven of safety for their partnersand babies that they could not provide. Fathers described the conflictingemotions of loneliness and wishing their partners were at home, versus the65security offered by their hospitalization.Because we can't say how quickly something can go wrong and, ofcourse we both want her home. She wants to be home and I want her to behome, but you know we'd really hate ourselves if we did that and thensomething happened to the baby, you know, that could have been preventedor helped had she been in here... cause its not a big period of time to reallygive up.When fathers had the opportunity to cope with managing the high riskpregnancy at home, they discovered that the stresses inherent in this homesupport role were often overwhelming. One father, who had cared for hispartner while she was on bedrest for four months prior to herhospitalization, described a sense of relief from the responsibilities of homecare.We have a lot of things on our plate right now and I am, thank the Lordthat she's in here, because she will get the proper care that I can't give herat home...it eliminates my schedule and gives me a bit of peace cause I don'thave to attend to [her] needs...I catered to her, like I cooked the meals,cleaned the house, vacuumed the carpets plus, you know, everything else...The security felt by the fathers was related to the availability of the besthealth care possible. Fathers explained that in ensuring their partners werein the "best place in B.C. and perhaps the world", they had done all that theycould to influence the outcome. Fathers acknowledged that this need tohave their partners in "the best place" was important because of theirfeelings of helplessness in being unable to influence the outcome of thepregnancy in any other way. Fathers explained the feeling this way:This is probably the best place for her right now if anything would gowrong. It makes you feel secure that you've got, you know, all the specialistsand all the care, all the equipment that's needed, everything is right here atyour fingertips so, I don't think there's a better place in B.C. for sure.66That's what you do right, trying to make the baby's chances the best...so even, with, urn, it would be nicer to have her up there, the advantageshere, is security...that's a big weight off my shoulders...its in the best placeit can be. What else can you do...One father related his role in ensuring his partner received the bestcare possible to smart consumer behaviour.Because of the, you know- you buy a VCR you're going to checkconsumer reports...you're going to try to get the best possible...I've talked tosome other people, you know, everybody says that [this hospital] is good... [ifshe had not been admitted here] I would have tried my best to get her downhere.When it appeared that their partners were not to be hospitalized inwhat they perceived to be the "best place", fathers experienced a certainamount of anxiety. One father described the stress that he felt because hispartner was initially refused admission and was to be sent to anotherhospital. In the end she was admitted to the tertiary level hospital and hisanxieties were relieved.Even when the pregnancy risk factors had resolved, and it was feasibleto return one woman to her community hospital for care so that she couldbe closer to home, the father was not comfortable.She'd be here with people who knew her, knew the case, kneweverything that's going on, why suddenly get up and leave the best placepossible for a baby...Sure it's a drag, I would much rather she was [incommunity hospital] and I could visit her every day but, you know, looking atthe practical end of things, it's the best thing for the baby is to be here.Feeling like an outsider. Many of the fathers described feeling like anoutsider in the hospital. They explained that the care in the hospital was so67focused on the mother and the baby, that they were really rather peripheralto the experience....to actually feel comfortable, I think that's the hardest thing, for afather coming in in that situation is, so much of the care is given towardsthe patient, so much is given towards that, that the father, you know, afather always does for me, sort of this thing from the outside...its very hardfor him to be comfortable...you feel like you're in a bit of a, well you are in aforeign environment.One father, when interviewed after eight weeks of his partner'shospitalization, admitted to a growing sense of feeling 'in the way'.Maybe I'm in the way, which I really didn't think I should be thinkingthat because I thought well no, we're here because [my partner is] here andthis is not just her problem, it's our problem.Another father described a past experience that indicated to him afailure to acknowledge his role.I've experienced some things in other hospitals, yeah, where there wasno consideration for the father whatsoever, and I think that was out of lackof wisdom. What they were looking at is well, here is the mother pregnant,that's what they're concentrating on, in other words, well this is what we'regetting paid for, but not looking at the husband's point of view also.One father, when asked to describe how he felt he was treated by thehealth care providers explained:I guess I'm on the periphery and an interested bystander, and whooccasionally, uh, he gets his two cents worth and asks the odd question ifit's pertinent.Even the most simple things contributed to this feeling of being anoutsider and emphasized the feeling of helplessness. A father described68feeling helpless because he even had to ask the nurses to get his partner ajug of ice water because of the location of the ice machine, even though hewas perfectly capable of doing this for her. He went on to describe a feelingof apprehension because he felt he may be blamed by staff for something hemay not do correctly in the hospital.You're almost like this person...You're always the person, you're waitingfor somebody to blame you for doing something wrong, or "why haven't youdone this?" rather than , "oh, come on over here".When this father was asked to suggest how this "outsider" feelingmight be alleviated, he made a proposal that eloquently illustrated hisfeelings of discomfort with the current system.The ideal thing of course is, if possible, if a father could come, thiswould be the real home for them. You could even sleep in the bed, youknow, it would be an ideal thing...you'd move into a hotel or something likethat, under constant supervision...there would be a nurse on staff...it wouldbe as normal, it would be as close to being at home as possible, except it'snot like you're interfering, I'm interfering. It's like, you're allowing the otherpeople to come into your environment rather than you're in theirenvironment...we'd be working together, and at this point we're not reallyworking together.Belonging. While the idea of feeling like an outsider was expressedstrongly by several fathers, and acknowledged by others, most of the fathersalso had positive feelings toward the hospital suggesting an element ofbelonging that was not entirely absent. Positive comments were related tothe environment and satisfactory interactions with health care givers.Fathers who felt accepted described the hospital as being unlike othersthey had been exposed to. They described the ward as "feeling as ifsomeone lives here", instead of sterile and unwelcoming. One aspect of the69environment that contributed to this sense of belonging was that patients'rooms were decorated with personal belongings and items such as picturesof their children and family.As important as the physical environment was to creating a welcomingatmosphere, it was not as important as fathers' perceptions of health careproviders' attitudes towards their presence Men who felt that the healthcare providers respected and valued their role as expectant fathersdescribed a feeling of acceptance and inclusion in the hospitalization....the one thing I appreciate is the nurse coming to do stuff and theydon't sort of, kick me out....[the doctor] certainly spoke to both of us...if [partner] felt like shecouldn't mention one of [their questions], I knew some of them she didn'twant to talk about, so I would ask [the doctor] and to start with I felt sort offunny about it, but the doctor's response was just as if [partner] had askedthe question, she would answer to both of us, and if [partner] asked thequestion she would answer to both of us.One father caught himself when he called the hospital "home". Hechuckled at the mistake and acknowledged that he did feel, in a way, thatthis was his temporary home. This father had managed to spend aconsiderable amount of time with his partner in the hospital and thisundoubtably influenced his sense of belonging.An important factor for some fathers that relates to the above, andcontributes to determining fathers' level of comfort within the hospitalmilieu, was their past exposure to illness and hospitals. One fatherdescribed great difficulty when his partner was initially hospitalized. Herelated his discomfort to the death of three close family members,including70his father, during the past year....suddenly all those feelings start coming back, you know, and so itwas very hard for me the first couple of weeks coming in here...because I'dsort of, a month and a half in the hospital and feeding him and stuff likethat, you know, and here it was coming back again...I think probably stuffthat I had pushed aside...Physical ImpactThe experience had wide ranging impact on the fathers' physicalwellbeing. This information was rarely volunteered. Fathers usuallymentioned the effects only when they were asked to comment on how theexperience was specifically affecting their lives in these areas. Why this wasso is open to speculation. Fathers in second interviews were only able tosuggest that the reason may have been the lack of focus on their own lives atthe time. Almost all of the fathers identified negative effects on severalhealth related areas including diet, sleep, exercise, and leisure activities.Only one father described specific physical symptoms of illness. Hereported that he had been unsuccessfully fighting a cold for the past threeweeks.Diet. Most of the fathers reported a poor diet since their partner washospitalized. They frequently ate on the run in fastfood restaurants or thehospital cafeteria. They explained that inadequate time, the lack of theirnormal daily routine, and the absence of their partner who usually assumedthe role of cook, all contributed to their culinary decline.I don't like cooking by myself so I just grab something. Eat at arestaurant or eat down here...71I find that I don't really have time to get out and do, do shopping andstuff like that.This father explained that food had become a necessity rather than anenjoyment for him.Well, you know, not all that great, I mean I look after myself and I getenough food, I eat to live at the moment...I'll cook something and, put it inthe fridge and then just go through it so, I liken it to a wolf going back tothe kill every now and again, I gorge myself, then go flying off in anotherdirection...Another father clearly related the change in his eating habits to hisincreased level of stress.I'm probably more tense than I was before and basically I think I'm, I'musually fairly laid back and I never have had stress problems or, I think I'vebasically just enjoyed things and so I'm very relaxed but I find myself in themorning, if I'm ever worried about something I have trouble eatingbreakfast, and I haven't eaten breakfast properly for ten days.Sleep. Most fathers reported a reduced amount of sleep. On average,they were sleeping one to two hours less than usual. Most fathers did notbelieve this was having a deleterious effect, though their descriptionssuggested the contrary. For example, this father was getting two hours lesssleep a night. When asked if this was beginning to wear him down hereplied:Not really, I feel like I'm back in college you know. In college I used togo on four hours a night and that's what it feels like...always, constantlystudying for an exam and trying to keep ahead of the assignments.Some fathers however, did describe feeling tired and worn down.72I don't get a lot of sleep anymore cause I'm here all the time and I gohome and I worry and she phones all the time and so I don't sleep too muchlately.Fathers reported difficulties getting adequate sleep because of theirworries, their hectic life, and because they were not used to sleepingwithout their partners. Fathers explained that they were often able to makeup for their lack of sleep by sleeping for extended periods on the weekend.Exercise/leisure activities. Time for exercise and other leisureactivities was a luxury that few of the fathers reported being able to pursuesince their partners were hospitalized. Routines such as going to the gym,running, or hobbies were abandoned as a result of their hectic schedules.For some, this meant that an important component of their normal routinefor physical and mental health was no longer available.Coping Strategies The fathers articulated four specific coping strategies which influencedboth the ability to carry out the two roles and the nature of the personalimpact. They included maintaining a positive attitude, taking one day at atime, having faith in a higher being, and seeking knowledge.Positive Attitude The ability to maintain a positive attitude was crucial to these fathers,and they used a variety of approaches to accomplish this. Some fathersrelied on 'focusing on the positive'. These fathers explained theirphilosophy this way:I try to put fears or worries basically out of my mind at this point andtry to focus on the positive that we're going to have a long boring time here73and we're going to have a healthy baby that can go home with us...I hope thatother things don't happen, that he doesn't have to get the ...respirator...youknow, that stuff like that isn't required. And I guess I have basicallyacknowledged all these things that are possible to happen. I, you know, anyone of those could be considered a fear I guess but I try not to focus on thosebecause you know I have no way of knowing that those things are going tohappen so it's not beneficial to sit there and keep thinking about thosethings.It seemed, it seemed like it was sort of under control, like, I suppose Inever really thought of it a lot, never, she always like if something, like I'mthe type of person, like if something bad is happening I'll just, or couldhappen, I'll