Abstract
Objective:
To hear the voices of women, their partners, and nurses about expectations and priorities during the postpartum hospitalization.
Design:
Focus groups using semi-structured interview questions.
Setting:
A 12-bed labor-delivery-recovery-postpartum unit at a small urban hospital in the Northeast.
Participants:
Women who planned to or had given birth, their partners, and the maternity nurses who cared for them.
Measurements:
Qualitative thematic analysis of focus group transcripts
Results:
Thematic analysis produced the following themes for women’s priorities: need for individualized attention to maternal physical and emotional care; fear of providing inadequate care for the newborn including establishing infant feeding; and, the difference between transitioning to parenting as a new mother versus as an experienced mother. Themes for nurses’ priorities included safety issues around sleep and breastfeeding; transitioning to parenting with an emphasis on maternal self-care; and addressing barriers to effective discharge education. Response comparison between the women/partners and nurses suggest that there is a disconnection between women’s and nurses’ priorities and expectations for care during the postpartum period
Conclusion:
Both women and nurses identified unmet needs in the postpartum period, consistent with current literature. It is likely that providing standardized education during the transitional period around discharge from the hospital to home is not optimal and may even detract from meeting needs for rest and connection with family and the health care team. Nursing care that extends beyond the maternity hospitalization may be needed to individualize care and meet previously unmet needs.
Keywords: discharge teaching, fourth trimester, health education, maternal satisfaction, patient satisfaction, postpartum
Precis
Differing priorities among women and nurses for postpartum teaching necessitate alternate ways to meet women’s needs, and suggest that nursing care should be extended beyond discharge.
Maternal-newborn care at its best is focused on health promotion during a critical developmental phase for families. Toward that end, education is a key aspect of the nursing role in maternity care. In fact, education is a deeply entrenched and valued professional nursing function (Bastable, 2008). Maternity care during the postpartum hospitalization blends responsibility for ensuring physical recovery for women, supporting newborns’ transition to extrauterine life, establishing newborn feeding, and educating families on newborn care and safety. There is much to accomplish during this brief hospitalization, conducted in an environment with many visitors, unpredictable newborn demands, and often fatigued mothers.
Reducing risks for maternal mortality and morbidity has become a public health priority (National Center for Chronic Disease Prevention and Health Promotion, 2017a, 2017b). Guidelines and tools for nurses to help address this need have been developed by the Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN, n.d.), with the goal of reducing postpartum complications through focused education. In addition, since 2016, a multidisciplinary initiative known as the 4th Trimester Project (UNC Center for Maternal and Infant Health, n.d.) has raised awareness of the myriad of unmet physical and psychosocial needs identified by both women and their health care providers (Lu et al., 2006; Martin, Horowitz, Balbierz, & Howell, 2014; Tully, Stuebe, & Verbiest, 2017).
For maternal-child nurses working in the postpartum setting, the importance of meeting the many needs of families creates an urgency around postpartum discharge education. Accrediting bodies such as the Joint Commission rightly seek documentation that patient safety goals are being met (The Joint Commission, 2019). Initiatives to improve care based on patient feedback, such as Press Ganey (2019), focus on goals of patient satisfaction. Professional organizations highlight the need for better preparation, recognition, and response to complications such as postpartum hemorrhage (AWHONN, 2017). Nurses juggle all these priorities in a fast-paced and frequently changing environment. It is no wonder that many standardized checklists are created to ensure that no topics are missed prior to discharge.
While nurses and other health care providers are charged with providing ever more content, there is little evidence to determine whether the breadth of discharge teaching is received and retained by women and families in this transitional life change, and some evidence that it is not (McCarter-Spaulding & Shea, 2016). Despite the large proportion of valuable nursing time dedicated to discharge teaching, current systems appear to be inadequate to address postpartum medical and psychosocial risks (Lu et al., 2006), or to meet women’s identified needs for support with breastfeeding, newborn care, maternal self-care, and postpartum depression (Kanotra et al., 2007; Kleppel, Suplee, Stuebe, & Bingham, 2016; Tully et al., 2017). Standardization of topics to be addressed may compete with individualized care based on maternal/newborn/family needs and priorities.
