Craving closeness: A grounded theory analysis of women's experiences of mothering in the Special Care Nursery

Article Outline

• Summary
• Introduction
• The study
  • Setting and participants
  • Data collection
  • Data analysis
• Findings
  • Basic social problem: learning to be a ‘nursery’ mother
  • Basic social process: ‘seeking connection’
  • Just existing
  • Striving to be the baby's mother
  • Trying to establish competence
  • Learning and playing the game
  • Consequences: becoming connected and struggling to mother
  • Mediating factors
• Discussion
  • Trying to reclaim their role as mothers
  • Seeking permission to touch
• Implications for practice
  • Understanding and facilitating closeness between mother and infant
  • Nursing the mother–infant dyad
• Conclusion
• Acknowledgments
• References
• Copyright

Summary 

Aim

The aim of the study was to increase knowledge and understanding of how women begin their roles as mothers when their infant is in the neonatal nursery.

Background

Research is limited into how women experience mothering in contexts such as the neonatal nursery. Consequently many nurses and midwives remain inadequately informed of parents’ experiences which we know may have long-term family outcomes.

Method

This paper presents the overarching synthesis of a grounded theory analysis of data collected from 28 Australian women whose infants were in Special Care Nurseries. It draws together a number of previous publications that have described in detail the categories derived from the analysis that explain the actions, interactions and reactions women engage in as they seek to ‘connect’ with their infant. Data collection consisted of two in-depth interviews conducted with women, 333h of taped cot side recordings, field notes and interview data collected from 20 nursery staff, 19 of whom were midwives.

Findings

Six major categories were identified that, when combined, explained the intense emotional, cognitive and worry ‘work’ women undertook with both their infants and the nursery staff in an effort to learn how to mother in the nursery. Four explained how women worked to get to know and connect with their infants. The first three were labelled ‘just existing’, ‘striving to be the baby's mother’ and ‘trying to establish competence’. The fourth, ‘learning and playing the game’, overlays the first three and represents the reality of having to undertake these already difficult and unexpected activities of mothering in the nursery. Two categories ‘becoming connected’ and ‘struggling to mother’ were identified as the consequences of women's actions and interactions. A significant finding of the study was the impact of the interactions between nurses and mothers’ mothering. The nurse–mother relationship had the potential to significantly affect how women perceived their connection to the infant and their confidence in caring for their infant which occurred through a three way interaction.

Conclusions

It becomes clear that the intense work women undertake as mothers in the nursery is focused on not only the infant, which might have been expected, but also the nursery staff. It is driven by their desire to develop or re-establish some sense of competence in the eyes of the nurse and to achieve control over the situation. Achieving physical closeness with the baby was a major strategy through which women not only learned about and gained intimate knowledge of their infant, but also demonstrated authority and ownership. It appears that reorientating the delivery of services from the infant to the mother–infant dyad would improve the care women and families receive during their nursery experience.

Keywords: Mothering, Level II nursery, Neonatal nurseries, Special Care Nursery, Relationships, Mothering role, Maternal identify, Transition to motherhood, Neonatal nursing, Maternal–infant relationship

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Introduction 

Histories of infant care and the evolution of the neonatal nurseries identify the influence of medical advances and the impact of societies changing beliefs and values on infants and children.¹ Today the newborn premature and/or ill infant remains the focus of intense medical and community interest as researchers continue to push the boundaries of viability. In the public arena, neonatal care is portrayed as having achieved some of the century's most profound technical advances. However a noticeable feature of the literature is the invisibility of the mother and the lack of acknowledgment of interdependent relationship she shares with her child.², ³, ⁴

