JOGNN PRINCIPLES & PRACTICE

Intrapartum Nursing: Integrating Rubin's Framework With Social Support Theory Martha Rider Sleutel

_ Numerous stud ies and articles on labor support have focused on the potential for improved labor and birth outcomes from supportive ca re during labor. Despite increased attention to labor support research, su rpri sing ly little has been written about the theoreti­cal underpinnings for intrapartum nursing ca re. Thi s article explo res Reva Rubin's framework and socia l support theory as a foundation for intrapa rtum nu rs­ing care. The most common features of soc ia l support provided the structure into which Rubin's descriptions of nursing care during labor a nd birth could be eva l­uated. Socia l support theory fit remarkably wel l, both with Rubin's views of the role of the perinatal nurse and with Rubin's observations of mothers' needs and feelings du ring chi ldbirth . Combining these theoretical frameworks provides a perspective of intrapartum nursing practice that has not been previously consid­ered in the published literature. JOGNN, 32, 76-82; 2003. DOl : 10.1 177/08842 17502239803

Keywords: Intrapartum nursing- Lobar sup­port-Reva Rubin - Social support-Theory

Accepted: March 2002

Helping mothers in labor is the essence of intra­partum nursing ca re. The porentia l role of labo r sup­port in improving la bor and birth outcomes has received much attention recentl y within both profes­sional and consumer-oriented litera ture. In the past several decades, the un ique subspecialty of intra­partum nursi ng care has had littl e pu blished descr ib­ing irs theoretical underpinnings . Perh aps as a res ul t, practi cin g intrapartum nurses may feel that nursin g theory does not have much mea ning to them or rel­evance to what they do. Yet, nursing theo ry should help improve nu rsing practice (Chinn & Kra mer,

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1999) . Two di verse sources, the writings of Reva Rubin and socia l support theory, p rov ide a remark­ably so lid theo retical foundation for nurses ' care of mothers in la bo r. This article inregrates concepts from both frameworks and applies them to labor and childbirth care by nurses .

Background

Neither the soc ial support litera ture nor Rubin 's fra mework are typ ica ll y appli ed to intrapartum nursing care. Reva Rubin was a nursing th eo rist w ho w rote of the morher 's experience of pregnancy, child birth, and matern al idenrity. H er innovat ive and now classic writings described w omen 's cogni­t ive work during pregnancy (i.e., how mothers thin k), in additi on to describing nursing ca re of pregnant women. Rubin 's works are w idely associ­a ted with pregnancy and matern al role a tta inment, focusing primari ly on the antepartum a nd postpar­tum periods. By contrast, the social support litera­ture spans severa l d isc ip li nes and has clea rl y shown that health outcomes are influenced by support. Labor support , as defined by Hodnett (2001 ), is strikingly si milar to the common defin iri ons of social support. Desp ite thi s pa ra ll el, soc ial support a lso is not com monly associated with nursing care durin g childbirth. Integra tin g both theoretical frameworks crea tes a linkage between the childbearing mother's cogniti ve and emotiona l processes and specifi c sup­porti ve nursing interventions ta il o red to meet her needs and optimi ze her birth experi ence.

Rubin 's fra mework ex plains the laboring moth ­er's psychological mil ieu, guiding th e suppo rt processes that ca n ease the tria ls of her labor, improve birth o utcomes, enha nce her self-esteem

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and identity, and provide a foundatio n for her ro le trans i­tion to motherhood. In describing the evolution in moth­ers' emotions, behavior, and se lf-view during and after birth, Rubin also affirmed or implied a great dea l about the need for nurses to provi de supporti ve care to women in labor. Most social suppOrt actions by nurses during labor are d irected toward two of the four components of what Rub in (1975a) described as pregnancy work : seek­ing safe passage a nd giving of oneself. Seeking safe pas­sage refers to the mother 's knowledge and ca re-seeking behaviors to ensure that both she and her newborn emerge fro m pregnancy and chil db irth intact and hea lth y. Thi s task is ma nifested by the mother's characteristi c wor­ries and co nce rns over porcnria l and real ha za rds or risks . Giving of oneself refers to the mother's willingness and ability to make persona l sacrifices (time, discomfort, etc. ) for the child (Rubin, 1975a ),

Socia l support is often described as an interpersona l tran sacti o n that contains emotional support or affect, information or advice, instrlllnental or ph ysical a id, and appraisal support or affirmation. Othet facets of socia l suppOrt include (a) social ties, relationships, or networks; (b) th e recipi ent's perception of available support; (c) the degree of reci procity with in the support relationshi p; a nd (d) the personalit ies of the support-gi ver and rec'p,em (Hupcey, 1998; La ngford , Bowsher, Maloney, & Lilis, 1997; Tilden, 1985 ).