Our purpose was to listen to the voices of women, their partners, and nurses about their expectations and priorities for education and anticipatory guidance during the postpartum hospitalization. These results are being used to inform strategies being developed by the hospital’s postpartum education committee to improve nurses’ ability to provide individualized care that also prioritizes safety.
Design
For members of the postpartum education committee to understand more clearly what women and families expected and desired, we convened five focus groups for women and their partners, and two focus groups for nurses. Our aim was to provide insight into whether nurses and childbearing women identified the same priorities for postpartum care. Currently in this hospital, women are given a standardized list of content areas to be covered, and they indicate which areas they would like to address with their nurse. This content is also available in a written booklet. During the hospitalization, nurses address each of these content areas with a woman and her family if desired. Once these items are addressed, both the nurse and the woman sign paperwork indicating that teaching has been completed. This form must be completed prior to discharge.
Sample
We recruited participants for this convenience sample from women who had given birth or planned to give birth at a 12-bed maternity unit of a small urban hospital in the Northeast, at which there are approximately 1,000 births/year, and from the nursing staff of the hospital. Following approval by the hospital’s Institutional Review Board, we convened a total of seven focus groups between 2015 and 2017--five with women/partners and two with nurses. We offered focus group participation to recent participants in a research study of postpartum discharge education, and women/partners who presented for care at prenatal, postpartum, or childbirth education settings (see Table 1). A total of 24 parents, representing both the prenatal and the postpartum period, participated in focus groups. We attempted to have separate groups for prenatal and postpartum respondents, but scheduling for interested respondents necessitated holding groups when the most people were available. The number of groups that could be held was limited by the availability of funding, so data saturation was likely not attained. We offered participation in the nurses’ groups to any staff nurse from both the labor-delivery-recovery-postpartum (LDRP) unit and the level II special care nursery, and ultimately included a total of 16 nurses between the two groups.
Table 1.
Population Sampled | Number of Participants | Participant Characteristics |
---|---|---|
Women who recently participated in a research study measuring outcomes of education about postpartum depression | 9 | 6 women after childbirth, with between 2 and 6 children at home 1 woman pregnant with second child 2 pregnant women, each with 1 child at home |
Women presenting for prenatal care | 2 | 1 adolescent couple expecting their first child |
Participants of postpartum mother-baby groups | 4 | 2 first-time mothers, 2 mothers with second children, all with newborns |
Women presenting for pediatric or postpartum care, or childbirth classes | 2 | 1 woman and her partner who recently gave birth to their third child |
3 | 1 first-time mother with newborn 1 first-time mother whose child was now 7 years old 1 woman currently pregnant with her third child |
|
4 | 1 couple pregnant with first child 1 first-time mother with a toddler 1 woman with other children as well as a newborn |
We held all groups at the maternity hospital; each lasted 2 hours and included a meal. We provided participants in the women/partner groups a $25 cash incentive following the group meeting. Nurses received documentation in support of their professional development. All participants gave written informed consent at the beginning of the meeting and agreed to be recorded. Research assistants participated by assisting with greeting, ensuring comfort, observing group dynamics, and providing the payments at the end of the group.
We conducted semi-structured interviews using a predetermined interview question guide. The semi-structured format provided a balance between an interviewer working flexibly with the interview guide and permitting time for the participants’ individualized narratives. We asked open-ended questions to enable participants to provide responses in their own words. If necessary, we utilized prompting questions to further expand upon participants’ narratives. We recorded the groups with a digital audio recorder and the recordings were transcribed professionally into a written form for analysis.
We used six-phase thematic analysis recommended by Braun and Clarke (2006). The six phases are (a) Familiarization with data; (b) Generation of initial codes; (c) Search for themes; (d) Review of themes; (e) Definition and naming of themes; and, (f) Production of report. We also used strategies outlined by Lincoln and Guba (1985) for transferability, dependability, confirmability, and credibility, to establish research trustworthiness (Krefting, 1991).
Results
Thematic analysis provided emergent themes related to women’s and nurses’ perceived priorities around discharge teaching. Women’s priorities included individualized attention to maternal physical and emotional care; fear of providing inadequate care for the newborn; establishing infant feeding; and transitioning to parenting as a new mother versus as an experienced mother.