just think well, it happens to other people. I try to keep thatattitude, I always like to keep a more positive attitude so...Another father related his approach to his optimistic personality.I'm an optimist, I keep thinking that she'll be here till the very end.Within the above descriptions of these fathers' attempts to maintain apositive attitude there is evidence of a certain amount of denial. Otherfathers were clearer in their description of denial:I wanted to trivialize it a little bit I think and say, well, that's not a bigdeal, it's happened to other people...I wanted to think that it was just a littlething that was going to happen for a while and then go away.I had my share of worries...I didn't like it if [partner] said "What if...", Ididn't want to talk about it...stuff like that, I might have had it but I justsuppressed them...I tend to not want to think about it and suppress it andit's difficult when [partner] says "I had this dream..." I say don't worry it'snot going to happen, everything's going to be fine.Rather than denial, this father described a process of 'holding back' toprotect himself from a potential loss.I'm still well, you know, this little part of me because of the, a lot of it'sbecause of just the rotten luck we've had, you know. I know it's lookingpretty good and everything...I want to make sure that everything is okay, Idon't want to treat this as another person again and to have something bad74happen again, and go through all that again, so, it's a measured sort of time.I'm coming around and now it's pretty obvious that there will be a little babycoming...One father described hope as being what sustained him through theexperience. He explained how on good days, when he and his partner wereoptimistic, they would allow themselves to focus on their hope and spendtime anticipating their future child.Just the hope that at least this time it will be different...we usually findourselves talking about, what we'll do, planning for the future, this kid'snamed and dressed and the nursery is built and everything else, and baddays you just try to get through them.One Day at a Time Integral to the ability to maintain a positive attitude seemed to be theability to approach the experience one day at a time.I just cope with it the best I can I guess. I take it day by day. Youknow, that's all I can really do.I'm trying to deal with it as best as I can... It's a bit like the alcoholicsanonymous, one day at a time.You could worry about that stuff for two or three weeks and then itdoesn't happen and you worried for nothing, right. So you have to be awareof the possibilities of, that things could happen...you have to deal with it as itcomes. You know if the baby is born premature we'll have to deal with thatthen, but at this point the baby is still inside her so why worry aboutprematurity or not. I'm basically trying to think of the positive.Some fathers acknowledged that by taking such an approach, theywere able to cope with a process over which they had no control.It took me a long time to develop that attitude...I just finally one daycame upon the realization that why worry about it, like you cross that bridgewhen you get to it...it's a very helpful philosophy in life to do that, you know,75you try not to let things bother you that you have no control over. And at thispoint we don't. I mean if that baby decides he's going to come out or if theblood pressure goes up, then it's going to happen and there's nothing wecan do about it. We can just deal with it when the time comes...that's helpedme out of a lot of frustrating things, you know, to remind myself that, thatsome things happen and they're out of your control so why get uptight overit...it's frustrating if something goes wrong and I think if a person canremind themselves, hey, well, you know, I couldn't have prevented thisanyway, so why waste the energy on getting upset over it, you know, just dealwith it as best as you can, at the time, when something has happened orwhatever, and carry on from there.Another father described how his experience as a photojournalist hadallowed him the opportunity to see a great many tragic experiences thatother people had learned to cope with. From this he had developed anunderstanding of how to approach the types of challenges over which he hadlittle control....it's given me some information,and also it's given me, you know, abackground preparation of how other people have dealt with such things.You know, knowing that you just have to get on, get on with it and not standand dwell on it too much , cause if you do you won't get, it won't be handled,you won't change anything and so if you could just make sure everything isset up the best you can and go for it, that's all I can do.FaithFaith in a higher being gave several of the fathers strength to cope withthe experience. By believing that God, or another vaguely defined 'spiritualbeing' had control over the events in our lives, fathers were able toacknowledge and accept the potential poor outcome....It is a possibility this child might not be born. We understand that,accept that, and know if it's not to be, that's God's will, and we're to try andunderstand and acknowledge if that be his will, that be his will.76So, you know, you sort of say thank you to the big guy and hope that,uh, that everything is going to turn out all right...One father explained that if he didn't maintain his belief in a higherpower he would be forced to accept the fact that he himself was in controlof everything, or that there was no control at all. He found both of thesealternatives frightening because the result would be an overwhelming feelingof helplessness. Instead, because of his belief in a spiritual being who didhave control over our lives, he was able to relinquish responsibility for theoutcome.I have difficulty living too far in the future, and I just know I have nocontrol over what happens so I just turn it over to God and what happens,happens; but I usually expect something good...I couldn't do anything aboutit so thinking about it would just get me upset, so I just think 'it's out of myhands'.Knowledge All the fathers discovered that increasing their knowledge of thephysiology of the high risk pregnancy and understanding the rationale forthe subsequent interventions by health professionals served to enhance theirability to cope with the experience.I didn't know too much about it, you know, I don't, you know she'sbeen here five weeks and I'm starting to learn a lot more. When we firstcame in here, like I didn't, you know, very little if anything...so I was prettyscared and asked a lot of questions...it helps to understand what's going ontoo. So we're, we're ready I think for, you know, anything they tell us now.All fathers felt comfortable asking questions in order to increase theirknowledge and generally felt that their questions were answered thoroughlyand honestly. Nevertheless, they commented on several areas that resulted77in less than ideal communication between health care givers (by and largephysicians) and themselves.One father felt physicians answered all of his questions but he wouldhave liked to have seen them volunteering more information.I'm not afraid to ask questions and if I don't get the answer I want I'llkeep pressing until I get the answer that I need to hear...I find thatsometimes that the doctors aren't the most readily flowing sources ofinformation in that they won't necessarily explain things if you don't askthem. They're quite good about answering if you do ask and especially if youshow some savvy I guess of perhaps general ideas of medical care...But I feelthat perhaps sometimes a doctor could volunteer information a little morefreely rather than have to be asked about it.This next father identified a problem in the level of communication ofinformation by physicians. He called this "doctor talk", and felt it was notalways directed to the level of understanding of the patient and family.They answer everything you ask them... Like they'll start talking, likewe'll start doctor talk. Don't forget we're not doctors and we don'tunderstand half so we try to tell them the simple parts so we understand.Some fathers commented on the difficulty in obtaining informationfirst hand from physicians. This occurred because most of them wereunable to be present during the doctors' rounds. For a few of the fathersthis meant they were unable to obtain all the essential information. Thisfather explained:I like to know what's going on too right. I don't like to hear, like I'vemissed a few things where the doctor has come in and told her, and so youknow I hear it from [partner] and she forgets a lot because she gets upset.So I like to be here when the doctor sort of comes by to talk to her...firsthand.78When asked what he did when he did not hear the information firsthand he responded:...then I wait, you know, like I run to [doctor] or [doctor] or somethinglike that, then I'll ask them about what [partner] has told me and I'll askthem some more questions too. They're pretty good, like I said, they'll tellyou anything you want to know.Another father commented that:I probably get about eighty percent of the information and twentypercent of course [partner] would naturally forget.The information he received was "filtered" through his partner. Thisdid not represent a problem to him at the time, because he felt that he wasable to seek out the information when he had questions. He recognized,however, that if his partner's condition was less stable, he would have agreater need to receive the information first hand.For some fathers, obtaining information second hand was not aproblem....whenever the doctor speaks to her I'm never here, I haven't beenhere anyway cause he has a schedule and he comes when he can, you know,and then she just tells me what he says...that's how I find out because I'mjust not here all the time.When asked if he would rather be hearing the information first hand heresponded:No, it doesn't matter to me. She's very thorough.It is important to note that when fathers obtained information secondhand this occurred not because the physicians did not acknowledge their79equal need to understand what was happening, but because of their frequentabsence from the bedside. This is in contrast to past experiences fathershad with health professionals. One father compared his experience with aprior pregnancy to his current experience....nobody really talked to me that much, they'd tell my wife what theywere doing and she'd have to tell me what was happening in, instead of sortof explaining to all of us.Compared with,...[doctor] has come in while I was there and talked to us...like I'venever been sort of excluded.There was some concern about the number of different sources ofinformation and their lack of consistency. One father explained:...I find that we find too many doctors tell us too many differentthings...we requested to talk to [doctor] on the phone the other day there atwork, I was at work,,,, and I, you know, I was confused and you don't knowwhat's going on anymore cause there's just so many people telling us somany different things...one doctor says one thing and the other doctor saysanother thing, and another doctor comes in and he'll tell you somethingtotally different too, so that's hard too.Despite being an exception, it is revealing to know just how far onefather was willing to go to obtain information. In this case it was notregarding his partner's specific condition, but was about the qualifications ofthe attending physician. This father took what one might consider drasticmeasures to ensure he had all the information he required to makedecisions.80I believe and also took council from the College of Physicians andSurgeons. I checked out (doctor) and, you know, everyone. Also we had asecurity company that I did some background checks also, cause this time,hey, were going to know data. How can you assess a situation unless youhave the data?Finding a BalanceIt was necessary for each father to find a balance between his roles asemotional caregiver and family sustainer. The relative emphasis placed oneach role varied from father to father, and with the same father, from timeto time. These variations were dependent on the influence of the balancingfactors as well as the inherent importance placed on the roles themselves.For the most part, the balance that each father achieved was a compromisebetween the two roles. Most of the fathers were relatively content with theposition they found for themselves. Some, however, expressed significantdissatisfaction with their position but were unable in the presentcircumstances to influence a change. The following four examples portraythe complexity of the interacting factors that determine the father'sultimate position.One father lived in a remote community, had financial responsibilitiesthat prevented him from taking a leave from work, and had a son to care for.This father, by circumstance, not choice, remained in his home to carry onwith the responsibilities associated with the role of family sustainer. If hehad been able to choose, he would have been with his partner providingemotional support. He was able to compromise to some extent by speakingto her frequently on the phone, traveling to the city every few weeks to bewith her for extended weekends, and making plans to come immediately to81the hospital if her condition should change. This last action demonstrateshow the high risk condition balancing factor of perceived risk can fluctuate,and thus influence a change in the determined balance. This father wasrequired by circumstance to maintain his role as family sustainer and placerelatively less emphasis on the emotional caregiver role.A second father found a different balance between the two roles. Hetoo lived in a remote community. While work was important to him, hechose to take the time off work to accompany his partner throughout herhospitalization. This father viewed his emotional caregiving role as being ofprimary importance, and virtually abandoned his family sustainer role inorder to remain in the hospital with his partner 24 hours a day. Hedemonstrated his own comfort with the hospital environment, but wasunavoidably aware of the system's discomfort with his presence. Hisdecision to remain with his partner was not supported by a high degree ofobjective risk to the pregnancy. In fact, his partner's condition was ofrelatively low risk since the fetus was an advanced gestational age. Thisfather placed greater emphasis on