Merging Rubin's Writings Into Social Support Theory

The rema inder of this discussion will focus on synthe­siz ing the two th eo ri es to form a bas is for nursing support of women in la bor. The ca tego ties a nd additional facets of socia l suppo rt theory provide an organizing framework, and Rubin's descripti ons fit easily w ithin those social sup­port components .

I ntrapartum nursing skills revolve around

facilitating a woman's abi lity to totally surrender

her body to a uniquely feminine task, that of

giving birth (Rubin , 1967c).

Emotional 01' Affect Support Empath y, esteem, concern, unconditiona l regard, and

reflective li stening arc emotionall y susta ining beha viors (Gottlieb, 1992; House, 198 1). Samples of how intra­partum nurses pro vid e emotional support include sta ying with the laboring moth er, mak ing eye contact, touching her hand , or telling her that "Those contractions are real -

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Iy strong. You are doing a great job!" Emotional support yields a sense of co mfort and security a nd a fee ling of being ca red fo r (Cutrona & Ru sse ll, 1990). Rubin (1984) w rote that interest, caring concern, and attention help the mother give birth and make her feel res pected and va lued . Labor pain is ameli orated by th e presence of a wi lling, ca pable, empathetic person. According to Rubin, after 4 cm of cervical dilation, laboring women should teceive continllou s nursi ng care to reduce their anxi ety and fear. Ca re provi de rs' indifference to pa in causes a sense of abandon ment and rejection, diminishing a woman 's self­worth. "Pain under cond itions of iso lat ion has no limits" (Rubin, 1984, p. 82 ).

r 10Li se (1981 ) cons idered emotional suppOrt to be the most important type of support in buffering stress a nd optim izin g health. In Cutrona a nd Ru ssell 's (1990) theo­ry of optimal matchin g, un controllab le events (s uch as labor) were considered most responsive to emotional sup­pOrt. Accord ing to Rubin 's framework, mothers should be attend ed and helped, nOt left a lone e' to swea t out labor" (Rubin, 1975a, p. 1683 ). She articu lated the essential nature of emotional support in labor as a strategy to pro­mote mothers' individua l strengths and capab ilities .

Information 01' Advice This category of soc ial su ppOrt fac il itates coping and

problem-solving through adv ice, suggestions, guidance, an d information (Cutrp na & Russell, 1990; Va ux, 1988 ). Intra partum nurses commonly provide thi s type of sup­POrt by expla in ing wha t is happening or suggesting posi­tions that might be more comfortable. Rubin (1984) wrote that keeping women informed in general , and aboLit labor progress specifica ll y, was essential to their self-image. Consistent with soc ia l support th eorists, she fel t that information and advice help mothers cope with labor by providing hope and reducing pain intensity. Nu rses ca n help a woman's coping a bilities by prov iding two specifi c ca tegori es of information: (a) defining the so urce, beginning, and end of contraction pain an d (b) or ientin g her to time, rate of progress, and di stance trav­eled toward the ultimate goal of delivery. Rubin believed that such a time orientation helps to anc hor the moth er to the rea l v,,'orld : "Cogn itive awareness ma rshal s her inner co ntrols" to relieve pain (Rubin , 1984, p. 94 ). The essence of nurturing intrapartum C3re is g iving the moth ­er contro l during a time w hen she must surrender all vol i­tion to th e forces of labor (Rubin , J 967c, 1984). Wh en Rubin ( 196 1 b) wrote th at nursing is creative in cultiva t­ing women's abilities and enhanc ing thei r potential , she described information suppOrt as a component of that care.

Affirmation or Appraisal Support This ca tegory of socia l support invol ves feedback and

socia l comparison (House, 1981 ) and ma y overlap some-

JOGNN 77

what with in formation support and with emotiona l sup­port. Intrapartum nurses who offer the mother encour­agement and va lidation of he r effofts a re providing affir­mation support (e.g., "Excellent pushing! You rea ll y moved the baby a lot that time!" ). Affitmation suppo rt bo lsters a person's sense of self-competence or self-esteem (Cutrona & Russell, 1990). Swann and Brown (1990) noted that peop le seek self-confitmatory feedback to ver­ify their se lf-conceptions and that negative self-views can ca use identity d isruption. Rubin (1984) described the sa me phenomenon, where the laboring mother compares her ideal self against her self- im age (actual ) and judges her performan ce and abil ities, someti mes harshl y. During labol; the loss of her abilities ca uses fee lings of he lp less­ness, entrapment, and victimiza tion. She dreads sllch loss of control in labor and works hard not to cry or scream. She feels shame in her own self-esteem and in how she believes others view her. "Shame is the personal pri vate judgement of fa ilure, passed on to self by self .... It is a merc il ess judgement" (Rubi n, 1968a, p . 23) .

