Support For Nurses Directly Involved With Women Who Chose To Terminate A Pregnancy

Research conducted by Poggenpoel, Myburgh and Gmeiner (1998:2-8) on “One voice regarding the legalization of abortion: Nurses who experience discomfort” indicated that the nurses were in favour of the fact that nurses should volunteer to participate in terminating a pregnancy of a woman. From our observations in clinics where nurses voluntarily participate in providing reproductive health services, in­ cluding termination of pregnancy, it became clear that supporting these nurses may be essential. To be able to provide support, it is necessary to identify, explore and describe nurses’ experience of being directly involved with women who terminate their pregnancy. To enable us to address the identified problems, a qualitative research strategy was implemented in which respondents were included in the sample through purposive sampling. Phenomenological interviews were conducted individually. Data was analysed by means of Tesch’s descriptive approach. Thereafter, guidelines for operationalisation were inferred from the results and a literature control completed to verify and enrich guidelines. Measures to ensure trustworthiness have been ap­ plied in the research and ethical measures have been strictly adhered to regarding this sensitive issue.


Rationale and Problem Statement
Since 1994, with the election of the Government of National Unity and the democratization of the South African society, many changes have taken place that also directly influence the health care delivery system in South Africa.
In the health care service delivery system particularly, wom en's health became a priority to be attended to -specifically their reproductive choices and their own health.This entail that they may also choose to terminate a pregnancy as stated in the Freedom of Choice of Terminating Pregnancy (Act no.92 of 1996).Since February 1997, more than 160 000 termina-

Research Article
tio n s o f p re gn an cy have been carried o ut (Badenhorst, 1999:13).The impact of this large number of terminations on the health delivery system is enormous.Little provision has been made in the infrastructure to absorb this reality (Beeld, 1997:5;P oggenpoel, M yburgh & Gmeiner, 1998:3).Not enough well prepared professionals, clinics and finances are available.
The nursing profession in particular, has been directly influ enced by the impact of the legalization of wom en's freedom of choice to term inate their pregnancy.Large numbers of nurses refuse to be involved in the nursing of women who chose to terminate their pregnancy (Barometer, 1997:8).In research conducted by Poggenpoel, Myburgh and Gmeiner (1998:2-8) on "One voice regarding the legalization of abor tion: Nurses who experience discomfort" , they identified five major themes regarding the termination of pregnancy.These five themes are: the freedom of choice of nurses to provide support before, during and after the termination of pregnancy; negative perceptions regarding the woman who requested a termination of pregnancy and staff providing a termination; the need for information to women, the community and nurses; turmoil regarding life versus death, and recommendations from nurses regarding the management of term ination of preg nancy.
From these results it became clear that the nurses were in favour of the fact that nurses may freely choose to be directly involved with the execution of the procedure.
From our observations in clinics where nurses voluntarily par ticipate in providing reproductive health services including ter mination of pregnancy, it has become clear that supporting these nurses may be essential.To be able to provide support, it is necessary to identify, explore and describe the nurses' experience of being directly involved with women who termi nate their pregnancy.
Little or no research has been conducted to explore and de scribe the experience of nurses directly involved in the termi nation of a pregnancy by a woman, or the support they need or receive.

Research Aims
Two aims were formulated for the research project described in this paper:

•
The exploration and description of nurses' experiences of being directly involved with women's termination of their pregnancy; and

•
The description of support needed to assist nurses who provide this service.

•
The focus in this article is on describing guidelines for support of nurses directly involved with wom en's ter mination of their pregnancy.
The focus was to obtain data that would facilitate understand ing of nurses' experiences of being directly involved with women who terminate their pregnancy.This understanding forms the basis for describing support guidelines to assist these nurses.