his role as an emotional caregiver, andsignificantly less emphasis on the family sustainer role.A third father found a different balance but expressed significantdissatisfaction with his position. Though he viewed his role of emotionalcaregiver as being very important, he did not feel entirely comfortableassuming this role for a number of reasons. These included his perceptionof the health care system's inability to truly accept and accommodate theneeds of the father, his lack of support in fulfilling his role, and hisdiscomfort with the hospital environment. This father clearly described the82feeling of being an outsider to the whole process, including thehospitalization. His family maintenance role was partially compromised as aresult of being unable to accept work opportunities that would take himaway from the city and his partner. He arrived at a balance that hedescribed as follows:I'm now the connection to her, to the outside so all the stuff she has toget done, I'm [doing that]. The staff nurses deal with the stuff on the inside,I'm the guy on the outside, I have to bring the videos, bring the so andso...we put our house on the market so there's all that stuff, and "have youseen any house yet?, clean the house", blah, blah, blah, all those things athome plus coming here.Another father found a different balance again. He lived relatively closeto the hospital and visited often, more because of the recognized desire ofthe partner for support than for his own expressed need to provide support.He continued to work almost full time as well as care for his young child,with the support of family. He did not perceive that there was any risk tothe pregnancy, so expressed a minimal amount of fear, or any otheremotion. His approach was matter of fact and rather distant to the potentialdrama of the high risk pregnancy. Nor did he consider the hospitalizationparticularly distressing in any way, though it was inconvenient. This fatherfound his balance by expending more energy and attention on the familysustainer role, and less emphasis on the emotional caregiver role.These examples serve to illustrate the complexity of the factors thatcontribute toward each father finding a balance between the two roles, andtogether with our understanding of the impact of the experience on the83father's own emotional and physical self, support the conclusion that theexperience was substantive in nature. The experience clearly holdssubstantial personal significance for the father and is not simply a subsidiaryexperience to that of his partner. There is evidence, however, that manyfathers perceived, to a greater or lesser degree, that others considered theirparticipation to be of a subsidiary nature. This was not a concern for somefathers because they did not perceive that they were being neglected in anyway as a result of this attitude. These fathers believed that while they wereexperiencing the phenomenon from their own unique perspective, theemphasis for themselves and others was appropriately on their partner andthe baby. They did not perceive a need for any more attention or supportfrom others than was already being provided.You're sort of going along with the game plan, yeah, it's really, no it'snot happening to you at all, your just helping your wife, helping her to feelgood, doing whatever you can to help her feel good...I didn't need anysupport myself, it wasn't me going through it, it was her.Others were decidedly dissatisfied with being treated as a subsidiaryparticipant in the process. These fathers also acknowledged that the focusfor themselves and others was on their partners and their physical andemotional experience. This focus away from themselves, however, resultedin a perception that they were supplemental to the primary experience oftheir partner. The failure of others to acknowledge the fathers' ownexperience as significant resulted in discomfort and unmet needs forrecognition and support....you're this thing on the outside, trying to get in, you know, trying toget like this little sperm, that's what you are...it's like you have the baby, and84the woman and, you have all these people around the woman, you're overhere, trying to get in, and then you're called in to do stuff and then you'resent away to do that stuff. Then the other people come in, you know, therelatives, the mothers, the nurse, and, you know, and your like the personon guard waiting to be called to do something. And, a lot of that, I think it' shalf of me and half the way it's, it's set up.SummaryThis chapter has described the analysis of the data that portrays thefather's experience of high risk pregnancy and antenatal hospitalization.The findings indicate that the father's experience was substantive in natureand involved finding a balance between two predominant roles - emotionalcaregiver and family sustainer. A number of factors served to influence thebalance, including the support system available to the father, high riskcondition factors, and geographical circumstance. Specific strategiescontributed to the fathers' ability to cope with the experience includingmaintaining a positive attitude, taking one day at a time, having faith in ahigher being, and seeking knowledge. The consequences of thephenomenon had a significant personal impact on the fathers' emotional andphysical wellbeing.The relative emphasis placed on each role varied from father to father,and with the same father, from time to time. These variations weredependent on the influence of the balancing factors as well as the inherentimportance placed on the roles themselves. Most of the fathers wererelatively content with the position they found for themselves. Some,however, expressed significant dissatisfaction with their position but were85unable in the existing circumstances to influence a change.The fathers' descriptions portrayed an experience that was unique andsignificant in their own right. A separate and individual version of thephenomenon of high risk pregnancy and hospitalization that was intimatelyrelated and interdependent to their partner's parallel experience, yetsubstantively different was revealed.86CHAPTER FOURDISCUSSION OF FINDINGSIntroductionChapter Three presented the outcome of grounded theory analysis ofexpectant fathers' collective descriptions of their experience when theirpartners are hospitalized with a high risk pregnancy. In this chapter, thedescription of the father's experience is discussed in relation to theliterature.Researchers have by and large concentrated their attention on thematernal experience of pregnancy and childbearing. Despite this focus, overthe years there has been increasing interest in the experience of expectantfatherhood in normal pregnancy (Colman & Colman, 1971; Cronenwett &Kunst-Wilson, 1981; Glazer, 1989; Hangsleben, 1980; Hines, 1971; Jordan,1990; May, 1980, 1982 a & b; Roehner, 1976; Wapner, 1976; Weaver &Cranley, 1983). Very little attention, however, has yet to be directedtowards the experience of the father when the pregnancy is determined tobe high risk, let alone when there is the additional variable of antenatalhospitalization.A few theoretical papers have explored the impact of high riskpregnancy on the family, including, to varying degrees, discussion regardingthe father (Gyves, 1985; Kemp & Page, 1986, Mercer, May, Ferketich, &deJoseph, 1986; Penticuff, 1982). Although it has been recognized thatresearch is needed to further our understanding of the expectant father's87experience related to high risk pregnancy (Conner & Denson, 1990) andantenatal hospitalization (May & Perrin, 1985), no research has beenpublished in the literature to date.Given the above, the following discussion will necessarily rely on workthat has examined the father's experience either within the context ofnormal pregnancy, from the perspective of the woman, or from a relatedsubject area.Finding a BalanceThe central theme that emerged from data analysis was a balancing ofroles. The fathers were in the position to carry out two primary roles - thatof emotional caregiving and sustaining the family In order to meet therequirements of either of these roles, each father found it necessary to finda balance that fit with his individual circumstance.A substantial body of knowledge has developed surrounding roletheory. Role theory emerged through the collective contributions of a widevariety of behavioural scientists since the 1930's and earlier (Biddle &Thomas, 1966). Roles are defined as "the more or less homogeneous sets ofbehaviours which are normatively defined and expected of an occupant of agiven social position" (Nye, 1976, p. 7). Role behaviours are what a persondoes in response to role expectations which are determined by society andrefined by the individual (Friedman, 1981). Individuals may carry out anumber of roles related to their particular position or social status(Friedman, 1981). A father's related roles may include, among others,88provider, companion, leader, child caretaker, and sexual partner.Role conflict occurs when a person perceives that there areincompatibilities regarding role expectations (Hardy & Conway, 1988).Interrole conflict may occur within an individual when he or she is requiredto enact many roles simultaneously, and at least two of the roles areperceived to be contradictory (Hardy & Conway, 1988). Role overloadoccurs when there are excessive demands made upon an individual relativeto the amount of time available (Hardy & Conway, 1988). Both role conflictand role overload may result in role strain which is the individual'ssubjective state of emotional arousal (Hardy & Conway, 1988).Role theory has been applied to the structure and function of the family(Friedman, 1981). Eight basic family roles (including marital and parentalroles) were identified by Nye (1976) including: the provider role, thehousekeeper role, the child-care role, the child-socialization role, therecreational role, the kinship role, the therapeutic role, and the sexual role.It is through the interactive, interdependent performance of these rolesthat individuals are able to maintain a dynamic equilibrium and satisfactorilyfunction as a family unit (Turner, 1970).It has been demonstrated that the illness of a family member maydisrupt this equilibrium, and that illness in the mother may be the mostdisorganizing to the family because of her pivotal role in family functioning(Friedman, 1981; Turk & Kerns, 1985). It has been noted that whenhealthy family functioning exists, remaining family members will adapt byeither assuming the necessary roles left vacant by the ill member or by89seeking outside support to assist in performing essential roles.Dysfunctional families are often unable to respond effectively to the newdemands brought about by family illness (Leavitt, 1982). However, evenwhen a family is functioning adequately, role strain may result (Friedman,1981).The fathers in this study demonstrated some evidence of role strain asa result of both role conflict and role overload. Role strain may be exhibitedby an increased level of awareness, overall emotional arousal, or feelings ofdistress, anxiety, or frustration (Hardy & Conway, 1988). In the role offamily sustainer, the fathers were required not only to carry on withpreviously adopted roles such as financial provider, but to assume roles thatmay normally have been carried out by their partners, such as housekeeperand child caretaker. Even in families where the division of family roles mayhave been blurred, the fathers were now required to assume soleresponsibility for the family sustainer role.In taking on the emotional caregiver role, the men assumed a roletraditionally assigned to women (Benson, 1968). In the past, men in oursociety have usually assumed instrumental roles while women have beenresponsible for expressive roles (Benson, 1968). Though these roleexpectations and behaviours are currently undergoing change in today'scomplex society, in most partnerships the woman continues to assume mostof the responsibility for emotional support. Because of this, and the relativeimportance the fathers placed on their ability to carry out this role, thefathers were placed in a situation where they were vulnerable to role strain.90Furthermore, the necessity to balance the roles of family sustainer andemotional caregiver created potential for role conflict and overload. Forsome fathers, it was physically impossible to carry out both roles to theirsatisfaction, which inevitably lead to role conflict. This was true in the caseof the father who was geographically separated from his partner. Otherfathers were able to find a more moderate balance between the roles. Thesefathers were faced with role overload until they were able to adjust to theirnew roles. While evidence of role strain is evident in their descriptions, itappears that all the fathers interviewed were able to adapt and assume theroles necessary to maintain family functioning.The analysis of data gave evidence to suggest that the central theme ofrole balance was recognized by the fathers as an experience that wassubstantive in nature. The fathers' descriptions portrayed a separate andindividual version of the phenomenon of high risk pregnancy and antenatalhospitalization to that of their partners'. Their experience indicates thatfathers are deserving of attention from others, particularly health careprofessionals, not just as appendages to their partners, but as individualsworthy of care in their own right.It is well documented in the literature that the expectant father'sexperience of normal pregnancy is different from his partner's experience(Antle, 1975; Heinowitz, 1982; Wapner, 1976). May (1978) noted that"while pregnancy is for most men an emotional, if not physical, experienceshared with their partners, many of the concerns and emotions of theexpectant father are sex-specific" (p. 10). Despite this recognition, an91examination of the literature reveals that the father continues to be castalmost exclusively in the role of supporter to his partner, regardless of therelevance of the events to his own emotional and physical wellbeing.In another grounded theory study, Jordan (1990) described theexperience of expectant and new fatherhood. One process the fathersunderwent was "struggling for recognition as a parent". This father'sdescription of his experience supports the notion that fathers may needrecognition of their own:It's always in reference to how [my wife] is doing, and I feel like I haveresigned myself more to just responding to what they are asking