Accord ing to Hob£all, Lilly, and Jack son ('1992), social suppOrt enhances self-esteem and a sense of mastery, enabli ng the rec ipi ent to protect and mainta in hi s or her identi ty. Although Rubin (1984) did not label it appraisa l sup port or affirmation, she implied that the intrapartum nurse can relieve the mother's fee lings of anxiety and shame by (a) expla ining what is norm al, (b) offeting reas­surance, and (c) contexrua lizing the functiona l losses as progress in her journey towa rd delivery an d ultimate res­olution and restoration of contro l. Nursing suppo rt invo lves enabling the mother to achieve control of func­tion appropriately in t ime and place (R ubin, 1968a). Facilitating or enabling control alleviates or even prevents the woma n from experiencing the frustration, fear, and despa ir of feeling t hat she ca nnOt control her destin y or even her body. Rubin ('I968a ) depicted this process of enablin g another to achieve or maintain control as a process of lendi11g ego. Rubin saw the primary goa l of nursing as ego main tenance and support du ring stressful dependency situations (Rubin, ·1968b). Lending ego and aiding the mother in maintaining control encompass the suppOrt catego ry of appraisal or affirmation support.

Tltstrumelttal or Physical Aid T hi s catego ry of soc ial suppOrt involves action to alter

the environment or provide a id, money, time, or labor (Gottlieb, 1992; Vaux, J 988). Examp les of instrumental or physica l support in labor a re providing sips of water, playing music, offe ring a warm shower, or helping moth ­ers into different positi ons. Instrumental support yields resources that a person needs to cope w ith a stressful event or situation (Cutrona & Russell, 1990). In strumen­tal or physica l support in the context of labor can be di vided into two components : (a) co mfort care and (b) clin ica l skill s and expertise.

78 JOGNN

Comfort Care. Rubin wrote a great deal about the pain of labor and the nurses' role in providing comfort. She exp lai ned that during labor, the mother's attention is con­centrated on an inner co re of pa in that spreads and immo­bilizes: "Time super imposed on layers of tension, discom­fort, and pain ... makes labor burdensomcly painful" (Rub in , '1984, p. 93) . She described interventions such as cool, intermittent contact that wou ld renew the mother's awareness of body bo undaries . A ca lm vo ice; a gentle, firm touch wi th an open palm; and sacral counterpressu re

M others with a recent experience of

appropriate and meaningful bodily touch

from a ministering person , like the intrapartum

nurse, are more likely to use nurturing

touch with their babies (Rubin , 1984).

help conserve body boundaries, relieve tension, and aid the mother in co ncentrating. Rubi n (1984) described spe­cific positioning techniques to a lleviate the pain and pres­sure of labor after the baby had entered the inlet of the pelvi s. Other interv.cn tions included co unterp ressure on sacral press ure point, cool ing washes, cooling compresses to eyes, an ice bag to the head, back massage, ice chips, and sips of cool water. Rubin (J984) noted that unre­lieved pain is subjectively experienced as a socia l reject ion of the self, leading to antipath y toward herself, her ch ild, and life. By contrast, mothers with a recent expe ri ence of appropriate and meaningful bodily touch from a minis­tering person, like the intrapartum nurse, are more likel y to use nurturing touch with their infants. In situations of "intense personal srress, si tu ations in which one feels iso­lated and vulnerable, there seems to be no other modality compa rable to touch in the immediacy of effective response" (Rubin, 1963, p. 828) .

Rubin (1963) elabora ted further on the nursing skills needed to provide adeq uate comfort to laboring mothers. She notcd that individualized touch is interpersona l com­munication that is significant in a way that verbal lan­guage is nor. Intrapartum nursing skills revolve around faci litating a woma n's ability to totally surrender her body to a un iquely feminine task, that of givin g birth (Rubin, 1967c). Nurses who are knowledgeable and sk illed can augment mothers' coping a bili ties by being supportive and responsive to the mother. Nurses shou ld communicate by eye-to-eye contact, verba l confirmation, reassuring touch, and restfu l massage . The knowledge and skills of the help ing nurse enhance the mother's abil­ity to cope with labor and prevent an immob ili zi ng spread

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of pain (Rubin, 1984). In the context of labor, instrumen ­tal support conn otes the nu rse as an instrument to allevi­ate pain and suffering through thera peutic use of self.

