Advanced Practice Nursing: Reva Rubin’s Concept of Maternal Role Attainment

The nursing profession is not only a discipline but an art. The work of nurses such as Florence Nightingale and nursing theorists has helped to develop nursing as both an academic discipline and a specialized field of practice. Since the work of Florence Nightingale in the 19th century, many additional theorists and their contributions to the profession are well-known. A few of the well known theorist, such as Romona Mercer, Jean Watson, Elizabeth Lenz, and Linda Pugh, along with Florence Nightingale, has lead the way for the continuing advancement of nursing practice (Klette & Peterson, 2017). A nursing theorist whose work has had a major influence on the way in which maternal identity and maternal health nursing is viewed and practiced is Reva Rubin.

Reva Rubin discussed maternal behavior, puerperal change, self-care, attainment of maternal role, and identity. Historical Background Reva Rubin introduced the concept of Maternal Role Attainment (MRA) in the late nineteen sixties (Rubin, 1984). Reva Rubin’s concept of maternal role attainment was developed to help women and nurses in the maternal experience and maternal identity (Rubin, 1984). Within her study, the subject in action were new mothers. The situation dictated by nature was the maternal experience. The natural setting was the nurse as an observer was natural to the maternal experience in a helpful and functional way (Rubin, 1975). Independent variable was the nurse and the dependent variable subject was the mothers. In the 1960s more than 6,000 patients were a part of a research study on a maternal experience (Rubin, 1984). Data was collected throughout the first missed menstrual period through the sixth week postpartum (Rubin, 1984). The primary question asked was “How does this woman feel about herself in this situation at this time?” another question was “How do women use nursing help in each stage of the postpartum experience if nursing is available and accessible?” (Rubin, pp. 170, 1984). She described the maternal role as a complex cognitive and social process which is learned, reciprocal, and interactive. Maternal identity is considered the endpoint of MRA, characterized by the woman’s comfort in her role. Rubin noted, “That the formation of a maternal identity that binds the women into this child and to becoming a mother of this child is gradual, systematic, and extensive” (Rubin, 1984). Prior to Reva Rubin’s theory of maternal identity, the maternal experience focused on the physiological and biological aspect of a woman’s care (Rubin, 1967). Rubin’s work assisted nurses to go beyond physiological and pathological aspects of childbearing.

Areas for providing additional help were identified by observing the maternal experience (Rubin, 1984). Rubin was able to help guide women and develop an understanding of these behaviors through this process. Major Concepts Reva Rubin focused on maternal nursing and developed concepts on maternal identity. She believed that a mother needed time to absorb and integrate her labor and delivery.

The changes that the woman undergoes are crucial within the first 24 hours of postpartum, especially the psychological changes. These changes might affect the woman permanently if not given the appropriate attention and care. According to Rubin, there are four maternal tasks the woman accomplishes during a pregnancy include: seeing safe passage for herself and her fetus, securing acceptance of herself as a mother and for her fetus (taking in), learning to give of self and to receive the care and concern of others (taking hold), and committing herself to the child as she progresses through pregnancy (letting go) (Rubin, 1967). During the Taking in phase, the mother is oriented primarily to her needs for the first day or two after delivery. Her primary focuses on sleeping and eating.

She may be quite passive and dependent. She is preoccupied with her needs and wants others to make decisions for her and take care of her. The mother is reacting to the intense, physical effort expended during delivery and the intense, emotional effort required of her during labor which may result from her immediate dependency due to physical discomfort from hemorrhoids, or the after pains and extreme fatigue. The mother does not initiate contact with the infant. Nevertheless, the mother is taking in information that helps her to identify the infant. The mother may use her finger-tip to touch her infant.