and that isto say how [she] is doing as opposed to me and how I am doing....I reallytried to initially go out...and open myself up and really share...but, so muchof the response is, "You've just got to stick it out. This is her time." There isno validation of the feelings. There is no recognition. I don't feel like Ishould deny my feelings and deny what's going on for me. The message isclear..."You need to focus on her." I just haven't found anybody that [sic] isreal understanding, like "What is the experience like for you?" (p. 14).Jordan (1990) also identified the impact that health care providershave on the father when this attitude is conveyed. The findings support thenotion that interactions with health care providers may convey theimpression that fathers are subsidiary. In Jordan's study, the participantsbelieved that health care providers did not consider fathers to be theirclient. They reported that when they attended prenatal or pediatric visitsto the physician they were infrequently recognized as a parent in their ownright, and were treated simply as supports to their partner.Wapner (1976) reported that in normal pregnancy, fathers feel thatthey are at the centre of action, not merely supporters of their partners.92The findings of this study do not agree with this assertion, since the fathersvery clearly indicated that they did not place themselves at the centre ofattention. This difference might well be explained by the criticaldifferences between a normal pregnancy and a high risk pregnancyrequiring hospitalization. It would seem logical that, if fathers experiencingnormal pregnancy feel at times that they are not recognized as legitimateparticipants in the process, fathers experiencing high risk pregnancy andantenatal hospitalization of their partners would have even more of a reasonto feel isolated from the experience.It is worth comparing the findings in this study with Valentines'(1982) work that identified four developmental tasks of the expectant father(As described in chapter one, p. 6 of this paper). The first task related tofetal attachment was not necessarily a behavior identified in this study,though indications of fetal attachment were found in the fathers'descriptions of fear regarding loss of the baby. The second task, concernwith practical issues such as finance, accommodation, and developing asense of being a good provider relate to the role of family sustainer. Thethird and fourth tasks, resolution of dependency issues, and coming toterms with his relationship with his father were not identified in the dataobtained from the fathers in this study.There may be two possible explanations for this difference. The first isthat there may be a difference in the necessary developmental tasks offathers experiencing normal pregnancy and fathers participating in a highrisk pregnancy. Fathers in high risk pregnancy may have other primary93issues to resolve at the time and may or may not address these twodevelopmental tasks at a later date. A second possible explanation is thisstudy did not seek to intentionally obtain these types of data, thereforediscussion regarding thoughts and behaviors related to these developmentaltasks may simply not have been mentioned by the fathers.The Role of Emotional CaregiverThe role of emotional caregiver was well articulated by the fathers inthis study. This role has received a considerable amount of attention in theliterature. Roehner (1976) found that, in normal pregnancy, fathers rankedhelping the mother deal with her physical and emotional problems as theirmost important function. Marquart (1976) found that it is normal forexpectant fathers to become more protective and nurturing of their partnersduring pregnancy. This complements the woman's increased introversion,dependency, and increased demand for nurturance that Caplan (1960)identified in women experiencing normal pregnancy. Thus, when thepregnancy develops complications, and the woman requires hospitalization,it would be expected that evidence of even greater nurturing and protectionon the part of the father would be found. This study supports this theory.Gyves (1985) postulated that a father may well be able to offer therequired support in normal pregnancy, however, in high risk pregnancy hemay be distracted by his own emotional responses including excessiveconcern for the baby, resentment, guilt, and inadequacy. Gyves suggestedthat the father's own emotional reaction might prevent him from fulfillinghis supportive role to his partner. However, in this study fathers gave94evidence to the contrary, suggesting that - at least from their perspective -they were very able and willing to provide support to their partner. In fact,they viewed this as one of their primary roles. Perhaps the fathers' ownemotional responses promoted rather than prevented the enactment oftheir support role. Of note is that fathers in this study did not describefeelings of resentment, guilt, or inadequacy per se as postulated by Gyves,which may account for the contrary findings.In a study on fatherhood in normal pregnancy, Roehner (1976)concluded that society and health care providers place so much emphasis onthe woman's experience, that fathers feel that they must also concentrate onher needs and virtually ignore their own needs related to parenthood.Roehner cited the Colemans' (1971) description of the forgotten father whois left out of the entire pregnancy experience, yet is expected to carry thedemands of emotional as well as material support. The fathers in this studydemonstrated that the focus for them and others was on support of thewoman.The fathers were able to articulate three reasons why this was so,including the physical reality of the pregnancy, their partners' greateremotional needs as a function of being female, and the isolation andboredom associated with their partners' hospitalization. The last reason inparticular is specific to antenatal hospitalization and has not been previouslyreported in the literature.The fathers gave detailed accounts of the ways in which support wasprovided to their partner. These included maintaining a physical presence,95providing comfort and compassion, acting as a psychological coach, being anadvocate, and providing protection. While the literature supports thegeneral concept of the father as supporter, there is very little availablediscussion regarding the specific ways the support is provided.Maintaining a physical presence was very important to the fathers inthis study. The literature addresses the importance of the fathers' presencein antenatal hospitalization from the woman's perspective (Carty et al.,1992; Loos & Julius, 1989; Merkatz, 1978; Waldron & Asayama, 1985;White & Ritchie, 1984). These references provide evidence that asignificant stressor for the woman who is hospitalized with a high riskpregnancy is the separation from her partner. Separation during such a wellrecognized period of vulnerability for both partners creates potential forimpaired ability to successfully negotiate the required developmental tasks(Rubin, 1975; Valentine, 1982). The previous discussion regarding feelingsof being an outsider supports the importance of providing the partners withunrestricted access to each other.In research related to labour and birth, MacLaughlin and Taubenheim(1983) interpreted the fathers' need to be present and act as the primarysupporter to their partners in labour as a need to establish territorial rights.A similar interpretation could be made for the fathers in this study.Providing comfort and compassion are well recognized methods ofproviding emotional support in any stressful situation, and high riskpregnancy certainly qualifies as a stressful event. The specific role ofpsychological coaching by the techniques identified in this study -96reassurance, reinforcing reality, encouraging a positive outlook, and takingone day at a time - have not been previously mentioned in the literature.The fathers' protective action of withholding the sharing of their ownemotions has been addressed in previous work on fathers in normalpregnancy. In a study on marital support during pregnancy, Brown (1986),identified that in normal pregnancy men were less satisfied than theirpartners with items related to sharing of private thoughts and dealing withfears of an abnormal baby. In another study, May (1975) found that fathersmay encounter problems dealing with their own anxiety about labour anddelivery since they may feel that by telling their partners about their ownanxieties they only add to her burden and thereby violate their role asprotector. The significance of the fathers' reluctance to share theiremotions with their partner will be evidenced in the discussion of thesupport system for the father.The Role of Family SustainerThe other focus for the father was the role of family sustainer. Thisrole was multidimensional and included responsibilities related to work,childcare, and domestic activities. These three areas of responsibilityactually correspond to three of the basic family roles identified by Nye(1976): the provider role, the child-care role, and the housekeeper role.A number of authors have identified the role of financial provider asthe primary focus for fathers in normal pregnancy. Glazer (1989) citedfinancial concern as the most frequently identified stressor of expectant97fathers (Antle, 1975; Colman & Colman, 1971; Heinowitz, 1982). Obzrut(1976) concluded that the provider role is of primary importance to theexpectant father. The activities of preparing the living arrangements for thebaby, and making financial purchases for the baby were the most frequentlyreported activities by expectant fathers in that study. However, May (1978)reexamined Obzrut's (1976) findings and suggested instead, that the dataindicated the opposite conclusion - that the provider role is not of primaryimportance to most men. May supported this interpretation by noting thatwhile 80% of the men in the study expressed concern about their infantcare skills, and 68% about their adequacy as a father, only 35% expressedconcern about financial security.In another study, Roehner (1976) also found that functional supportwas felt to be a function of lesser importance than emotional support. Only19% of fathers indicated that "providing money for the care of mother andbaby" was their most important function, whereas 50% felt that "makingsure the baby's mother remains healthy" was more important, and 84% feltthat to "help the baby's mother deal with her physical and emotionalproblems" was more important (p. 18).Beyond discussing the maintenance of financial security for the family,the literature does not deal with the other components of the familysustaining role in the specific circumstances that are the focus of this study.The literature related to hospitalization in general does provide empiricalevidence that role changes occur within the family during illness andhospitalization. The hospitalization of a family member may lead to "role98gaps" when the patient is no longer able to fill certain responsibilities. Theremaining family members must learn to reorganize and adopt these roles orconfusion may result (Stember, 1977). The role components of childcareand domestic responsibilities remain, in most families, a primary function ofthe mother. The fathers in this study provided evidence that theassumption of primary responsibility for these tasks was a challenging if notstressful endeavour, particularly in light of the existing anxiety surroundingthe hospitalization.Balancing FactorsSupport System It is well documented in the literature that social support is a mediatorfor the ability to cope effectively with life stress (Cobb, 1979; House, 1981).Researchers have examined the particular implications of social support inrelation to the transition to parenthood (Cronenwett, 1985; Wandersman,Wandersman, & Kahn, 1980), and more specifically, in relation to thetransition to fatherhood (Cronenwett & Kunst-Wilson, 1981). Social supporthas been defined by House (1981) as "a flow of emotional concern,instrumental aid, information, and/or appraisal (information relevant to self-evaluation) between people" (p. 26).Each of the fathers in this study identified a support system of someform or other that influenced his ability to carry out the two roles. Asupport system is an "enduring pattern of continuous or intermittent tiesthat play a significant part in maintaining the psychological and physical99integrity of the individual over time" (Caplan, cited in Garland & Bush, 1982,p. 118). The fathers' support systems included their partner, family,friends, the church, and health care givers. Fathers did not necessarily useall of the above sources of support. In fact, what was evident was that mostfathers used only a few of these sources, and some relied, by choice orcircumstance, on virtually no external supports.The father's primary source of emotional support was his partner, yethe recognized that because of the need to protect his partner from her ownworries, he was unable to take full advantage of her support. In a study onmarital support in the normal pregnancy, Brown (1986) found that bothmen and women relied on their partners for an overwhelming amount ofsupport. A further finding was that men expressed less satisfaction withtheir partners' support in the areas of being allowed to talk about personaland private things, and being helped to deal with fears of an abnormal baby.Given that the fathers in Brown's study were experiencing a normalpregnancy, it may be reasonable to hypothesize that that fathersexperiencing a high risk pregnancy and separation from their partner wouldexpress even less satisfaction in this area. This hypothesis is supported bythe findings in this study. However, there is also evidence from somefathers that although they did give more support to their partner than theyreceived, their partners were able to reciprocate with some support forthemselves.Very little emotional support was received from sources other thantheir partners. This finding is supported by Brown's (1986) work, and by100Lein (1979), and Kempter (cited in Cronenwett & Kunst-Wilson, 1981).Some fathers reported receiving emotional support from their families butthis was described as minimal, and one father whose religious faith wasstrong received substantial emotional/spiritual support from his church. Byand large, little support was sought or received from friends, male orfemale.Practical support was mostly received from family, particularly