Clinical Skills and Expertise. Rubin (1975b) spo ke of nurses as skilled professionals and, within the hospital, as a collection of specialized expertise working in the patient's behalf. Rubin (1975b) described si lent miracles that occurred when normal labors "go bad, very bad w ithi n minutes" and nurses who were an indispensa ble pa rt of mirac ul ous outcomes (Rubin, 1975b, p. 1683). Such acrivi ti es as "ready ing the gases," scr ubbing, drap­ing, and getting blood chemistries, and weaning preterm infants £r0111 oxygen are instrumental or tangible aid. Rubin (1968 b, 1984) wrote that nurses develop skill s of in formation-gathering th rough touch using these sk ills to

make diagnoses and as a vehicle for personall y meaning­ful communication. Instrumental support consists of clin­ica l sk ill s and expertise, th e tools by which nurses assume vigil ance for the mother's safe passage through childbirth. It should be noted that whereas Rubin briefl y mentioned technical ski lls, she extensively emphasized the crucia l role of nurses in provid ing comfort through their presence and sk illful, nurturing care.

Social Network Perhaps reflective of the era , Rubin mentioned signifi­

cant others during labor only wi thin the context of avoid­ing isolation of the mother within a labor room. Rubin (1984) noted that th e presence of fami ly members is use­fu l but not sufficient to the mother's ca re an d that fam ily members feel helpless and angry when they are isolated with help all around, yet not present or available to the mother. Howeve r, in her explanation of basic materna l behavior ('1961 a) and attainment of the maternal role (1967b), Rubin desctibed how throughout pregnancy, the mother uses cultural comparisons and role mode ls within her circle of acq uaintances to form a basis for her behav­ior and evolving maternal identity. Childbitth classes as well as pregnant fr iend s and relati ves provide opportuni­ties for mothe rs to identify and compare themselves to other pregnant women. This process entails the rea lig nin g of kinship and friendship bonds, tightening some and loosen ing others. The net result is a shift from one social sphere to another, to use selected models and referents to

ptocess her assimilation to another identity (Rubin , 1970). Soc ial network s provide social identities, soc ial esteem,

social norm s, and a sense of belonging (Vaux, 1988). Accord ing to Swann and Brown (1990), social relation­sh ips offer self-confirm atory feedback to veri fy indi vidu­als' identity and self-conception s, a process ca ll ed identi ­ty support. This sounds remarkably similar to the maternal role attainment process, in w hich the mother's fam il y and friends playa key rol e (Rubin , 19673, 1967b) . Throughout pregnancy, the mother's reflection of sel f is

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modeled upon significa nt othets. The mother assesses and ex plores her relat ionsh ips through interpersonal exchanges that provide data about childbirth and moth­erhood. Additiona lly, the moth er's tasks in childbearing are "to conserve the intactness of the self and of the fa m­ily as ongoing, open systems and to orchestrate the assim­ilat ion and accommodation of this ch ild into the self and family systems" (Rubin, 1984, p. 53). Knowledge of these processes can aid the nurse in eva luating the mother's attendants and assisting them to validate her efforts and bolster her self- identity.

Recipient's Perception of Support Perceived support has been shown to be more strongly

associated w ith improved outcomes than are other meas­ures of social network support, such as the number of fa mil y members or frien ds, and even actua l s upport received . Perceived support is theorized to be influenced by cu lture, development, personality, social settings, and life tasks (Procidano & Smith, 1997). Accord ing to Cohen (1992), perception of support reflects a id provid­ed from the social environment, which, durin g labor, includes the intrapartum nurse. Rubin (1967c) wrote that nurses must understand the mother's pe rception of her si tuation and have empath y in order to rendet care. The mother perceives la bor and birth as a threat to her well ­being. She fears being damaged, losing bodil y functions and body intactness, and not su rviving. She regards th e hospital as a site of ~ompeten t and knowledgeable per­sonnel and feels secure when she believes the staff is qual­ified and knows her situation or condition (Rubi n, 1984). Understanding the mother's fears and building on her confidence in mod ern hea lth care, nurses can tailor labor support to allay those universa l fears and to maximi ze the mother's sense of security and control.