There can be little argument that the theories of maternal–infant attachment and bonding⁵, ⁶, ⁷ have facilitated changes to neonatal practice, and the place mothers are now afforded in the nursery. Research suggests, however, that our understanding of women's experiences of mothering, and their parental needs remains limited.⁸, ⁹, ¹⁰, ¹¹, ¹² Nursing and midwifery research,¹ especially in the neonatal nursery, has continued to draw heavily on the discipline of psychology, constructing birth as a crisis.¹³, ¹⁴ There is a continued strong commitment to the rhetoric of ‘bonding’ which has significantly influenced how women and health professions think about, and subsequently act out their understanding of what constitutes love for a child and the role of a ‘good’ mother.¹⁵, ¹⁶, ¹⁷ As a result many practitioners continue to be concerned with the pathology of poor attachment and the need to maintain infant safety. This has perpetuated a focus on monitoring the performance of the mother in relation to the health outcomes of the infant and in maintaining an infant centred approach to care provision.¹⁸, ¹⁹, ⁴

Contributing to this is that the majority of research carried out on maternal–infant attachment, role transition and identity has been undertaken with white, middle class, American women giving birth to healthy full-term infants. While there are of course exceptions to this (20, 21 and more recently 9, 22) a focus on the way in which a mother is supposed to be, rather than the circumstance in which she has to mother, has provided us with a limited understanding of mothering in diverse contexts.²³ It could be argued that this situation has contributed significantly to the lack of appreciation on the part of some neonatal nurses for just ‘how’ women experience mothering in the nursery. The impact of the nurses role on the development or otherwise of the mother–infant relationship is poorly understood.⁴, ²⁴

The research undertaken sought to address these issues. It provides greater understanding of how women take up their role as mothers within the context of the nursery and how this may change over time. By exploring the roles, relationships, language and practices of mothers in the Special Care Nursery (SCN or Level II) we also hoped to provide some insight into the discrepancy between the philosophy of family centred care²⁵, ²⁶, ⁴ currently espoused in the literature and clinical practice.

This paper presents the substantive theory, and contributes to the body of knowledge on mothering in the nursery, by drawing together the more focussed previously published work, expanding on these to demonstrate the overarching theory. It begins to explain an important distinction between nursing and midwifery and suggests a new way of providing care in this setting that transcends both.

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The study 

Setting and participants 

The research was conducted in the SCN of two Australian Neonatal Care Units. These nurseries were selected because infants are not acutely ill and likely to remain in this environment for some weeks. Special Care Nurseries are considered a place where parents should ‘take up their role’ as parents. In this environment the health worker interactions are prolonged and of a more ‘caretaking’ nature than in a Neonatal Intensive Care Unit that provides critical care for the infant that must be more professionally dependant.

Of the 31 families who consented to the study 28 women participated in a semi-structured qualitative interview while their infants were in hospital. Twenty-three women participated in a second interview conducted 8–12 weeks after the infant was discharged home. The average age of the women was 28.2 years and the average length of an infant's nursery stay was 6.4 weeks. Women were not recruited into the study if they did not speak English or were under 18 years of age. Women whose infants had a nursery stay of less than 7 days were also ineligible to participate.

Data collection 

Four forms of data were collected. These included:

4.Field note documentation: which included descriptive narrative of the nursery context, relevant observations made during the time the first author spent in the nursery collecting interaction data and recruiting families, issues raised during formal interviews and documentation of informal conversations with nurses and women and their families. A summary of the data collected is presented in Table 1 (for a more detailed description of the setting, participants and data collection see references 27 and 28).

Table 1. Summary of data collection

	Nursery one	Nursery two	Total
Months in nursery	3.5 months	4.5 months	8 months
Days in nursery	21 days	37 days	58 days
Hours spent collecting cot side tape recordings	8080min (134h:40min)	11,895min (198h:15min)	19,975min (332h:55min)
Daily cot side taping hours (average)	384min (6h:24min)	321min (5h:21min)	344min (5h:44min)
Number of cot side interactions recorded	102	265	367
Number of infants participating in cot side taping	13	13	26
Number of families recruited	15	16	31
Women's 1st interview	13	15	28 (Average length 45 to 90min)
Women's 2nd interview	5	13	23 (Average 90–120min)
Telephone interviews	5	–
Nurses/midwives interviewed	8	12	20 (Average length 30–90min)
First author field note data/tapes (3h in length)	6 (18h)	4 (12h)	10 (30h)

Applications to Research Ethics committees at both hospitals and the University of Technology, Sydney were made and permission was granted to proceed.