mothersand sisters. Lein (1979) confirms this finding. In a study of fathersexperiencing a normal pregnancy, Jordan (1989) reported that material(practical) support was most often identified by fathers as both helpful anddesired. Lein also found female neighbours a source of support. Only onefather in this study described practical assistance offered by neighbours.Lein (1979) found that men's social networks mostly included co-workers who typically offered little practical support. Fein (1976) foundthat when support was received from people from work, it was usually not inthe form of practical support such as flexible hours or paternity leave.Contrary to those findings, the fathers in this study were well supported byemployers who accommodated their need for flexibility and leave fromwork. Fein's study was examining fathers of normal pregnancies however,and this may explain the difference in employers' willingness toaccommodate the fathers' needs.Informational support was received either from health care givers, orsecond hand from their partners. The finding that few of the mendescribed receiving information from nurses is of concern, and has not101previously been noted in the literature. Given the importance of information(as noted previously in the discussion regarding information seekingbehaviour as a coping strategy), and the infrequency of physician - fathercontact, the opportunity for nurses to act as significant informationalsupporters is obvious.House (1981) identified a fourth type of support - appraisal support.Appraisal support is the "transmission of information relevant to self-evaluation" (House, 1981, p. 24). This type of support is received fromothers who are in the same situation. Self-evaluation is accomplished bycomparing one's actions and responses with that of others. None of thefathers described receiving this form of support from other fathers sharing asimilar experience. At least one father did, however, suggest that a fathers'support group would be valuable, and it is in a group such as this thatappraisal support would be received. Taubenheim and Silbernagel (1988)described the successful implementation of an expectant fathers supportgroup with a low risk pregnancy focus. The additional needs of fathersexperiencing high risk pregnancy suggest that this type of group might beeven more important for these men. A salient point, however, was made byone father when he stated that many men do not want to share theirfeelings. Obviously, the need for appraisal support of this kind variesdepending on the particular individual.It is perhaps appropriate to complete this discussion of support with aquote almost twenty years old:"It is in the area of providing support for the husband duringpregnancy and during fatherhood that the health professions have been most102remiss....little is said about the needs of the expectant father and newfather....he is expected to take on all the former functions of the extendedfamily himself in relation to his expectant wife and new mother, but who isgoing to provide the support for the father?" (Hines, 1971, p. 195).The findings in this study reveal that the problem of insufficientsupport, at least for some fathers experiencing high risk pregnancy andantenatal hospitalization, remains to be adequately addressed.High Risk Condition Factors The high risk condition factors of anticipated versus unanticipatedrisk, perceived severity of risk, and prior high risk experience wereidentified as having influence on the balance of the roles. Some evidence canbe found in previous work to support the findings.Snyder (1984) discussed the impact of anticipated versusunanticipated risk and the resulting abruptness of intervention. It wassuggested that a high level of anxiety is usually associated withunanticipated problems requiring acute intervention such as preterm labourwhereas anticipated admissions due to known problems are less likely to beperceived as stressful. There was no documentation offered by Snyder tovalidate this theory.There is empirical support for the finding that the perceived severityof illness influenced the fathers' emotional response. In researchsurrounding the familial response to illness and hospitalization in patientswith medical and surgical problems, Stember (1977) found that the moresevere the illness, the greater the degree of stress experienced by the familyupon admission of the patient to hospital. Of significance is the finding that103the families perceived the illness to be more severe than either the patientor physician. This suggests not only that it is their perception that is therelevant factor rather than actual severity of illness, but also that inaccurateperception results from inadequate understanding - a consequence of lack ofcommunication with the family.Fathers' past experience with high risk pregnancy or a pregnancy lossalso mediated their response. This is intuitively logical and is supported bytheory related to stress and coping. Lazarus (1984) proposes that anindividual's response to stress and the way he copes is related to how heappraises his relationship to environmental events, and that appraisal isdependent on past experience and memory. Lazarus' theory supports thisstudy's findings that fathers who had experienced past success with a highrisk pregnancy felt a certain amount of confidence about the outcome of thecurrent pregnancy, whereas fathers who had experienced poor outcomes inprevious pregnancies were more apprehensive about the result. This alsosupports the finding that fathers who perceived there to be more at stakedisplayed greater distress than the other fathers.Geographical CircumstanceSnyder (1984) identified antenatal hospitalization in a distant perinatalcentre as an additional stress factor for women. There is little mention inthe literature, however, of the impact of geographical separation on thefather. It was clear from the two fathers in this study who lived far from thehospital that geography had a significant impact on their ability to carry outtheir defined roles. Compared with fathers who resided near the hospital,104fathers separated by a substantial distance were less able to find acompromise between the two roles. For various reasons, both of thesefathers were only able to focus on one role, and direct less attention to theother. This author has, however, observed fathers who found a middleground even when geography was a factor. One father spent one week athome working and keeping the home together, and the next week in thehospital with his partner. He was able to sustain this activity for almost amonth. Though he acknowledged feeling exhausted, he felt that he wouldnot have done it any other way.Personal Impact of the ExperienceEmotions Surroundin. the High Risk PregnancyResearch in normal pregnancy has determined that the safety of thewoman and fetus is a major concern for the father (Antle, 1975, Colman &Colman, 1971; Gerzi & Berman, 1981). Glazer (1989) found that thestressors most frequently identified by men were "if your baby will behealthy and normal" (95%), "your partner's pain in childbirth" (95%), "yourbaby's condition at birth (94 %), and "any unexpected things that mighthappen during childbirth" (90%). May and Perrin (1985), in their review ofthe father in pregnancy and birth, listed the common concerns of fathers:financial pressures, fears about labour and birth, fears about their own role inbirth, fear for the safety of their partner and baby, anxiety about their abilityto succeed in the father role, and worry about the effect of the child on theirmarital relationship.The above research supports this study's findings that fathers105experienced a tremendous amount of fear for the wellbeing of the fetus. Itcould be expected that fathers facing the additional problems and risks of ahigh risk pregnancy would focus even greater emotional energy on thisparticular fear than fathers in normal pregnancy.The fathers in this study described a fear that their child wouldsurvive, but with a handicap. For most of the fathers this was the greatestfear. Gerzi (1981) found that normal pregnancy induced in some fathers thefear of a "defective child". Penticuff (1982) acknowledged this fear as apossible inhibiting factor for normal psychological adaptation to the highrisk pregnancy for both men and women but does not reference any specificresearch to support this statement.Fathers in this study also described a fear for their partners' health,and even life; this supports previous research (May & Perrin, 1985). Theimplications of illness derived from the high risk pregnancy status, and theneed for their partners' hospitalization could only contribute to their fear.Almost all of the fathers would have spent some time in the high risk labourand delivery unit. The environment of high risk, high technology,pregnancy care involving intravenous lines, medications, tests, beepingmonitors, ever present vigilant nurses and multiple physicians conductingmurmured consultations in the corner of the room no doubt contributed tothe frightened father's confusion regarding whose life is actually at risk - themother's or the fetus's.The research in normal pregnancy suggests that fathers have concernsabout the effect of the pregnancy and child on their marital relationship106(May & Perrin, 1985). Penticuff (1982) and Gyves (1985) both noted thatthe emotional upheaval that a couple faces when the pregnancy is high riskmay place considerable strain on their relationship. In this study, the focuswas more on the impact of the potential loss of the baby or of the birth of ahandicapped baby on the couple's relationship. The fathers were aware thateither scenario had the potential to bring the couple closer together, butthat there was also risk to the stability of the relationship associated withthe stress of a negative outcome.Fathers also expressed concern about their ability to meet theirpartners' and others' expectations regarding their support role. Thisperformance anxiety suggested an underlying discomfort related to the"ideal father" role promoted by current societal beliefs and values. There ismuch evidence in the literature to suggest that fathers display differentinvolvement styles ranging from fathers who are comfortable with simplyobserving, to those that prefer to manage, and those who have intenseemotional involvement (May 1980). May (1982b) concluded that currentexpectations regarding the ideal level of father involvement may lead to thelesser involved father feeling a certain amount of guilt and anxiety becausehe is not living up to his role. Similarily, the highly involved father mayencounter disappointment when his experience falls short of hisexpectations.In addition, fathers who are wishing to become more involved mayencounter the "quandary" described by the father in the study who believedthat while society claims it wants the father to be involved, we have not yet107constructed our practice to facilitate full participation. The literature is richwith evidence to support this father's finding (Jordan, 1990; Hangsleben,1980; May & Perrin, 1985).Concerns that are described in the literature as common for fathers innormal pregnancy, but were mentioned less frequently by the fathers in thisstudy, are worry regarding their partners' pain in childbirth and concernregarding their own role in labour and delivery (Glazer, 1989; May & Perrin,1985). The decreased prominence of these particular worries might beexplained by an adjustment in the emphasis of concern so that the processof labour and delivery took on relatively less meaning to fathers who werenot even certain of the health of their baby. It would seem reasonable that aprocess of priorization may take place allowing a father to focus on only somany anxieties at one timeThe emotional distress due to feelings of uncertainty expressed by thefathers in this study are supported by other authors. In research onwomen's feelings in response to high risk pregnancy, uncertainty isidentified as a potential source of anxiety (Clauson, 1992; Kirk, 1989;Riddell, 1992; Snyder, 1984; Waldron & Asayama, 1985). Penticuff (1982)hypothesized that the impact of ongoing uncertainty in high risk pregnancyis also highly stressful for the father, though there is no other empirical datato support this.Studies related to women's experience identify helplessness as asignificant emotion (Carty et al., 1992; Loos & Julius, 1989; Waldron &Asayama, 1985). In Penticuffs narrative paper (1982) learned helplessness108theory was applied to couples experiencing high risk pregnancy. It washypothesized that the diagnosis of high risk pregnancy creates anunpredictable and uncontrollable situation that prompts behaviours intendedto reduce the risks. However, when the behaviours fail to alter the riskstatus, a sense of helplessness may develop. It is notable that though therewas evidence of feelings of helplessness in their discussions, this emotionwas not openly acknowledged by most of the fathers in this study.It is possible that fathers were reluctant to reveal feelings ofhelplessness since it is an emotion associated with loss of control. Evidenceof loss of control was mostly identified in discussion related to other facetsof their experience rather than when discussing their emotional response.In fact, fathers were able to articulate reasons why they did not even feel asif they should be in control in the first place. Research on fathers'participation in labour and birth suggest that the need for control is relevantto most men but to different degrees (Chapman, 1991). Leonard (1977)noted that fathers felt helpless during their partners' labour. It washypothesized that the fathers' passive roles of supporter and protector inlabour are contrary to the predominant masculine image of the maledominating and taking control of the situation.The father's role antenatally in high risk pregnancy is mostly, but notexclusively, a passive one. It is possible that the fathers' reluctance to admitthey felt a loss of control - despite this emotion being apparent in theirdescriptions - is a result of societal conditioning which implies that it is notan acceptable masculine emotion.109Emotions Surrounding the HospitalizationThe fathers in this study described feelings of loneliness, loss ofintimacy, feelings of security, feeling like an outsider, and feelings ofbelongingness related to their partner's hospitalization. With one exception(Gyves, 1985), a thorough review of the literature failed to find anydiscussion