Reciprocity Within the Suppo11 Relationship Social support researchers have examined various

qualit ies of the social exchan ge of support, such as (a) the degree of equity between the support giver and the sup­port receiver and (b) the immed iacy of the benefit (Anton ucci & Jackson, 1990) . Rubin (1984) expressed an interacti ve view of support, noting that when a mother accepts ass istance, it is "an act of giving and nOt JUSt pas­sive acceptance" (p. 66) . Thus, by accepting the intra­partum nurse's care, the laboring mother g ives the nurse her trust at a time when she is most vulnera ble . Another interactive perspective, that of a "support bank," is that in times of need, indiv idu als ca n draw strength from pre­vioLis SLi ppOrt deposits (i. e., previous episodes of being valued and nurtured). Rubin (1984) mirrored this social suppo rt perspective when she descr ibed "gifts" to the mother of nurturing assistance, personali zed care, encouragement, and kindness by family, friends , and care­g ive rs: "The attendance of another, particula rly in times

JOGNN 79

of uncerta inty and stress, is perceived as a gift " (1' . 68) . Furthermore, "G ifts serve as na rcissistic suppli es, charg­ing th e batteries of self-respect throu gh the symbo lic ex press ion o f ano th er's obj ective respect for and esteem of oneself" (Rub in, 1984, Pl'. 66-67) . When ca re provid ers express interest, make time fo r her, li sten, and arc con ­cerned fo r her we lfa re, it shows th e mother that she is valued and respected. These gifts of suppo rt compensate fo r the difficult ies of childbearin g and build up a reserve of giving to be extended by the mother to th e baby a fter birth (Rubin , 1984 ).

Role of Personality T he cogniti ve and emotion al renov;1rioll s that occur

during pregnan cy represe nt qua litati ve pe rson ality changes, al tering mo thers' recepti veness to rece iving aid (Rubin , 1984). This is consistent with current theories, w hich state th at the personali ties of those rece iving sup­parr influence their perception of the avai labi lity and use­fulness of a id (Dunkel-Schetter & Benn ett, 1990). Factors slich as personal effi cacy, gender, social competence, cop­ing style, cog ni tive perfo rm ance, and self-concept have been found to influence percepti o ns o f suppo rt (Sa rason, Pi erce, & Sa rason , 1990) . In add ition to affecting support perceptio n, pe rso nality varia bles a lso influence problem perceptio n, he lp-seeking behaviors, and mo ti vation to seek help (Va ux, 1988) . Gottli eb (1988) suggested tha t there is a mutua l interplay amo ng suppo rt provid ers, recipi ents, and types o f support. Fo r exampl e, the express ing o f distress e lic it s support in prov iders, yet rec ipients are more likely to in d ica te di stress to pro viders who appea r ca ring (Collin s & DiPaula, 1997) .

Highl y re levant to nursing is earl y resea rch suggest ing that personality fa ctors of th e s upport provider contribute to th e support rend ered and to ~the recipi ent'S perception of s uppo rt. Two such persona lity characterist ics a re d is­posi ti o nal empa thy (emotiona l ca pacity) and causa l attri­buti ons (th e tendency to beli eve mi sfortun e is deserved) (Co llin s & DiPaula, '1997) . Fo r instance , a ca regiver who is nOt elTIpathet ic and w ho blames hardships o n the vic­tim would be less likely to render a id and the recipient would be less likely to fee l supported. Expanding this pe r­spective to peri nata l care, Ru bin (1975b) wro te that the most significa nt contributi o n of intrapa rtum nursing w as the foc us o n the mother. Additi o na ll y, she o bserved that the nurse must be empathetic a nd tailor her ca re to the pa rticu lar psychosocial situa ti o n and the self-es teem of each mother (Rubin, 1984) .

The so c ia l suppOrt literature refl ects an intrica te inter­acti o n among many vari ables, including personali ty, lea d­ing to improved hea lth o utco mes (Pierce, La key, Sarason, & Sa rason, J 997) . This is consistent w ith Rubin 's w ri t­ings of the changin g land sca pe of the mo ther's persona li­ty, so c ial c ircle, and recepti veness to g ivin g of care by oth­ers. The mothe r's cognitive and emoti o nal changes affect

80 JOGNN

her recepti veness and response to suppOrt provided by the intrapartum nurse. The social support literature suggests that e ffects of support are contingent on the character of the relationship between the pro vider and recip ient and th e manner in which th e suppo rt is conveyed (Go ttli eb, 1988) .