This serves as one of the first steps in the identification process. Also, she holds the baby facing her so they can explore each other’s face (in the face position). The mother relives the delivery experience which allows her to integrate it fully with reality, fully realized her baby is born, and to identify her infant as being outside and separate from her. This phase, taking-in phase, may last for a day or two. The nurse should plan activities so that the patient can rest as much as possible because failure to allow the patient to receive the necessary and earned rest may yield a “sleep hunger” which may be manifested by irritability, fatigue, and general interference with the normal restorative process (London et al., 2017). During the Taking Hold phase, this is 2-3 days after delivery.

This phase usually lasts for about two days, and the latter part of this phase is accomplished at home. The mother strives for independence and autonomy, she becomes the “initiator”, and however, she is still dependent as well. The mother is ready to resume control of her life and assumes responsibility for her newborn as her needs are being met. She is ready to try to control her bodily functions (that is, bowels, bladder, and if breastfeeding, concerned about the adequate amount and quality of milk). She may also be concerned about her ability to take care of her newborn. This is a good time to begin teaching, providing explanations and reasoning, instruction, demonstrations, and providing reassurance and guidance.

The woman still needs positive reinforcements despite the independence that she is already showing because she might still feel insecure about the care of her child (London et al., 2017). The Letting-Go Phase occurs around the fifth-week postpartum, while at home the mother adjusts to her new role. She establishes and accepts the new image of her baby, family, and role while trying to relinquish her former role before the baby.

The mother must adjust her life to the relative dependency of her child. If she quits work, she must adapt to less freedom, less autonomy, and less social stimulation. If she continues to work, she must handle the additional strain of finding sitters and meeting additional workload. The mother may experience a temporary postpartum depression or “baby blues” period (London et al., 2017). Applied Use within Advanced Practice Nursing Rubin’s theory goes well together with standardizing nursing care and creating nursing practice interventions. The theory was first developed and recognized in the 1960s, its use and application are still relevant in the mother’s postpartum care today. Nursing programs today are still applying maternal role attainment and identity in the nursing criteria.

Nursing theories serve as a basis for knowledge that will affect nursing practice. The maternal identity theory and other nursing theories help guide nursing’s knowledge and practice about how to best help new mothers transition from being a woman who is carrying or birthing a child into a woman who identifies with the role and duties associated with motherhood (London et al., 2017). The theory helps the nurses assess, plan, implement and evaluate the care of mothers and children (London et al., 2017). The theory also helps to have educational and interventional programs for the mothers who are at risk for not transitioning well into their role (London et al., 2017). Advanced practice nurses who work in obstetric services (obgyn, and nurse midwives), postpartum, or with pediatric patients (nurse practitioners) can also benefit from knowing Rubin’s work as they care for their postpartum. They often see both mother and child interactions and may be aware of family dynamics and factors that exert an influence on how well mothers do or do not transition into their role or identity. Their added clinical knowledge and experience may also help to identify women or mothers with postpartum depression and be in need of intervention. Theory and scientific knowledge within nursing are key to ensuring the future of the nursing and nursing practice flourishes as a practice and a discipline (London et al., 2017). Benefits and Limitations Original theories should still be used but practiced within nursing based on current knowledge.

Rubin’s theory has led to major advances that support a woman through the postpartum process. Despite what is considered to be significant advances in maternity care, such changes should be recognized as based on information obtained from mothers from 1960s (Rubin, 1975). Social and technological changes have made the family now vastly different from those families of the earlier periods regarding attachment. For instance, now we have 3-D ultrasounds that can show you what your child will look like rather than an ultrasound that shows you the basic body structures. This allows the parents as well as the family members to grow attached to the baby in a different way than they would in the 1960s. The parents identify more with the baby by saying ‘he/she has my nose or lips’. This then leads to different outcomes in the postpartum stage with the concepts of taking in, taking hold, and letting go. Nowadays, there are many different portable technology devices available for postpartum mothers. Parents now have the ability while still in the taking hold stage to access all the information they need for free from the comfort of their home.

The hospitals see fit to discharge mothers from the hospital during the taking hold stage even if they have not learned everything at the hospital they can continue their learning from home. As a result, much of the information on which Rubin based her observations is obsolete today.

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