NSG/506 Week 2: Nursing Theory and Practice, sample paper

Swanson's Theory of Caring at the Follow-Up Visit After Early Pregnancy Loss: A Middle-Range Theory Guiding Nurse Practitioner Practice

[Student Name]

University of Phoenix

NSG/506: Transition to Advanced Practice Nursing

Week 2 Assignment

[Instructor Name]

[Date]

The practice, patient and visit are a composite written for a model paper. No real patient is described.

Early pregnancy loss is common, occurring in about 10% of clinically recognized pregnancies, and most women are managed in outpatient settings (American College of Obstetricians and Gynecologists [ACOG], 2018). The medical care is often straightforward: confirming that the loss is complete, checking hemoglobin and Rh status and discussing contraception or future pregnancy. The follow-up visit two weeks later is frequently brief. Yet many women describe the weeks after a miscarriage as a time of grief that clinicians did not seem to notice. A visit that confirms a normal hemoglobin and schedules nothing else can be medically complete and still leave a woman feeling that her loss did not count. This paper examines how Kristen Swanson's middle-range theory of caring can guide a nurse practitioner's follow-up visit after early pregnancy loss.

Origins and Structure of the Theory

Swanson (1991) developed her theory inductively from phenomenological studies in three perinatal settings, including interviews with women who had miscarried, parents and professionals in a neonatal intensive care unit and socially at-risk mothers receiving long-term home visits. She defined caring as a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility, and identified five caring processes: knowing, being with, doing for, enabling and maintaining belief.

Knowing means striving to understand an event as it has meaning in the life of the other, avoiding assumptions and centering on the person. Being with means being emotionally present, conveying availability and sharing feelings without burdening the person. Doing for means doing for the other what she would do for herself if possible, including comforting, anticipating needs and protecting dignity. Enabling means facilitating the other's passage through life transitions and unfamiliar events by informing, explaining, supporting and validating. Maintaining belief means sustaining faith in the other's capacity to get through an event and face a future with meaning.

Because the theory came directly from research with women who had miscarried, it fits this clinical situation unusually well.

Applying the Five Processes to One Visit

The composite patient is a 33-year-old teacher seen two weeks after a miscarriage at nine weeks, managed with medication at home. It was her first pregnancy, and she and her partner had told their families.

Knowing. The nurse practitioner begins not with the checklist but with a question: how have these two weeks been for you? She learns that the patient blames herself for a glass of wine she drank before she knew she was pregnant and that her partner has returned to work as if nothing happened. The nurse practitioner avoids assuming what the loss means to her, whether relief, grief or both.

Being with. The nurse practitioner sits down, maintains eye contact and allows silence when the patient cries. She acknowledges the loss directly, using the word baby when the patient does, rather than clinical terms such as products of conception.

Doing for. The nurse practitioner handles the clinical tasks efficiently and gently: she confirms by history and a negative pregnancy test that the loss is complete, reviews the hemoglobin, confirms that Rh immune globulin was given as indicated and arranges a quiet exam room away from the prenatal waiting area for the visit.

Enabling. She explains that about half of early losses are caused by chromosomal problems in the pregnancy and that early loss is not caused by ordinary activities or anything the woman did (ACOG, 2018), including a glass of wine before she knew she was pregnant. She describes what physical recovery usually looks like, when periods typically return and what the evidence says about trying again. She validates that grief after early loss is real and that partners often grieve differently.

Maintaining belief. She expresses confidence that the patient can get through this, notes that most women who miscarry go on to have healthy pregnancies and offers a follow-up call in two weeks and information about a pregnancy loss support group.

Evidence From the Theory's Own Research

Swanson tested her theory in a randomized trial of caring-based counseling for women after miscarriage. Swanson (1999) randomized women to three one-hour counseling sessions based on the caring processes, to measurement only or to other conditions and followed their well-being over a year. Women who received caring-based counseling showed greater reductions in overall emotional disturbance, particularly depression and anger, in the months after loss, and the passage of time itself was associated with healing. The trial gives the theory an unusual advantage for a middle-range theory: it has been tested in the same population to which this paper applies it.

Extending the Processes Beyond the Visit

The theory also suggests changes around the visit, not only inside it. Knowing and being with can begin before the patient arrives: a flag in the scheduling system can alert staff that the visit follows a loss, so that the patient is not asked at check-in how far along she is, and she can be roomed promptly rather than waiting among pregnant patients. Doing for extends to the partner, who in this case had returned to work as if nothing happened; with the patient's permission, the nurse practitioner invites him to the follow-up call and acknowledges his loss as well. Enabling continues after the visit through a written summary of what was discussed, since grieving patients often retain little of what they hear. Maintaining belief continues at the next pregnancy, when the practice can note the prior loss and offer an early reassurance visit. Applied this way, the theory shapes a small system of care around a common event rather than a single conversation.

Why Theory Matters in Advanced Practice

Nurse practitioners are often trained, evaluated and paid according to a medical model focused on diagnosis and treatment. A theory like Swanson's reminds the advanced practice nurse that the nursing perspective remains part of the role. It does not replace clinical guidelines on managing pregnancy loss; it structures the relationship in which those guidelines are delivered. In a busy practice, the theory also gives a reason to protect time for this visit, since the evidence suggests that caring-based contact after miscarriage affects women's well-being.

Limits of the Theory in Practice

The theory has limits. Its concepts describe relationship processes that are difficult to measure in routine practice, so a practice cannot easily audit whether caring occurred. The caring-based counseling tested by Swanson involved three one-hour sessions, far more time than a primary care or women's health visit allows, so applying the theory in a single 20- or 30-minute visit is an adaptation rather than a replication. The theory was developed largely with women in one cultural context, and the meaning of pregnancy loss varies across cultures and religions, which makes the knowing process especially important. Finally, the theory focuses on the individual relationship and does not address system factors, such as scheduling women after loss in crowded prenatal clinics, that the nurse practitioner may need to change at the practice level.

Conclusion

Swanson's theory of caring gives a nurse practitioner a clear structure for the follow-up visit after early pregnancy loss: knowing what the loss means to the woman, being present with her, doing the clinical tasks with care, enabling her through information and validation, and maintaining belief in her future. Because the theory was built from and tested with women who miscarried, it fits this visit closely. Used with awareness of its limits, it helps ensure that a medically complete visit is also a caring one.

References

American College of Obstetricians and Gynecologists. (2018). ACOG practice bulletin no. 200: Early pregnancy loss. Obstetrics & Gynecology, 132(5), e197-e207. https://doi.org/10.1097/AOG.0000000000002899

Swanson, K. M. (1991). Empirical development of a middle range theory of caring. Nursing Research, 40(3), 161-166. https://doi.org/10.1097/00006199-199105000-00008

Swanson, K. M. (1999). Effects of caring, measurement, and time on miscarriage impact and women's well-being. Nursing Research, 48(6), 288-298. https://doi.org/10.1097/00006199-199911000-00004