regarding the father's feelings related to antenatal hospitalizationfrom his perspective. The literature available for review was limited toresearch on women's experience of antenatal hospitalization, the father'sexperience in normal pregnancy, and the medical - surgical literature. Thefindings in this study may therefore be considered of particular interest tothe development of our understanding of the father's experience.Loneliness is a feeling well documented in the literature on high riskwomen who are hospitalized (Carty et al., 1992; Loos & Julius, 1989; Taylor,1985). However, feelings of loneliness for fathers has not been previouslydescribed in the literature, except as it related to loss of intimacy. Therehas been some work in the area of men's sexuality during pregnancy (May,1987), suggesting that most men experience some period of disruption oftheir sexual relationship with their partner, and that most are able to adaptwithout much difficulty. The fathers in this study have, however,experienced virtually a complete loss of all forms of intimacy with theirpartner. Fathers readily volunteered feelings related to loss of intimacy, butdid not discuss feelings specific to their sexual relationship with theirpartner.A feeling of security was a predominant emotion related to110hospitalization. There is some evidence in the literature to support thisfinding in relation to the woman's experience. Women identified thesecurity the hospital provided as the most positive aspect of theirhospitalization (Carty et al., 1992). Merkatz (cited in Gyves,1985), foundthat a woman who has experienced a previous pregnancy loss may berelieved to be in the hospital. The attentiveness of hospital staff and theavailable technology can be very reassuring to the woman and her partnerexperiencing a high risk pregnancy. What has not been reported previouslyin the literature is the particular security felt by the fathers knowing thattheir partners were not only in the hospital, but in "the best place" -referring to the tertiary level care provided by the hospital where theirpartners were admitted.Feeling like an outsider is a concept that has previously beenaddressed in the narrative literature by Gyves (1985). Gyves suggested that"whereas the husband was at one time an integral part of the pregnancyexperience, he abruptly finds himself to be an outsider, physically separatedfrom his wife for all but a few hours of visiting each day" (p. 77). Thisfeeling has also been described in the literature addressing the father's rolein labour and birth. Hangsleben (1980) stated that fathers may feel likevisitors in a foreign environment when they accompany their partners to thehospital. This feeling is related to the fact that all of the attention in thehospital is focused on the mother and baby.Hangsleben (1980) and others (May & Perrin, 1985) suggested thathospitals should make every effort to include the father as an essential111member of the family, not simply as a visitor. One father suggested that theideal situation would be a hotel-like setting with health care supervision.This father was not only describing his feelings related to being an outsiderin the system, but also the resulting feelings of helplessness and loss ofcontrol. His suggestion has been considered by others. Rosen (1975) andMerkatz (1978), both advocated the creation of policies and facilities in thehospital to accommodate the partner and/or other family members on theantenatal unit. This practice is well supported in other "family centered"care facilities such as pediatric care by parent units (Stember, 1977).Bothamley (1990), noted that fathers may feel inhibited in the foreignenvironment of the hospital to the degree that they do not even feelcomfortable moving a chair without permission. This feeling was welldescribed by the fathers in the study. For instance, because of the physicallayout of the ward, performing a simple task such as obtaining ice water fortheir partners required asking a nurse to help them.Nevertheless, many of the fathers were able to identify several positivefeelings related to comfort and belonging. The most important determinantof feeling either like an outsider, or of feeling as if they belonged, was thefathers' perceptions of health care providers' attitudes towards theirpresence. When fathers perceived they were treated with respect, andwere made to feel welcome by staff, they felt as if they belonged - at least toa certain extent. Stember (1977) provided evidence to support theimportance of including families in hospital care in order to increase theirsense of belonging.112Physical ImpactThe physical consequences of pregnancy for the father have beenexplored in the literature as they relate to symptoms of couvade syndrome.Fathers experiencing normal pregnancy have been found to have a higherincidence of a variety of somatic symptoms including indigestion, gastritis,food cravings, nausea and vomiting, increased or decreased appetite, weightgain, diarrhea, constipation, colds, insomnia, headache, toothache,nosebleed, puritis, muscle tremors, rashes, styes, or non-specific aches andpains (Clinton, 1987; Klein, 1991). The fathers in this study described achange in diet resulting from a disturbance in normal routine and leading toa general decline in the quality of their nutritional intake. They did notindicate whether they experienced a weight change as a result of theiralteration in diet. Consistent with previous work is their report of reducedsleep. Only one father reported specific symptoms of illness which waslingering cold symptoms.Clinton (1986) examined the risk factors associated with couvadesymptoms and found that, among others, general stress was a risk factor forcouvade symptoms. Others have also found an association between stressand anxiety and couvade syndrome (Strickland, 1986; Trethowan, 1968).More specifically, anxiety created by concern over his wife's pregnancy hasbeen identified as a risk factor (Trethowan, 1972). This would appear to bea logical relationship and invites the hypothesis that men whose partnersare experiencing a high risk pregnancy would be at greater risk of couvadesymptoms. Surprisingly, however, Lipkin and Lamb (1982) failed to find anassociation between couvade syndrome and pregnancy complications113experienced by the mother. While the numbers in this study are too few todraw any specific conclusions about this relationship, it is evident that manyof the fathers experienced a recognized alteration in their physicalwellbeing as a result of their experience. Further exploration of therelationship between high risk pregnancy and couvade symptoms appears tobe indicated.Coping StrategiesGiven the dearth of research in general on fathers' experience of highrisk pregnancy, it is not surprising that there is limited reference in theliterature to specific coping strategies used by fathers. Again, discussionwill rely on the literature available in related subjects.The fathers' reliance on maintaining a positive attitude, taking one dayat a time, having faith, and seeking knowledge correspond with discussionsin the literature about learned helplessness (Penticuff, 1982). Penticuff(1982) suggested that the high risk couple must implement suitable copingstrategies in order to avoid the detrimental effects of learned helplessnessincluding an overwhelming sense of vulnerability, passivity, fatalism, anddepression.The strategy of denial was alluded to by some fathers when theydescribed their attempts to maintain a positive attitude. Denial, while oftendefined as maladaptive, may allow a person to maintain hope in the light ofoverwhelming odds (Wong, 1986). In high risk pregnancy, denial may be aneffective coping strategy to relieve stress on the family (Jones, 1986).114"Holding back" was a form of denial described by one father. He used thisstrategy to protect himself from another potential loss. By not allowinghimself to become fully involved, he hoped to limit the emotional trauma ifthe outcome was poor.Seeking knowledge has been generally accepted as an importantcoping strategy for anyone experiencing the unknown. The need for highrisk mothers to be fully informed has been well documented (Carty et al.,1992; Loos & Julius, 1988; Merkatz, 1978; Snyder, 1984), and theinformational needs of expectant fathers in normal pregnancy have beenreviewed (Hangsleben, 1980; May & Perrin, 1985; Taubenheim &Silbernagel, 1988). Empirical evidence is limited regarding the informationseeking behaviours of fathers in high risk pregnancy. Penticuff (1982)postulated that actively dealing with the possibilities of high risk pregnancyrequires the couple to obtain information related to the well being of thefetus, to the result of tests, and to medical management. This knowledge iscritical to a father's ability to understand and participate in any decisionsand thereby maintain some sense of control and prevent helplessness.Waldron and Asayama (1985) concluded that information provided to themother and family may enhance their sense of mastery.SummaryIn this chapter, the findings of the study are compared with theavailable literature. For the most part, little research has been previouslyconducted in the specific area of fathers' experience with high risk115pregnancy and hospitalization. For this reason, much of the discussionreferred to related subject areas. Certain components of the study'sconceptualization were validated; others were found to be contrary toprevious findings or hypotheses. Overall, however, there was evidence in theliterature to support the findings in this study.116CHAPTER FIVESUMMARY, CONCLUSIONS, AND NURSING IMPLICATIONSSummaryDespite increasing interest in the role of the father in pregnancy,birth, and parenthood, little attention has been given to the particularexperience of expectant fathers coping with a high risk pregnancy and thehospitalization of their partner. This study was undertaken to furtherunderstanding regarding the experience of the expectant father from hisown unique perspective. Using the grounded theory method, fathers'experience of the phenomenon of high risk pregnancy and antenatalhospitalization was explored, resulting in a descriptive analysis thatconveyed a common conceptualization of the experience.Participants were selected from the tertiary care facility serving theprovince of British Columbia. Nine fathers participated in the studycontributing a total of 16 interviews. The fathers' ages ranged from 29 to 40years. At the time of the first interview, pregnancy gestation ranged from24 weeks to 35 weeks. Pregnancy complications varied in nature reflectiveof a high risk population.Transcripts were analyzed using the coding procedure described byStrauss and Corbin (1991). The outcome of the analysis was an explanatorytheory that describes the experience of high risk pregnancy andhospitalization from the perspective of the expectant father. Central to thefathers' descriptions were the roles they assumed in relation to their117participation in this phenomenon. The two predominant roles wereproviding emotional caregiving to their partner and sustaining the family'sfunctional responsibilities. The primary theme that evolved through analysiswas a process of finding a balance between these two roles.The relative emphasis placed on each role varied from father to father,and with the same father, from time to time. These variations weredependent on the influence of specific balancing factors as well as theinherent importance placed on the roles themselves. Specific strategiescontributed to the fathers' ability to cope with the experience. Theconsequences of the phenomenon had a significant personal impact on thefathers' emotional and physical wellbeing.For the most part, the balance that each father achieved was acompromise between the two roles. Most of the fathers were relativelycontent with the position they found for themselves. Some, however,expressed significant dissatisfaction with their position but were unable inthe present circumstances to influence a change.The findings indicate that the father's experience was substantive innature. The substantive nature of the experience is emphasized by therange and intensity of the emotional and physical impact described by thefathers. These fathers were not simply experiencing the phenomenon as"interested bystanders". They were intimately involved in the process andconsidered themselves to be legitimate participants, despite theirperception that others did not necessarily support this belief.118ConclusionsThis study characterizes fathers' participation in the phenomenon ofhigh risk pregnancy and hospitalization as a substantive experience. Centralto the expectant father's experience were two roles: emotional caregiverand family sustainer. The predominant theme that evolved through analysiswas a process of finding a balance between these two roles. Severalbalancing factors contributed to the relative emphasis placed on each of theroles. A number of conclusions can be made based on thisconceptualization.1. The experience for fathers is substantive in nature. This describesa personal participation in the phenomenon that has particular meaning andsignificance separate from the experience of his partner. Thisconceptualization lends support to the belief that fathers deserve care andattention from health care providers and others not just as appendages totheir partner, but as individuals with equal validity.2. Fathers are profoundly affected emotionally by the experience. Thepredominant feelings are related to either emotions surrounding the highrisk pregnancy, or those emotions related to the actual hospitalization oftheir partner.Emotions related to the high risk pregnancy include fear/anxietyregarding the wellbeing of the baby and their partner, the potential impactof the experience on their couple relationship, and their performance as asupportive partner. Emotions related to hospitalization include feelings ofloneliness and loss of intimacy, security, feeling like an outsider, and a sense119of belonging.3. Fathers are affected physically by the experience. There exists apotential for negative impact on their health, including diet, sleep, andexercise/leisure activities.4. The role of emotional caregiver is one of the fathers' fundamentalroles. The role of emotional caregiver comprises the following behaviors:maintaining a physical presence, providing comfort and compassion, actingas a psychological coach, being an advocacte, and providing protection.Fathers