Research Method
The research was conducted in two phases.
Phase 1: The exploration and description of nurses' experi ence of being directly involved with women's termination of their pregnancy In phase 1 attention will be given to sampling, data gathering, data analysis and literature control.The issues regarding trust worthiness and ethics will further be addressed.
Sampling: Respondents were included by way of purposive sampling (Creswell, 1994:15).The criteria for inclusion were: nurses who are voluntary directly involved with women who choose to terminate their pregnancy and who consent to par ticipate in the research.
D ata c o lle c tio n : Data w as g a th e re d by m eans of phenomenological interviews and field notes.
Phenomenological interviews (Kvale, 1996:81-107;Marshall & Rossman, 1995:80-83;Ornery, 1983:61) were conducted with respondents.These interviews focused on the lived experi ence of each specific respondent (Poggenpoel & Myburgh, 1999:2).One central question was posed, namely: "How did you experience being directly involved with a woman's termination of her pregnancy?" The interviewer created a context where the respondents could speak freely and openly by utilizing communication techniques such as clarification, paraphrasing, summarizing, probing and minimal verbal as well as non-verbal response (Wilson & Kneisl, 1996:110-131).
During the interviews the interviewer used bracketing (plac ing preconceived ideas aside) and intuiting (focusing on the lived experiences of the respondents regarding the termina tion of a pregnancy).The interviews were conducted until the data was saturated as demonstrated by repeated themes.
The interviewer wrote field notes based on observations made during interviews.These field notes addressed the interview er's observations, personal experience, methodological issues and theoretical notes (Wilson, 1989:436-438).
Data analysis: Data was descriptively analysed using Tesch's (in Creswell, 1994:154-156) method of descriptive analysis.An independent coder analysed data independently from the vari ous researchers (Creswell, 1994:158;Krefting, 1990:216).Con sensus discussions were held between the independent coder and researchers and identified themes were refined.A litera ture control was done to verify the results (Poggenpoel, 1993:3).
Measures to ensure trustworthiness were applied.Guba's (Lin coln & Guba, 1985:290-327) strategies of credibility, transfer ability, dependability and confirmability were applied.Activi ties in achieving credibility were prolonged engagement in the field, keeping reflexive journals, the researcher's authority, tri angulation, peer review and structural coherence.Transfer ability was achieved through a dense description of the data and purposive sampling.Dependability was achieved by a description of the method of data gathering, data analysis and interpretation.Finally, confirmability was achieved by ensur ing an audit of the entire research process, reflexive analysis and triangulation.
Ethical measures (Democratic Nurses Association of South Africa, 1998:7) were adhered to during the research regard ing this sensitive issue.These included ensuring quality of the research, informed consent of respondents, ensuring confi dentiality and anonymity, protection from harm and providing feedback on the project to the respondents.

Curationis March 2000 71
Phase 2: The description of support guidelines to assist nurses directly involved with a woman's termination of her pregnancy Dala_gathering: Inference (Copi, 1986:57) was used to iden tify support guidelines from the results obtained in phase 1.
Data analysis: These were discussed with caring profession als to ensure trustworthiness.Thereafter a literature control was done.

Results And Discussion
Five major categories were identified from the experiences of nurses directly involved with wom en's termination of their preg nancy.Refer to Table 1 for an overview of major categories, subcategories and direct quotes from nurses directly involved w ith te rm in a tio n o f pre gn an cy.These c a te g o rie s and subcategories will only be referred to briefly, as the focus of this article is on guidelines for support of nurses directly in volved with termination of pregnancy.
Description of guidelines for support of nurses directly involved with women who chose to terminate a pregnancy From the results of interviews on nurses' experience of being directly involved with termination of pregnancy as depicted in table 1, it can be inferred that they need support.Support for these nurses will be provided by means of a continuos support group based on Yalom's (1985;1-500) ap proach of group therapy.The time frame for these groups can be many weeks or months.The goal for the advanced psychi atric nurse practitioner will be to build cohesiveness over many sessions, and allow the nurses involved with termination of The above results are discussed in more depth in Gmeiner, Van Wyk, Poggenpoel & Myburgh, 1999 -Unpublished article).