Data analysis 

Grounded theory was deemed the most appropriate methodology to use in this study as it provided a systematic approach to research within an interpretative framework. Using the techniques of constant comparison²⁹ the aim of the analysis was to formulate an understanding of the women's nursery experiences from their own perspective.³⁰ In this study, while we were mindful of the different philosophical underpinning's that have developed since the inception of grounded theory,³¹ we took a contructivist, interpretative approach. The process of analysis closely adhered to the principles, underlying logic and procedures set down by Strauss and Corbin.³² Box 1, Box 2 provide a summary of the process undertaken.

The nurses’ interview data, the cot-side interactions between nurses and parents, and the field note data were used to support and validate the emerging grounded theory of women's experiences of mothering in the nursery. In essence it provided an ‘etic’ or outsiders view of the women's experience.²⁹ Thematic analysis was used to analyse the nurses’ interview data and the field note documentation. Content analysis was used to analyses the interaction data. The results of these analyses are presented elsewhere.²⁷, ³³

The theory developed and the relationship between categories developed through the analysis are explained by using a paradigm model,³² see Fig. 1, and demonstrated diagrammatically in Fig. 2. The basic social process (BSP), identified as ‘seeking connection’ runs through the model and is represented by the wavy line. Each category, other than ‘just existing’, was made up of a number of subcategories. Subcategory labels have been included in Fig. 1. The concepts and themes arising were regularly discussed and debated at research meetings. Comments and questions generated by this process provided further avenues for reflection and exploration during the next data collection period. Diagrams were used to make linkages between different concepts and audit trails (see Table 2, Table 3, Table 4, Table 5, Table 6, Table 7) were used to demonstrate the rationale for decisions around category formation. The women's own words appear in italics within double quotation marks throughout the text.

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• Figure 1. 

  The relationship between the all the categories within the framework of Strauss and Corbin's³² paradigm model.

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• Figure 2. 

  Diagrammatical representation of the grounded theory, “Learning to be a nursery mother”.

Table 2. Audit trail for the category ‘Just existing’

Table 3. Audit trail for the category ‘Striving to be the baby's mother’

Table 4. Audit trail for the category ‘Trying to establish competence’

Table 5. Audit trail for the category ‘Learning and Playing the game’

Table 6. Audit trail for the category ‘Becoming connected’

Table 7. Audit trail for the category ‘Struggling to mother’ [adapted from 26]

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Findings 

Basic social problem: learning to be a ‘nursery’ mother 

In this study ‘Learning to be a nursery mother’ emerged from the analysis as the core category that integrated other categories and described and explained the actions and interactions that women engaged as they take up their role as mothers in the nursery. For the 28 women interviewed in this study, mothering in the nursery required them to ‘work’ at two distinct levels. The first was in relation to their child. The analysis revealed that nursery mothers, who are not dissimilar to women with full-term healthy infants, engaged in an array of activities that were aimed at generating intimate knowledge of their infant. The end result for these women however, unlike other mothers, was that they hoped that this knowledge would assist them establish or arguably re-establish some sense of authority over their child and the situation in which they found themselves.

The second, and perhaps most significant, level of mothering ‘work’ required of these women was because the maternal–infant relationship occurred through a three-way interaction. Being a ‘nursery’ mother was therefore about engaging in considerable thinking and worrying ‘work’ in an effort to learn, negotiate and navigate the nursery staff, rules and routines. It was about “living up” to other people's expectations in an effort to gain access to their own child under difficult and socially and emotionally traumatic circumstances. Learning to be a ‘nursery’ mother thus represents the intense ‘work’ women engaged in as they seek to establish and reclaim their role as the most important person in their child's life.