believe that while they are deserving of emotional support, theirpartners' needs are greater than their own.5. The second fundamental role is the role of family sustainer. Rolebehaviours include maintaining work, providing childcare, and taking ondomestic responsibilities. These activities are directed towards the realityof sustaining the life of the couple in the real world.6. Coping strategies influence fathers ability to carry out the roles.They also exert an influence on the emotional and physical components ofthe experience. Four specific coping strategies are identified. They includemaintaining a positive attitude, taking one day at a time, having faith in ahigher being, and seeking knowledge. Through the effective enactment ofthese coping strategies fathers are able to successfully negotiate their ownparticipation in the experience.7. The support system available to the father serves as a balancingfactor. Fathers vary in their assessment both of their need for support andthe extent to which they receive it. The primary support for fathers is their120partner - a person with whom they are frequently unable to openly sharetheir fears and emotions due to feelings of protectiveness. Family is aprimary source of practical support, and friends are only infrequentlyidentified as sources of support. Health care professionals are the providersof informational support. While some fathers do not perceive a greater needfor support, others acknowledge an acute awareness of lack of support and adesire for better recognition of their needs from others.8. Certain high risk condition factors may also influence the balance ofthe roles. These include whether the risk associated with the high riskpregnancy and hospitalization were anticipated or unanticipated, thefather's perceived severity of risk, and any prior experience related to highrisk pregnancy.9. The distance a father lives from the hospital where his partner ishospitalized may have a profound influence on the father's balance of roles.These fathers are often forced to make a choice between the two roles, andthis may result in neglect of one of the roles.10. Fathers go through a process of balancing the two predominantroles. The resulting role balance is not static, and may be influenced bychanging conditions in either of the two roles or the balancing factors.11. The father's experience deserves considerably more attentionthan it has thus far received from health care providers. In fact, the findingsof this study support the contention that the father's experience is asdeserving of attention as his partner's. A father who is supported throughhis own experience may be better able to enact both the role of emotional121supporter and family sustainer. The more able he is to carry out these tworoles effectively, the healthier the overall family functioning will be,resulting in an improved experience for both the high risk mother andfather.Nursing ImplicationsLittle is known about the experience of high risk pregnancy andhospitalization from the perspective of the expectant father. This studyprovides evidence that the father's experience is highly personal andsignificant in his own right, and is not simply an adjunct to the experienceof his partner. As a result, there are a number of implications for nursingpractice, education, and research that will promote greater understandingof these men's unique needs.Implications for Nursing PracticeHealth care providers in general, and nurses in particular, must finallycease giving lip service to "family centered care" and develop patterns ofpractice that support the intent of this concept. While this can be said ofobstetrical care in general, the importance of adopting a truly "familycentered" approach for families experiencing high risk pregnancy andhospitalization is evidenced by this study.Our understanding of the needs and concerns of high risk women, andways to provide sensitive, effective hospital care is developing. The time hascome to direct our attention towards the needs and concerns of theexpectant father. Fathers have remained the "outsider" far too long. It is122recognized that every father will respond to the pregnancy and subsequenthigh risk events in his own way, reflecting individual patterns ofcommunication, coping, and involvement. However, nurses must beprepared to provide an environment of caring that recognizes the father'sexperience as having significant individual meaning that is interdependentyet separate from that of his partner's.Specific attention should be directed towards encouraging fathers toverbalize their own emotional responses. By providing recognition that hisfears, anxieties and concerns are not only legitimate, but deserving ofattention, the nurse can validate the significance of his emotionalexperience. This can be done at the bedside with the couple, however,consideration should be given for providing the opportunity for a privatediscussion with the father separate from his partner. This may beworthwhile given the desire most fathers had to limit sharing of their ownfears in order to protect their partner. The nurse can then facilitatediscussion between the couple, encouraging when appropriate, the mutualsharing of emotions.Discussion should include feelings that fathers might potentially beexperiencing. Presenting common feelings to the father gives permissionfor these emotions to be expressed and normalizes their nature. Suchintroductory statements as "It's not uncommon for fathers to fear that theirpartner's life is in danger because of the high risk pregnancy. Have you hadany similar worries?" opens the discussion to an emotion that the fathermight otherwise have felt uncomfortable verbalizing. Similarly,123acknowledging the potential feelings of fear for the life of the baby, fear of ahandicapped child, uncertainty, helplessness, loss of control, and loneliness,offers the opportunity for discussion of these and other emotions.Based on the study finding that the experience had wide rangingimpact on the fathers' physical well-being - yet this information was rarelymentioned by fathers voluntarily - the nurse should explore the ways inwhich the experience is impacting the father physically. Fathers should beinformed that their own health may be affected by the pregnancy, that this isa common occurrence not reflecting any inherent weakness on their part,and that as caregivers we are genuinely concerned about their symptoms.Specific questions should be asked about their own health history both onadmission, and on an ongoing basis. Questions about diet, rest, exercise,and specific physical complaints, particularly those symptoms identifiedwith couvade syndrome, will identify areas requiring support andintervention. By providing an opportunity to discuss the father's symptoms,information may be obtained that reveals the possible underlying meaning ofthe symptoms as they relate to his overall pregnancy experience. Theseissues may then be explored in greater depth.Few of the fathers in this study had been able to reserve any privateleisure time to pursue exercise or hobbies. Encouraging the father to allowhimself even a small amount of time each day to himself may promote hisown physical and mental health and increase his ability to cope effectivelywith the experience.It is important to recognize that fathers often feel like "outsiders" inthe hospital environment, and there are measures nurses can take to124alleviate this feeling. In the study, one father suggested that a heightenedawareness regarding this feeling was necessary. He explained that no oneintentionally tried to make him feel uncomfortable, but that there weresome simple things that the nurses could have done to promote his sense ofbelonging. "By not taking any action they make the person feeluncomfortable, so they actually have to be proactive to make them feelcomfortable".Simple routines that are easy to implement may go a long way towardsalleviating the "outsider" feeling. Taking the time to specifically welcomethe father to the unit, and giving him a tour of the surrounding environmentwill help him feel more comfortable. Showing him where the linen cart islocated, how to obtain ice water, what to find in the unit kitchen, and howto access wheelchairs will increase his sense of usefulness. A unit specificpamphlet with information regarding hospital routines and resources can bedirected towards both the woman and her partner's needs.It is critical that the concept of the father as a "visitor" be eliminatedentirely from antepartum family centered care. Recognizing the father as anessential team member, not just a visitor who makes unnecessary demandson the system, requires nurses to truly embrace family-centered carephilosophy. Several authors have suggested the development of antepartumfamily care facilities that resemble housekeeping units or hostel facilities(Merkatz, 1978; Rosen, 1975). Such adaptations to the environment canshift the source of power away from the health care providers to the family.In the study one father suggested that this would eliminate his sense of125"interfering" because the family would then be allowing the health careproviders into their environment - 'We'd be working together, and at thispoint we're not really working together".Fathers' access to their partners should not be restricted in any way.Visiting hours should not apply to fathers as they are not visitors. Fatherswho wish to remain with their partner for extended periods should beencouraged, as should overnight stays. The importance of promoting accessfor the father is emphasized by the relatively high value fathers in the studyplaced on their ability to maintain a physical presence. Obvious limitationsexist, however, when a woman is confined to a multi-bed room. Attemptsshould be made to accommodate fathers who wish to stay overnight withtheir partner. If private rooms are not available for this purpose, then oneoption is to set aside a room on the unit as a family overnight room thatcouples can rotate into as the need arises.Assistance can be given to fathers in their role as emotional caregiver.Besides unrestricted physical access to their partner, couples should haveaccess to a telephone 24 hours a day, preferably at the bedside. Fathersattempts to provide comfort and compassion can be facilitated by nurses.Understanding their need to act as an advocate, protector, and psychologicalcoach will allow nurses to recognize such behaviors and facilitate them.An assessment should be made of the father's role as family sustainer.Exploring with both the father and his partner the work, childcare, anddomestic responsibilities that he must maintain, and encouraging discussionregarding these obligations will allow the father an opportunity to verbalize126his feelings regarding these activities. Discussion will also promote problemsolving in areas that are of concern.The nurse can assist the father to identify the strategies he is using tocope with his experience. Allowing discussion to focus on how he is coping,rather than on how is partner is coping, validates his experience andprovides opportunity for exploring the effectiveness of his coping skills.A coping strategy that is particularly amenable to nursing interventionis the seeking of knowledge. It was noteworthy that most of the fathersobtained information regarding the condition of their partner and thepregnancy second hand via their partner. Nurses can facilitate first handinformation in several ways. It was revealing that few of the fathersdescribed nurses as sources of information. This is unfortunate since thereis an obvious role for nurses to provide information to fathers. This isparticularly true since nurses are always available at the bedside, even in theevening hours when a working father may be present. Nurses can alsopromote physician - father interaction by facilitating opportunities fordiscussion. For example, the nurse can arrange specific consultation timeswhen the father will be available, or encourage the father to phone thephysician for first hand information and discussion.Other sources of information include prenatal classes, and written andaudio-visual teaching materials. Programs may be developed for thehospitalized woman without specific consideration given to the partner'sneeds. Is the father given an opportunity for prenatal classes? Does he haveaccess to the written and audio-visual material available on the unit? Is127there material available that specifically addresses his needs? What may alsobe required is a change in the way the availability of the resources arepresented to him. Fathers should be specifically informed about theeducation opportunities so that he receives the message that health careproviders consider the information to be relevant to him and his needs.Determining with the father who comprises his support system andways in which to access the different forms of support is indicated.Remembering that the hospitalized woman is likely to be the father'sprimary source of emotional support emphasizes the importance offacilitating unrestricted contact between the couple. Furthermore,consideration needs to be given to allowing for some privacy for the couplein order to encourage intimate conversation. Couples may need assistancein successfully addressing the emotional support needs of the father sincethe fathers in this study demonstrated protectiveness by withholding thesharing of their fears with their partners.Nurses need to validate that it is legitimate for the father to requestboth emotional and practical support from family and friends. Fathers mayrequire encouragement to seek or accept support from others. Nurses canassist by helping fathers identify tasks that could be reasonably delegated toothers.Opportunities for appraisal support could be facilitated by nurses. Ahigh risk father's support group could provide fathers with support fromother men sharing a similar experience. Since this type of support hasproven successful in other areas (Taubenheim, 1988), this strategy might be128effective. Other ways to increase opportunities for appraisal support includehaving a family lounge available on the unit that promotes informalinteraction not only between patients, but fathers as well, and thedevelopment of a video directed towards fathers that explores, in a supportgroup format, the experiences of other men.Nurses need to be aware that high risk condition factors such asanticipated versus unanticipated risk, perceived severity of risk, and priorhigh risk