T ab le 1: An o verview of m ajor c a teg o ries and su b categ ories of th e results of nurses' ex p erie n c e of being d ire c tly involved w ith term in a tio n of pregnancy
pregnancy to describe their experiences, share their feelings, and assess their strengths.The main goal will be to support nurses involved with termination of pregnancy to express and find new meaning in their every day experiences, through dis cussing and entering their experiences in their reflective dia ries.Short-term goals might focus on involving the nurses in volved with termination of pregnancy in a support debriefing process, verbalisation of experiences and listening to other experiences, decreasing isolation and providing support for others.The story needs to be told from group meeting to next group meeting.As Yalom ( 1985: 467) states:" group therapy is often cyclotherapy, because they must return again and again to the same issues in the therapeutic work" .
Support group interventions in this context will provide a unique opportunity for nurses involved with women who chose to ter minate a pregnancy to feel accepted, trusted, cared for and supported by others.Yalom (1985:3-18) describes these fac tors of feeling accepted, cared for, trusted and supported, as therapeutic factors.He suggests that therapeutic change is an enormously complex process and occurs through an intri cate interplay of various guided human experiences.These factors are: catharsis (ability to ventilate feelings/experiences), group as a second family; awareness (thoughts, feelings and/ or bodily responses); group cohesiveness (involvement); re ceiving information; imitative behaviour (modeling); faith and giving and receiving help.The nurses involved with termina tion of pregnancy will also have the opportunity to get insight into the universal commonness of their feelings, ideas and behaviours and will appear to feel a sense of caring or love for one another.
In providing support, members receive through giving -not only as part of the reciprocal giving-receiving sequence, but also from the intrinsic act of giving.The experience of finding that you can be important to others is refreshing and boosts self-esteem (Yalom, 1985:14).The value of this support group then lies in the following story: "There is an old hasidic story of a Rabbi who had a conversa tion with the Lord about Heaven and Hell."I will show you Hell," said the Lord and led the Rabbi into a room in the mid dle of which was a very big round table .The people sitting at it were famished and desperate.In the middle of the table there was an enormous pot of stew, more than enough for everyone.The smell of the stew was delicious and made the Rabbi's mouth water.The people around the table were hold ing spoons with very long handles.Each person found that it was just possible to reach the pot to take a spoonful of the stew, but because the handle of the spoon was longer than anyone's arm, no one could get the food into his mouth.The Rabbi saw that their suffering was indeed terrible!" Now I will show you heaven," said the Lord, and they went into another room, exactly the same as the first.There was the same big round table and the same enormous pot of stew.The people, as before, were equipped with the same long-handled spoons, but here they were well nourished and plump, laughing and talking.At first the Rabbi could not understand." It is simple, but it requires a certain skill," said the Lord."You see, they have learned to feed each other!" Yalom's approach to support in a group, within the context of narrative therapy will be utilized in providing guidelines to as sist nurses directly involved with women choosing to termi nate a pregnancy.Figure 1 depicts a conceptual framework for the support group.The figure will now be discussed.
The goal of this support group as we conceptualized it will be to support the nurses to work through their own personal trauma, psychological defense mechanisms, hosting secre tiveness and their need for support.The group's task might be to help members overcome feel ings of self-contempt, loneliness, alienation and disengage ment and to help them attach new and different meanings to their experiences through reflection.The hope is to trigger a small change in the picture or in the nurses' understanding of the picture (Andersen, 1987:427).

Suggested structure of the support group
Relationship phase (creating a context) A context needs to be created where the nurse involved with women who chose to terminate a pregnancy, can develop as a reflective practitioner.The nurse needs to develop the abil ity and skills to reflect on the influence of the process of abor tion on her internal world, and to voice these experiences through utilizing reflective diaries and meanings.Reflective diaries will provide the nurse with the opportunity to enter her interactions into the diary, focusing on the situation, her thoughts, feelings and actions.She will bring this diary to the support group and will be able to discuss issues concerning him/her (Weiner, Caldwell & Tyson, 1983:179-183).In this way new ideas can be generated for the nurse involved with women who chose to terminate a pregnancy.In the social sciences, at least, it is now generally recognised that it is not possible for people to have a direct knowledge of the world, that an objective description of the world is not available to us and that no-one has privileged access to the naming of reality, whatever reality is.What the nurse involved with the termina tion of pregnancy know of the w orld, she/he only knows through experiencing it.The best that can then be done in this support group is to interpret the experiences, that is the expression of experiences as they go about the business of interpreting it for themselves.
To interpret (the interpretation of others) the advanced psy chiatric nurse practitioner has to rely on her own lived experi ence and imagination.The most she can do is to identify her own experience of the experience, as expressed by the group members.Thus "empathy" is a critical factor in the interpreta tion or understanding of the experiences of these nurses (Epston & White, 1989-1991).
Certain questions are raised to investigate the ways these nurses make sense of their lives to themselves and others, and focus attention of the processes through which meaning is attributed to experiences.By asking these questions, the meaning these nurses ascribe to their experience, can be deconstructed: • What process is used by these nurses to develop an understanding of their experience and give meaning to?
• How do they make sense of their experience to them selves, and how do they make sense of their experi ence to others?
• What processes are involved in their interpretation to articulate their lived experience to themselves and oth ers?
• What facilitates the expression of their experience?
• How does the expression of their lived experience af fect their lives and relationships?
In order to give meaning to experience it must be organised, framed and given a pattern (Epston & White, 1989-1991:79).