Basic social process: ‘seeking connection’ 

In this study the BSP that both motivated and guided women through the experience of learning how to be a nursery mother, or alternatively left them floundering, was labelled as ‘seeking connection’. The process was about women's search for confidence, competence and a sense of control within the nursery in regard to their infant. The analysis reveals that when undertaking the activities women deemed essential to the development of the relationship they shared with their child, they were repeatedly confronted with issues of ownership and control. All the women in this study, despite their perceptions of success and subsequent behaviours, wanted to assume some responsibility for their infant, not merely ‘participate’ in the care. In essence, ‘seeking connection’ was about women trying to find a place for themselves in their infant's life, as they ‘worked’ to establish and/or strengthen their tenuous identity as a mother.

Just existing 

“I wasn’t mentally prepared … the fact that you don’t get to see them very much and when you do you’re not feeding them, it's very distancing … I felt very odd about the whole thing, it didn’t feel real, ’cause it happened so quickly, I didn’t feel like they were my babies … you’re not looking after them and you can’t sort of do anything, I think it inhibits your reactions with them and what you do with them. You’re watching everyone and it's as though it's all a dream … just feeling tired and lifeless …” (Trina)

The uncertainty surrounding the infant's condition created a situation in which women felt they were frozen in time. Women described feeling vulnerable, inadequate and disconnected. They spoke of “just existing” as they lived through the emotional turmoil attached to the uncertainty surrounding their infant's condition and progress. This was a time largely characterised by maternal passiveness. The concentrated medical and nursing activity focused around, and directed on the infant, left women feeling unable and incapable of meeting any of their infant's needs. The amount of time women spent in this state differed, and was influenced by the mediating factors of maternal confidence, infant wellness and the nurse–mother relationship. All the women, however, eventually described and were observed to seek some ownership and control. This generated a ‘shift’ in how women positioned themselves in relation to the infant.

Striving to be the baby's mother 

“I guess for about ten days I was very teary and you know very sensitive … with the baby improving it got better … like then I wanted to do things for her … like a mother should be doing …” (Sarah)

It was at this point that women not only began to strive to be their baby's mother but they also yearned to commence undertaking the role they had imagined during their pregnancy. In this phase women sought to undertake specific activities, not unlike mothers of full-term healthy infants, in an attempt to develop intimate knowledge of their infant, fulfil their own expectations of ‘motherhood’ and establish an identity as their infant's mother. Seeking physical closeness, information, support and learning how to provide the basic physical aspects of their infant's care were all strategies that women employed to achieve these aims. If women were successful in their quest to become informed and “do things” for their infant, then feelings of involvement and connection were established.

Trying to establish competence 

“She got out of the oxygen and off all the monitors - and when I could start holding her myself and not be told, “would you like to hold her” or “would you like a cuddle”. Like being able to come in and pick her up myself, and sort of start managing it myself, making more decisions rather than waiting for the nurses. I think that's when I started feeling more like a mother … and I know her now and when she is wide awake she looks into my eyes, and when you talk to her she knows that this is mum …” (Emma)

As women learned to mother their infants they became increasingly confident in their ability, they felt more comfortable in the nursery environment and they began to know and connect to their infant. As a result women began “to try” and assert more control over the care their infant was receiving. They did this through actions that demonstrated active and skilled participation in the care of their infant. Being successful in their desire to take an active part in the care of their infant through negotiation, directly initiating care and feeling confident to assess their infant's wellbeing and progress engendered feelings associated with being a “real” mother. Consequently, women who successfully negotiated this hurdle felt in control and capable of mothering even within the abnormal situation of the neonatal nursery.