experience will influence a fathers experience. These factorsshould be taken into account when assessing the father's response andplanning care to meet his needs.Similarly, the geographic location of the couples residence relative tothe antenatal unit is a factor relevant to understanding the specific demandsplaced on the father. These fathers require particular attention since theyare inevitably required to compromise either the emotional support role orthe family sustainer role. Assessment of the father's unique circumstancesand a review of the possible options available to the couple will providesupport with complex decisions. Certainly the availability of accommodationfor fathers either on the unit with their partner or in nearby facilities isessential. Consideration must be given to providing the father with as muchinformation as possible on an ongoing basis regarding the condition of hispartner. When possible, advance notice of plans for delivery should be givento the couple so that the father can be with his partner at this critical timeCurrent administrative leadership requires revision in order to supportthe above changes in practice. Without explicit support from129administration, the current clinical "inertia" hindering full implementationof a family-centered care practice will remain unobtainable. The obstetricdepartment must have a written philosophy that is explicit in describingbeliefs and values which recognize the role of the father during thechildbearing period, his rights to participation in the process, andobligations the hospital and its' caregivers have to provide optimal care tothe father as well as the mother and fetus/newborn.Written policies must be developed where indicated to implement theabove philosophy. For example, policies need to reflect support of thefather's access to his partner 24 hours a day, particularly in relation toovernight stays. Policies regarding his presence at other times, such asduring procedures must also be made explicit. Admission policy andprocedure routines should be developed that reflect the inclusion of thefather in the process. By including in the admission policy the expectationthat fathers are given a full orientation to the unit, staff will be directed toinclude this practice in their everyday care. Communication regardingadministrative policy supporting the role of the father must be carried outduring orientation of new staff, staff inservices, and reinforced on a dailybasis in the clinical setting.Care planning and documentation tools should reflect the recognizedrole of the father. Admission assessment forms, teaching records, standardand individualized care plans, and nursing kardexes could all appropriatelyinclude father focused assessment, planning, and care.In order to obtain evaluative information, hospital quality improvement130programs should reflect the philosophy as well. Chart audits could includereviews on father related assessment and interventions, and patientsatisfaction questionaires could include a section for the father to completeto provide an opportunity for feedback related to his experience.Finally, the implications for changes in practice derived from thefindings of this study should not be limited to the high risk population. Thedemonstrated need for greater awareness and sensitivity in our provision ofcare to the father of a high risk pregnancy must also be applied to themajority of fathers who are participating in a low risk pregnancy and birth.Implications for Nursing EducationThe findings of this study provide initial information that increases theunderstanding of the father's experience. It offers direction to nursingstudents in providing care to families that incorporates the father'sexperience as an essential and relevant aspect of care.In most programs, maternal-child nursing curricula already promotethe philosophy of family centered care for the childbearing family. Generalconcepts appropriate for the family experiencing a normal pregnancy maybe applied to high risk families. However, the specific considerations offathers experiencing high risk pregnancy and hospitalization deserveincreased attention. Other than providing introductory content, this topicmay be beyond the basic level relevant for nursing students in generalprograms. It is, however, appropriate and essential that it be covered inadvanced maternal-child nursing programs. It is desirable that equal time isgiven in education programs to the experiences of fathers in their own131right, and not just as "interested bystanders" or supports to their partners.Educators must also examine why the health care system hasresponded so slowly to the required changes necessary to implement carefor the childbearing family that recognizes the role of the father. Fathersparticipating in a normal pregnancy and childbirth experience have yet to befully embraced by a system that is responsive to his needs. Until thisoccurs, fathers experiencing high risk pregnancy and antenatalhospitalization are unlikely to advance in the quality of care they receive.Both nursing program curricula and inservice education programs need toaddress the sociological and political factors that hinder implementation ofchanges in practice so that graduating and practicing nurses are betterprepared to act as change agents with in the system.Implications for Nursing ResearchThe study question: "What is the experience of an expectant fatherwhen his partner is hospitalized with a high risk pregnancy" wasapproached using grounded theory methodology. The resulting conceptualframework provides a basis for further research. A number of areas ofinvestigation arise from this study that are worthy of exploration:1. Further qualitative and quantitative research is required todetermine whether the sample population in this study is representative ofthe population of expectant fathers experiencing high risk pregnancy andantenatal hospitalization.2. The fathers in this study were primarily of Canadian cultural origin.Assumptions about the influence of culture on fathers' experience can not bemade on the basis of this study. Further exploration of the experience as132described by fathers of other cultures is very important.3. Research has now been conducted exploring individually, theexpectant woman's and the expectant man's experience of high riskpregnancy and hospitalization. Since there is some evidence that coupleinterviews may provide richer data than individual interviews (Chapman,1992), it would be valuable to obtain the combined perspective of the couplethrough joint interviews.4. This study demonstrated that nurses have potential to be importantcontributors to the type of experience the father undergoes. Research intonurses' perceptions of the role of the father in high risk pregnancy andhospitalization would provide valuable insight into the caregivers' values andbeliefs and how these influence nursing care.5. Further research is needed on the influence of the various balancingfactors on the father's experience.6. Greater exploration of the differences in experience betweenfathers with and without young children at home is necessary.7. All of the fathers in this study appeared to have been able to adaptto the role strain they experienced. A larger study that was able to includefathers who were having problems adapting or whose family response wasconsidered dysfunctional in some way would provide greater understandingof ineffective or maladaptive behaviors.8. The development of a family centered antepartum unit withadministrative, clinical, and practical support for care that recognized therole of the father is recommended. This would give opportunity for a pre133and post implementation study that could examine the impact of this modelof care.9. All of the fathers in this study experienced a pregnancy thatconcluded in a healthy outcome. A study that included fathers whoexperienced a negative outcome such as significant neonatal morbidity ormortality would identify the ways in which the experience is different forthis group.10. With larger numbers, a qualitative study could explore how thethree different types of father participation (as identified by May, 1980),might influence fathers' experience of high risk pregnancy - with andwithout hospitalization as an additional factor.11. A study exploring the implications of high risk pregnancy on thedevelopmental tasks of expectant fathers would provide comparative datawith fathers experiencing a normal pregnancy.12. Further research is needed to explore the relationship betweenhigh risk pregnancy and the incidence of couvade syndrome.In summary, this thesis has described the experience of expectantfathers when their partner is hospitalized with a high risk 'pregnancy. Thefindings indicate that the father's experience is substantive in nature andinvolves finding a balance between two predominant roles - emotionalcaregiver and family sustainer. A number of factors serve to influence thebalance, including the support system available to the father, high riskcondition factors, and geographical circumstance. Specific strategiescontribute to the father's ability to cope with the experience including134maintaining a positive attitude, taking one day at a time, having faith in ahigher being, and seeking knowledge. 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Social Work in Health Care, 10 (3),75-89.Wandersman, L., Wandersman, A., & Kahn, S. (1980). Social support in thetransition to parenthood. Journal of community psychology, 8, 332-342.Wapner, J. (1976). The attitudes, feelings, and behaviors of expectantfathers attending Lamaze classes. Birth, 3 (1), 5-13.Weaver, R., & Cranley, M. (1983). An exploration of paternal-fetalattachment behavior. Nursing Research, 32 (2), 68-72.Williams, F. (1974). The crisis of hospitalization. Nursing Clinics of North America, 9 (1), 37-45.White, M., & Ritchie, J. (1984). Psychological stressors in antepartumhospitalization: Reports from pregnant women. Maternal-Child Nursing Journal, 13 (1), 47-56.Wong, D. (1986). The potentially terminally ill child. In S. Johnson (Ed.),Nursing Assessment and strategies for the family at risk (pp. 214-239). New York: Lippincott.Appendix A142143THE EXPECTANT FATHER'S EXPERIENCE OF HIGH RISK PREGNANCYAND ANTENATAL HOSPITALIZATIONJune 1992My name is Meggie Ross. I am a registered nurse with over ten yearsexperience in caring for women and families during pregnancy, labor andbirth, and after delivery. I am completing my Master of Science in Nursingat the University of British Columbia. I am interested in learning more aboutthe experience of men whose wife/partner has been hospitalized because ofa high risk pregnancy. This study is being done because we have littleinformation about how a woman's high risk pregnancy and hospitalizationaffect the expectant father. It is hoped that the information that is gainedfrom this study will help us find ways to be of more assistance to expectantfathers such as yourself.You are invited to participate in this study. Should you agree, yourparticipation will involve one or two interviews. The first interview will takeplace, with your permission, at Grace Hospital. The second interview willbe arranged at your convenience, either at Grace Hospital or in your home.Interviews will be thirty minutes to one hour in length. In order for me toconcentrate on our discussion, I would like to tape record the interview. Ifat any time you wish a part of the interview erased; it will be erasedimmediately. Confidentiality will be maintained throughout the study by theuse of subject code numbers and the tape recordings will be erased at the144end of the study. At no time during the study or in any report willpersonally identifying information be revealed. Results of this study will beavailable to interested participants on completion of the report.Participating in this study will not involve any risks to you or yourpartner. Your participation in this study is voluntary and you are free towithdraw at any time without jeopardy to the conduct of you or yourpartner's care by health professionals. The interviews should provide youwith an opportunity to express your thoughts and experiences to aninterested and concerned nurse.If you are interested in learning more about this study please completethe attached form and leave it at the Dogwood nursing station, GraceHospital, or call Dogwood Square 875-2424 local 6296 and leave a message.I will call you and answer any questions you may have about the study and ifyou wish to participate, I will arrange an interview at your convenience.Sincerely,Meggie Ross, R.N., B.S.N.Thesis supervisor: Elaine Carty, U.B.C. School of Nursing, 822-7444145The Expectant Father's Experience of High Risk Pregnancyand Antenatal HospitalizationI am interested in learning more about this research study and may bewilling to participate.My name is :^My partner's name is :^I can be reached at the following phone number/s :^ (home)^ (work)Date:^Appendix B146147Consent FormTHE EXPECTANT FATHER'S EXPERIENCE OF HIGH RISK PREGNANCYAND ANTENATAL HOSPITALIZATIONInvestigator: Meggie Ross, R.N., B.S.N.,U.B.C. Master's of Science in Nursing studentThesis Supervisor: Elaine Carty, U.B.C. School of Nursing, 822-7444000000 0000000000 00 00000000000 000000000000 00 0000000000The purpose of this study is to explore the experience of men whosewife/partner has been hospitalized because of a high risk pregnancy. It ishoped that the information that is gained from this study will help nursingand other health professionals find ways to be of more assistance toexpectant fathers.I understand that the study will involve 1 or 2 audiotape recordedinterviews, each lasting 30 minutes to 1 hour. I am aware that myparticipation in the study is strictly voluntary and I have the right towithdraw at any time without influencing the care my family receives.I agree to participate in this study, and I have received a copy of thisconsent form. I am aware that confidentiality will be maintained throughoutthe study by the use of subject code numbers and the tape recordings will beerased at the end of the study. I have been assured that at no time during148the study or in any report will personally identifying information berevealed.If I have questions about the study or about my participation I cancontact Meggie Ross by leaving a message at the Dogwood nursing station,Grace Hospital (875-2424 local 6296).DATE^ SUBJECT'S SIGNATUREINVESTIGATOR'S SIGNATURE

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