Termination phase
The nature of the frames that facilitate the interpretation of experience needs to be deconstructed.The narrative/story provides the primary frame for this interpretation for the activ ity of meaning-making; it is through the narratives or stories people have about their own lives and the lives of others, that they make sense of their experience.
For deconstruction to take place the context created by the advanced psychiatric nurse practitioner must be open, flexible, filled with respect and curiosity to facilitate con versation, utilising different facilitative techniques.Circu lar questioning to map interaction, focusing on behaviour, perceptions, feelings, beliefs and ideas, e.g."the more you say this the quieter the group becomes".Reflective ques tioning to facilitate reflection -"what do you think happens to the rest of the group when you do this?" Letter writing as a way of reflection from the therapist.The therapist can write a letter to the group commenting on the process of externalizing problems (Epston, 1994:32).The letter can also act as a mechanism for continuous interaction.
Following is a discussion of a suggested process for the im plementation of a support group.

H
Opening and glimpses A decision should be made about who should attend the group (criteria for inclusion) and how many members.Proper pre group orientation leads to greater member satisfaction, in creased group cohesiveness and an increased level of inter personal exploration (Yalom, 1988:118).The initial interview could be the beginning of support and the nurse involved with termination of pregnancy needs to take the responsibility to decide what she would like to address/share in this process.The s u c ce ss o f s u p p o rt g ro u p s a lso d e p e n d s on the commonalties that members share and should be considered in the initial phase (Weiner, Caldwell & Tyson, 1983:179-183).It might be suggested that the initial meetings are approached by providing structure, realizing that defense mechanisms play a significant role in providing equilibrium to the nurse involved with the termination of pregnancy and that removing or ad dressing these too soon, might lead to some of the nurses experiencing a deep sense of sadness and depression too suddenly.Initially, the success of groups is also determined by providing structure (Weiner, Caldwell & Tyson, 1983:179-183).According to Yalom (1998:121) structure should be provided in the first meeting (opening) commencing by going around the room, giving each nurse involved with the termination of pregnancy, the opportunity to discuss the goals they have, aloud.
It is also imperative that the advanced psychiatric nurse prac titioner guides the members in the group right from the begin ning to interact directly with other members of the group and explore interactions (activating the here-and-now).Questions should be worded in a non-threatening way for the support group to be beneficial.
In creating the support group McDonald (1994:40) also states that the program should have the full support of all levels of management.Everyone must understand the value of the support group, as one nurse stated: "Even if it's a bad day, you cannot cancel the support group" (McDonald, 1994:40).Norms need to be set in the opening meeting that include a consistently available meeting room, refreshments and spe cific times.Perceived safety and privacy of the group is a key stone to its growth (McDonald, 1994:40).McDonald (1994:40) also suggests that consistent advertis ing; exploration and recruitment will be needed to attract regu lar group members.A meeting for six to nine months of the year is a good strategy, taking a break before reconvening.
In this initial opening the nurses should be allowed to share the experiences of their involvement with women who chose to terminate a pregnancy and be allowed to experience a sense of reliving and meaning generation (Barker, 1987:121).
The first two to three meetings could be utilized as debriefing sessions, and a way for the nurse involved with termination of pregnancy, to share his/her feelings and experiences.Debrief ing especially focuses on facts, thoughts, reactions and symp toms regarding termination of pregnancy.
The nurse involved with the termination of pregnancy could be encouraged to talk about those aspects with which she/he feels most comfortable.She could share with the group what she sees daily and how she reacts to this stimuli.
The advanced psychiatric nurse practitioner can slowly facili tate this conversation into feelings, focusing on how the nurse involved with the termination of the pregnancy felt then and how she is feeling now.A context for telling a story and creat ing meaning will be created (Miller, 1992:58-60).The advanced psychiatric nurse practitioner also needs to be reflective on the process of the group and therefore needs to keep brief data notes on a weekly basis for the purpose of maintaining continuity of the support group discussion (Guillory & Riggin, 1991:173).The nurses involved with the women who chose to terminate a pregnancy could also be asked to keep a re flective diary, entering reflections of their experiences of work ing with these woman and reflecting on their interactions with meaningful, significant others (colleagues and family).This could be brought to the support group as means of discus sion (Burns & Grove, 1993:387).
Hamilton and Kieter (in Burkes, 1998:111) also suggest that the following questions could be useful in the opening phase of a support group: What is the purpose of this new support group?How will the meetings be structured/unstructured?Will speakers of presentations be part of this support group?How frequently will this group get together and what time of the day?How long will the meetings last?Where will the meetings be held?How do we plan to announce meetings -by mail, word of mouth or phone?Does anyone in the organisation need to be notified about the existence of the group?Any refreshments?The name of this group?
Nurses who have made the choice to work with women who chose to terminate a pregnancy have to learn to care more for each other and give more support to one another.