Not all women in this study were able to successfully employ these strategies. Directing their infants care was only possible where this was facilitated within a positive and shared relationship with the nurse caring for her infant. For others taking a lead role in their infants care and establishing a sense of control meant becoming assertive and ‘speaking up’. This seemed easier for those with a well-developed sense of maternal identity or confidence in themselves as mothers. In the situation where the mother perceived herself as “quiet and unassertive”, and in a position without any power, it was very difficult to gain any confidence to be able to openly question, negotiate and direct the care of her infant.

Learning and playing the game 

“And when you walked in physically the nursery was lovely … But when it actually comes to having to deal with things and you’ve got to start dealing with the people and personalities - you know how it is when you’re new, you sort of sit back and you kind of let things happen and you go with the flow. So you can sort of see the politics and try and work out how to fit in and not be a problem …” (Brynnie)

As demonstrated in Fig. 2 the category ‘learning and playing the game’ overlays the first three phases of the woman's nursery mothering experience. It represents how mothering tasks were undertaken whilst being constantly scrutinised by professionals within the confines of the public space of a nursery environment. The concepts informing this category demonstrate the ‘work’ women felt they needed to undertake in an effort to gain access to their infants and ensure they received the very best of care. This required women to not only learn about their infant, but also about the rules of the nursery and the expectations placed on them as mothers. This was hard work, exhausting and a constant challenge. Women quite quickly realised that their success was dependent to varying degrees on their ability to adapt and adjust to the nursery environment and navigate the nurse–mother relationship. Learning and playing the game represented how women learned, used and became familiar with actions and interactions that they believed would assist them build and maintain ‘friendly’ relationships with nurses, and thereby facilitate their active involvement with their infants [for a detailed description of this category see reference 34].

Consequences: becoming connected and struggling to mother 

‘Becoming connected’ and ‘struggling to be a mother’ were the two categories that represented the outcome or consequence of women's actions and interactions in the nursery. If the actions women employed and the interactions they engaged in, as they attempted to mother were successful, women spoke of feeling “involved”, “part of (their) infant's life” and “more like a mother”. Comfort and familiarity both within the nursery and with their infant created a positive cyclic effect whereby women became increasingly knowledgeable and confident. As a result women described feeling “connected” and in “control” of the events happening to and around their infant.

“We talked about when would be the best times to come in … capitalise on his awakeness and that sort of thing … now I feel fairly confident … you get a familiarity with everything so that you don’t have to feel like you have to ask … they want you to do as much as possible for him but I mean they don’t mind doing it for you … they like it when you do it yourself … and now I’m doing the things I imagined I would with him … I’m doing everything … I’m building up an image that I am actually a mother …” (Fiona)

Alternatively if women perceived their actions and interactions to be unsuccessful they described almost the opposite. Hindered in their efforts to take up their role women experienced a myriad of feeling from anger to distress through to inadequacy, guilt and frustration. Because women had to leave their infants in the care of others they had to consider their relationships with staff and perhaps guard how they should or could respond. This had the potential to increase women's feelings of alienation perpetuating further distress and disharmony. As a result women described feeling uniformed and powerless making the whole experience of learning to be a nursery mother and the process of seeking connection “harder”. Under these circumstances women struggled to become the mother they envisaged they could be and wished to be [for a detailed description of these categories see reference 35].

“They discouraged me from touching her as much as I wanted. You feel like – god, touching her might make her stay longer. You don’t want that. I didn’t feel like her mother. I still feel detached from her”. (Mary)

Mediating factors 

It is appropriate at this point to briefly discuss the variables that either constrained or facilitated how women moved through their nursery experience. Strauss³⁶ labelled these factors as intervening conditions and described them as broad and general influences that include time, space, culture, history, career and individual biography. Rogan et al.³⁷ defined these intervening conditions more specifically as ‘mediating’ factors in their work on motherhood.

The grounded theory analysis identified three mediating factors. The first related to the infant's wellbeing and progress. This influenced ‘when’ and ‘how’ women took up their role as mothers in the nursery and sought to become connected to their infant. While the infant remained extremely unwell, requiring extensive medical treatment, women understood and expected restrictions in their ability to connect with their infant. However, when there was some ‘certainty’ about outcomes, even if this was short term, women began to want to play some part in their infant's care, regardless of how small that might be.