The impact of any particular suppo rti ve efforr depends 011 th e mo ti va tion s and expectations of both prov ider and recip ient, the nature of rhe re la tionship in w hich the suppo rr ive exchange occurs, and the problematic si tuati o n to which rhe supporti ve e fforts are di rected. (Sarason, Sarason, & Pierce, 1992, p. 145)

The effecti veness of the support depends upon the cogn i­ti ve a ppra isa ls of th e pa rticipants in that interaction (Sarason et a I. , 1992 ). Recent resea rch suggests that per­ceived suppO rt is a meas ure o f the recipient'S sense of accepta nce and feeling o f being valued (Sarason et aI. , ·1990). Th e interacti ve view of social support suggests that the personality of the labor nu rse and her style o f provid ­ing care w ill ha ve a g rea t impact o n the mo th er's perce p­ti on of her ca re (Sarason et a I. , ·1990).

I ntegrating Rubin's framework with social

support theory can help guide intrapartum

nurses' labor support strategies more

effectively toward the goal of improving

labor and birth outcomes.

Di scuss ion

To some degree, Rubin 's \¥riting may reflect an era in w hich hands-on ca re \..vas morc valu ed and there was no t yet an ove rwhelm ing emphasis on technology and proce­dures slich as contin uo us fetal heart rare monitOring or 011

time-consu ming documentatio n. Many w ould arg ue that these newe r Ilursing responsibiliti es ex pand ed w hil e dimi nishing rhe nurse's role in prov iding comfort and sup­porr to mo thers in labo r. T hree work sampling studies of intrapartum nursing ca re fo und that nurses spent onl y 60/0 to -120/0 o f thei r rim e providing supporti ve ca re and o nly 11 0/0 to 390/0 o f their time providing direct ca re (Gagnon & Wagho rn , 1996; Gale, Fothergill -Boutbonnais, & Chamberla in, 2001; McNlven, Hodnett, & O ' Brien­Pallas, ·1992). There were no work-sa mpling studi es in th e time frame of 1960 to 1978, bur Rubin 's descriptions impl y th at direct and support ive ca re was (or sho uld be) nurses' primary focll s. Sc ientific evidence suggests that providing comfort and support to mo thers in labor has a far g rea ter impact on birth outcomes than does app lying

Volume 32, Number 1

techno logy to normal childbirth (H o dnett, 2001 ; Kar­dong-Edgren, 20 01 ; Thacker & Stroupe, 2000) . The inte­gra tion of Rubin 's fra mework wi th social supp o rt theo ry can help guide in tra pa rtu m nu rses' la bo r suppo rt strate­g ies more effectively towa rd th e goal of improvi ng la bor a nd birth o utcomes .

Conclusion

Both the socia l su pport li rcra w re a nd Rubin 's w rit ings p rovide a th eoretica l fo und ation fo r in trapar tulll nu rs ing ca re. Rubin (1968 b) desc ribed nursing as a n in te ractive helping process and suggested tha t inrraparrul1l nurses sho uld c rea te in t he la boring woma n feelings of accept­ance a nd of be ing va lued. Regard in g th e nurse as a sup­po rt provider, Rub in clea rl y esta bli shed bo th the p riv ilege and comm itment tha t nurses have when they help women "through t he va ll ey of the shadow tha t a ll wo men wa lk to

have a child " (Ru bi n, 1975b, p . 1685) . To prov ide nu r­wr ing and empatheti c carc, nurses need a se nse of respect a nd awe fo r the t ria ls a nd endeavors o f la bo ring women . A fina l qu o te ca ptures the e mbedd edness of soc ia l support theory within Rubin 's fra mewo rk :

Nu rses perfo rmed miracl es of heali ng ... . T here is someth ing very specia l a bo ur the la ying o n of ha nds right w here th e h urt is . .. . Mothers lefr the hosp ita l fo r ho me fee ling ca red fo r, res pected , and wa n ted in thi s wo rld. (Rub in, '19 75a, p. 1682)

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Ma rtha Rider Sleutel, PhD, RN, eNS, is a n assista l1 t professor of Ilu rsing, Angelo State Unive,-sity, San Angelo, TX.

Address for correspondence: Mmtha Rider Sletf tel, Ph D, RN, eNS, Department of Nursing, Allgelo State University, 2601 West Avenue N, San Angelo, TX. E-mail: martha.sleutel@ange­IO.edll .

Volume 32, Number '/