■
Out of the prison of confusion (value clarification) Those who come in contact with the emotional needs of the patient need some support and reflection for themselves.The goal in this phase might be to explore the nurses' perception of their values and how these might relate to perceptions re garding patients.The central concern will be to explore why the nurses involved with termination of a pregnancy experi ence the predicament of an unwanted pregnancy in such judg mental terms.Could this be an argument best understood by unpacking and exploring their identity as nurses, mothers and wives?According to Walker (1994:43-67) in this discourse abortion symbolises a denial of a woman's true calling.
One aspect that needs to be addressed in this group is the issue of role-clarification.On the one hand nurses are com pelled to adhere to legislation and on the other hand nurses are socialised as caregivers.As such they are expected to empathize with and understand the very difficult and often traumatic experiences women have when faced with the predicament of an unwanted pregnancy (Walker, 1994:70-71).
Most of the women in this study were African nurses and as Walker (1994:58) states: "Role conflict might be heightened by the high status held by African nurses in their community.African nurses are members o f the Elite in their communities, as evidenced by their friendships, lifestyles and membership o f professional and voluntary organisations."As discussed previously this lead to the nurses becoming secretive about their work, related to fear for stigmatization and victimization.Christianity also proves to be a significant source of inner con flict regarding abortion.These questions of religion and mo rality need to be dealt with in this group.When nurses are confronted with the question of abortion they overwhelmingly tend to retreat into cold indifference.They withdraw from their patients and do not empathize with or take action to help their patients in any way (Walker, 1994:58-59).This could be dealt with by enhancing ethical-moral reasoning and behaviour.According to Brammer and Shostrom (1989:340-341) the nurse should be helped to develop more complex processes for making value decisions based on reflection of their ultimate values.The nurse involved with term ination of pregnancy needs to focus more inwardly, and learn to trust what he or she uncovers from his or her core being.The task of the ad vanced psychiatric nurse practitioner will be to help nurses involved with the termination of pregnancy to examine their implicit beliefs, to know how they are projecting their core val ues and to see how they perceive external values.These core values are learned during a growing-up process from values held by parents and others close to the person.According to Brammer, Shostrom and Abrego (1989:343) the structure that constitutes reasoning about value issues involves the follow ing set of interrelated mental activities, and could be utilized as a framework in this support: group to clarify beliefs and values: 1.

2.
Interpretation of values with possible referral to biblio therapy or pastoral counseling.Determination of pos sible meanings.

3.
Consideration of probable consequences of specific acts on self and others.

4.
Judgment about what to do. 5.
Supervision of judgm ent while remaining open to new information.Brammer, Shostrom and Abrego (1989:343) also suggest that the advanced psychiatric nurse practitioner can enter into dia logue with the nurses involved with termination of pregnancy to help them engage in reflective activity, entailing systematic questioning and listening, to discover contradictions, distrac tions, discrepancies and hidden meanings in beliefs and val ues underlying their decisions.LeBaron and Carstarphen (1997:341-358) agree that these value issues/conflicts could be dealt with in small groups where personal interaction is possible.In these groups, members share stories of how they came to their belief about abortion.
The small group activities are designed to break down stere otypes and allow each other to reveal shared concerns, hopes and values.Through this whole process trust and empathy must be fostered.