Women's confidence in themselves as mothers was the second factor that influenced how they experienced mothering in the nursery and the process of seeking closeness and intimacy with their child. Women with other children tended to demonstrate a strong maternal connection to their newborn, despite them being in the nursery. These women, unlike many first time mothers, regarded themselves as “mothers from the start” and as such often found the restrictions imposed on their mothering by the nursery environment very difficult to accept. A couple of first time mothers also demonstrated well-developed maternal identities. These women described a sense of connection with their infants when they were in utero. Often this strongly felt connection appeared to parallel situations where the woman had been at risk of losing her baby over an extended period of time. The data suggested that it was this sense of their child and their relationship to it that enabled women to more readily give voice to their needs, wants, concerns and fears. The result, however, was that these women often came into conflict with nurses sooner and more often as they were not prepared to “wait and be told” just when and how they could mother.

The relationship between nurse and mother, the third factor, appeared the greatest single influence on the woman's experience of establishing connection with their infant. Being a mother in the nursery meant that women always ‘mothered’ their infants in the presence of a third person. By the very nature of having an infant admitted to the neonatal nursery, mothering became a three-way interaction between mother, nurse and infant. The relationship between the mother and nurse impacted on the interactions between the mother and the baby, working to either constrain or facilitate these actions. The degree of success achieved by women, as they worked to gain intimate knowledge of their infant and some control over mothering, was largely dependent on the nature of the social and emotional environment created by the nurse (for a detailed description see 38, 27).

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Discussion 

The grounded theory analysis presented in this paper supports the work of others and demonstrates that women engaged in, or attempted to engage in, three distinct ‘action’ phases in an effort to develop or re-establish their ‘tie’ to the infant³⁹ (p. 179). The strategies identified within the major categories, ‘just existing’, ‘striving to be the baby's mother’ and ‘trying to establish competence’, represent numerous specific endeavours that nursery mothers undertook in their efforts to foster a sense of themselves as mothers. These findings have important implications for nursing and midwifery practice given that the majority of work concerning parent infant nursing and parental development has been undertaken with mothers of full-term healthy infants.⁴⁰, ⁴¹, ⁴²

Trying to reclaim their role as mothers 

Reva Rubin's influential work on maternal role attainment, identity and transition to motherhood, while attracting criticism⁴³ and conducted many decades ago, offers some important insights which are supported by the findings presented in this paper. For example, Rubin initially identified two, then later three phases of maternal attainment. Rubin described and characterised the first phase, labelled taking-in as passive and dependent behaviour.⁴⁴ Here Rubin makes reference to the fact that women watch, copy and role play. This conceptualisation seems to help explain the actions that women described, and were observed engaging in, as they moved from a state of ‘just existing’ to one where they strived to learn “everything” about their infant and began to, albeit tentatively, take up their role as mothers. For nursery mothers, however, this passive state was further reinforced by the reality that their infants were requiring concentrated medical and nursing support during the early days of their life.

The actions identified in the category ‘striving to be the baby's mother’ have some synergy with Rubin's second stage taking-on,⁴⁵, ³⁹ although the time frame is different. To achieve intimate knowledge of their child and an understanding of their situation, women began to actively seek information and support, craved physical closeness with the infant and attempted to involve themselves in the daily routine care of the baby. Steele⁴⁶ also described similar actions undertaken by parents in the nursery. She labelled these as ‘hanging-on’ and contextualised them within a state of ‘waiting’ and that of a ‘detached observer’ (p. 24). The women's accounts suggest that being able to successfully undertake these activities, builds confidence and fosters a sense of ‘being a mother’. The analysis also supports Zabielski²¹ conclusions that participating in ‘care’, creates situations that trigger ‘maternal identity’ in women with full-term and preterm infants (p. 31).