■ Act of reliving and remembering personal trauma / Addressing the monstrous consequences of psychologi cal defense mechanisms
Psychological defense mechanisms act as a shield of protec tion against emotional pain.Many of these nurses intellectualized and rationalized their experiences regarding their in volvement in termination of pregnancy.According to Richards, Cozzarelli, Cooper and Zubek (1998:735-752) the more women coped with their abortion-related emotions through avoidance strategies, the less well adjusted they were.
Coping with abortion-related emotions through seeking so cial support was associated with lowered levels of psycho logical distress.The aim of this group will then be to facilitate ventilation of feelings, and addressing defense mechanisms through illiminating the process and activating the here and now.
The aim is not just to focus on the explicit content (spoken words) but to ask the question: "What do these explicit words, the style of the participants, the nature of the discussion, tell about the interpersonal relationships of the group members, and of the group member him-/herself" .By reflecting on this, the group members will also have the opportunity to explore their own personal worlds and reflect back on that (Yalom, 1998:45).Thus the advanced psychiatric nurse practitioner focus on the meta-communicational aspects of the message and wonder why, from the relationship aspect, the nurses make a statement at a certain time in a certain manner to a certain person.As the group progress and build trust, the advanced psychiatric nurse practitioner can also steer the group into the here and now, away from the discussion of outside material and focus their energy on their relationships with each other coming from the same clinic, in order for them to be able to provide feedback to each other's behaviour, and develop more reflexivity about their own interpersonal skills.A balance be tween structure and space for personal reflection needs to be provided to break down the defenses against anxiety (Franks, Watts & Fabricius, 1994:1168).

H
The community and the wall of silence Silence in this context lies in the unpacking and exploration of these nurses' identity as women, mothers and nurses.The constructed meanings they have about the above, need to be explored.For most of these nurses ideas about womanhood and motherhood are intricately interwoven and culturally de termined (Walker, 1994:47).
Another voice introducing silence, is the power of men com manding obedience from African women in this context.The nurses need to voice these silences and generate new mean ings to this story.A way of doing this would be to consult the consultants -the advance psychiatric nurse practitioner can consult the community leaders in generating a new story for these nurses or consult the nurses themselves.
According to Epston andWhite (1989-1991:17) when people are established as consultants to themselves, to others and to the therapist, they experience themselves more of an au thority on their own lives, their problems and the solutions to these problems.Special attention could be given to an explo ration of how they arrived at this knowledge, and how this knowledge affects their lives.

Termination phase
In the process of reconstruction the hope would be in the end to provide a context where the nurse involved with termination of pregnancy, felt love form him-/her-self, allow others to care and to love her/him and to be more reflective and to search and trust his/her own values.Termination is but a stage in the nurse's career of growth, and is not tantamount to stagnation (Yalom, 1975:369).Nurses involved with termination of preg nancy will continue to change and derive new meanings from their experiences.According to Yalom (1975:369) not only growth, but also setbacks occur following term ination and some of the nurses might encounter stress, anxiety and de pression following departure from the group.A period of mourning is an inevitable part of this phase.The group may need some sessions to work on their loss and to deal with many of these termination issues.The advanced psychiatric nurse practitioner needs to call the nurses' attention to the impending termination.The group might be reminded that this is their group and they can decide how they want to end it.The final meeting can be embraced by personal testimoni als, reminding one another of the way they were then, and how they are now, reflecting on the entries in their diaries.These new and different meanings can also be documented in discourse and within the diaries.White and Epston (1989Epston ( -1991:16) :16) found the following approaches helpful in reviewing their exploration of practices of re-incorporation, and recon struction can involve the identification of change and could include:

•
Celebrations and prize givings and awards, attended by significant others.

•
Purposeful "new releases" where pertinent information as to the nurses' arrival at a new story/meaning is made available through one another to one another (reflexivity).
• Personal declarations and letters of reference.
• Consulting the community in a formal sense in relation to the solutions/ knowledge that have enabled them to free their lives.
The advanced psychiatric nurse practitioner needs to facili tate the process throughout, by reflecting on her/his own feel ings about separation and ideas around reconstruction (Yalom, 1975:374).

Conclusion
The process of deconstruction assist in establishing a sense of empowerment for nurses involved with termination of preg nancy -being able to play an active role in the shaping of their own lives and their involvement with termination of pregnancy.This sense of empowerment is established through a process of co-construction through the development of some aware ness of the degree to which extent their involvement with ter mination of pregnancy shape their existence.This provokes in the advanced psychiatric nurse practitioner a curiosity with regard to alternative versions of who these nurses might be.This is a curiosity of how things might be otherwise and differ ent, in reconstructing new and different meanings.