Rubin's third phase, labelled ‘taking-hold’, seems to explain the shift in maternal position identified as women gained confidence and endeavoured to establish themselves as the most important person in their infants life, building on and utilising intimate knowledge of “their” child.⁴⁷ Rubin described how women moved from “how does one behave” to “how will it be for me”⁴⁷ (p. 242). Establishing competence in the nursery was about actively working, either with or without approval, to make decisions about their child's care. Women “pushed” for things to happen or be done, as they believed they should be. It was a time of “testing out” their knowledge and confidence and learning from their own mistakes. Women thus moved from a relative passive state to one of independence and autonomy.⁴⁴ In the context of the nursery, however, women had to employ additional strategies to assist them gain the autonomy and control that they so desperately wanted to achieve.

Ramona Mercer's work, which followed Rubin's and in general supports it, also supports this interpretation of the women's data. Mercer⁴⁸ identified four stages of role attainment. The fourth stage, Mercer labelled ‘personal’ and refers to a time when women seek to develop and establish their own unique behaviours. Mercer used the words ‘confidence’ and ‘competence’ to inform this phase (p. 74). It reflects, we believe a synergy between Mercer's ideas and the meaning apparent in this data described as ‘trying to establish competence’. Both Rubin and Mercer comment that this occurs when women cease following the rules and directions of others and no longer accept other people's interpretations of their infant's behaviour. This could help explain why some women discontinued or refused to engage in the actions associated with the major category ‘learning and playing the game’. Women who described and were observed to have a strong sense of themselves as mothers, found it easier to be direct and open about their concerns, the actions of staff and the care their infant was receiving. As one third time, mother remarked, “I don’t give a shit what they think of me I want it done my way. He's my baby”. While we do not advocate that this is the end point of maternal attainment for all women mothering in the nursery, the actions reported in these data suggest that this state is what some women were working hard to ‘try’ and achieve.

Seeking permission to touch 

The need to achieve physical contact with one's infant emerged strongly from the analysis and demonstrated the ‘work’ that women engaged in as mothers in the nursery. Being able to cuddle and hold their infants was something women not only desired but also were desperate to achieve. As Long⁴⁹ also reported, women “hang out” to touch and hold their babies. The women's accounts of physical closeness in this study however, were dominated by restrictions or “not allowed” to touch. It is here that these women's narratives contrast to those of mothers with full-term infants who have been found to focus much more on how they ‘feel’ about their infant.²¹ Being unable to achieve physical contact with their infants left women feeling “disconnected” and “not like a mother”.

The importance to women of establishing and maintaining physical intimacy with their infant can also be understood through the literature on the development of maternal identity.⁴⁷, ⁴³, ⁵⁰ Through physical contact women could learn about and become familiar (or arguably re-familiar) with every ‘inch’ of their baby.⁵¹ In this study, as in Zabielski's²¹ work, seeing the infant, holding the infant and/or interacting with the infant were all events that contribute to the development of a woman's sense of herself as mother during the nursery experience.

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Implications for practice 

This work has significant implications for neonatal nursing and midwifery practice. The theory presented in this paper, developed from the women's own nursery experiences indicates the need to change how nurses and midwives practice in the SCN.

Understanding and facilitating closeness between mother and infant 

The analysis suggests nurses and midwives need to acknowledge that the specific activities women undertake with their infants are far more than ‘simple’ tasks which “allow” them to feel “involved”. Interacting with their infants, in whatever way possible, plays a significant role in how women develop a sense of themselves as mothers, and therefore has consequences for the development of healthy maternal–infant relationships. During women's early nursery experience physical closeness to the infant lessened women's distress and feelings of inadequacy. As time passed interacting physically with their infant became a vehicle through which women not only learned and gained intimate knowledge of their infant, but also demonstrated some authority and ownership. Ensuring maternal–infant closeness is achieved should always be a nursing priority and one that not only guides but also underpins nursery and midwifery polices and protocols.

From admission of the infant, nurses and midwives have a responsibility to assist parents find their place and a role. Staff must respect the woman's need to actively participate and be involved in decisions regarding the care of her child. Nurses and midwives need to understand that it is they that are actually the ‘visitor’ in the infant's life. The comment that mothers need to be “in charge”,¹¹ while seemingly simple, is an important concept for nurses to understand and put into practice. One of the first and best ways to achieve this is by ensuring the mother and family has unrestricted access to their child. Practice standards therefore, should reflect a commitment to assisting parents achieve a high level of contact with their infant.

Nursing the mother–infant dyad 

In this study the relationship between mother and nurse was not only a significant focus, as Wocial⁵² also identified, but the interface of nursing interventions.⁵³, ⁵⁴ It was the relationship with women and families, not infants, which provided the medium through which high quality care was delivered. The analysis suggests that nurses and midwives working in the neonatal nursery need to construct the client as the ‘mother–infant dyad’, with roles and responsibilities focused on facilitating the maternal–infant relationship. We would argue that, within these three-way relationships, nursing practice could best be conceived as a triangle, positioned on its side, with the nurse providing care to both mother and infant. This in turn facilitates the connection between mother and baby. Fig. 3 represents this diagrammatically. The over lapping circles represent the interdependent relationship between mother and infant. The importance of the nurse/midwife to both mother and infant is delineated by the fact that the carer's circle touches but does not over lap either that of the infant or mother. The thicker arrow between mother and infant depicts the stronger relationship. Constructing the neonatal nursing process in this way acknowledges the unique and special relationship between infant and mother and ensures the woman and family are seen as central to care and their infant's life.

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• Figure 3. 

  Three-way nature of neonatal nursing.

There is also a need to develop tools that can better evaluate women's and families’ satisfaction with nursery care and their feelings of confidence, competence and a sense of control at discharge. The theory generated in this research provides the basis on which such a tool could be developed and tested. Longitudinal qualitative research with parents who have experienced the birth of a sick and/or ill infant also remains an imperative. We must continue to evaluate how the care we provide infants and their families impacts on long-term health outcomes of all those involved.

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Conclusion 

This study examined the experiences of 28 Australian women as they began their roles as mothers in the neonatal nursery. The theory presented in this paper illuminates a more complete picture of the intense work women undertake as they strive to take up their roles as parents. The findings of the research describe and explain the actions and interactions in which women engage as they seek to develop or re-claim intimate knowledge of their child and establish their place in their infant's life.

Exploring the literature on maternal identity confirms that nursery mothers engage in, or at least ‘try’ to engage in, many of the same activities as those women with full-term healthy infants. The major difference is the extraordinary effort that this requires when women are dependent on others to gain physical access to their child. In contrast to mothers of full-term infants, women with babies in the nursery are much more concerned about establishing ‘rights’ and their position as their infants mother. Establishing and maintaining collaborative relationships with nurses and midwives thus becomes a key feature of their experience, as does demonstrating appropriate ‘expected’ maternal behaviours in order to prove themselves worthy of being their baby's mother. Women's perceived level of success at achieving intimate knowledge of their infant, as well as their confidence, competence and a sense of ownership was therefore mediated by how nursery staff interacted with them.

The analysis highlights the extremely challenging and public nature of these women's mothering experiences. It becomes clear that, to facilitate maternal infant and family relationships, neonatal nurses need to reconstruct the identity of their client. That is ‘who’ is the client. It appears that reorientating the delivery of services to the mother–infant dyad may help improve the care women and their families receive during their nursery experience.

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Acknowledgments 

The research on which this article is based was supported by a National Health and Medical Council Grant and an Australian Postgraduate Award. We also wish to thank our colleagues and the mothers with whom they work, for permitting us to work with them in undertaking this research.

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• 1 The term nurse in used to describe the staff employed in the nursery during this study.