Individualized Attention to Both Maternal Physical and Emotional Care
Women consistently expressed that attention paid to physiological changes far exceeded attention paid to their emotional needs. The combination of physical changes and sleep deprivation had many wondering, “When will I feel normal again?” Women also expressed a feeling of being forgotten during the time between discharge from the hospital and their first postpartum visit. A priority for the women who participated in this study was more individualized attention that focused on both emotional and physical changes.
“I feel emotional needs and change…gets pushed to the side or it’s neglected a little bit. …the focus is so much like on physiological stuff. I remember I was really blind-sided…”
“And the next time you get checked out it’s 6 weeks later…and the baby gets checked out multiple times…you’re kind of forgotten.”
“I need you [nurse] to be an extension of my family…so it’s as easy as it possibly can be.”
“…different reaction from me if you asked me face-to-face versus a questionnaire [depression screening]. I felt like if somebody was there and you had to look someone in the eye, it would be a lot more personal.”
Fear of Providing Inadequate Care for the Newborn
Women’s comments reflected a sense of catastrophic thinking regarding care of the newborn and establishing newborn feeding. Were they giving their newborn appropriate care and nutrition? Many shared the feeling that they ‘didn’t know what they didn’t know’ or that they had forgotten essential information regarding newborn care. Women expressed a feeling of self-reproach because they felt they were providing inadequate care. Many shared a sense of failure that they did not remember everything they had learned about newborn care or that they were unable to focus as they tried to remember everything.
“I’m afraid there will be one thing on the list that he’s not doing or that I haven’t noticed him doing.”
“I remember the first baby…didn’t even know what I didn’t know. I went home in 3 days sobbing.”
“Everyone says breastfeeding is the best but no one talks about how difficult it is…I still don’t feel like I know what I’m doing.”
Transitioning to Parenting
There were distinctly different themes between first-time mothers and experienced mothers. First-time mothers shared they felt like they had no other choice but to care for the newborn. They struggled because they often felt like the child within this new experience. They expressed anxiety about leaving the hospital and being solely responsible for the newborn.
“We’ve never done this before, so of course we’re a child in that way.”
“I was a little bit anxious about leaving. I didn’t know what I was doing. I was surprised they were letting me leave with a kid.”
Experienced mothers shared they felt more prepared for the birthing process but stressed that every pregnancy and birth are different and they still required help. There was a call for nurses to not assume a woman was ‘good to go’ because they were not new mothers. Experienced mothers’ concerns included the perception that they remembered everything from other births; breastfeeding issues; and how to reconcile the desire to return home to their other children and being petrified to ‘take it all on’.
” I was a little bit less wrapped up in my brain the second time around.”
“My second one--I was thinking,’Holy Crap, what did I just do? I have two kids now’.”
Nurses’ perceived priorities around discharge education focused on safety issues including safe sleep, breastfeeding, transitioning to parenting with an emphasis on maternal self-care, and addressing barriers to effective discharge education.
Safety Issues
Nurses expressed that safe sleep practices were an essential part of the discharge education. They acknowledged that in general new mothers seemed under-informed regarding safe sleep products. In addition, cultural and familial traditions often superseded the advice given during discharge education regarding safe sleep and breastfeeding.
“There are a lot of products on the market that babies sleep really well in that are really unsafe.”
“It’s what Grandma is telling them, what culture does.”
“I feel like a lot of women unless you’re really committed to breastfeeding and you know how to resist your mother and mother-in-law who are just telling you ‘Just give them a bottle, it will be okay’. That’s harder than anything.”
How to do…not battle, but counteract years of acculturation and this is what is best for your baby.”
”…many people are on the verge of neglectful about really knowing how often a baby needs to eat and they can be told over and over again and they’re just not taking it in.”
Transitioning to Parenting With an Emphasis on Maternal Self-Care
Nurses appeared to agree that all mothers, new and experienced, when discharged to home are faced with many challenges. Nurses recognized that many mothers meet these challenges by sacrificing focus on self and self-care. Nurses conceded the limited impact postpartum discharge education may have on these individuals and stressed the need for ongoing resources and support for both new and experienced mothers.
“…[mother] feeling responsible for everything except for yourself, taking care of yourself.”
“We expect them to take care of their own bodies and their own needs and their baby’s.”
“The really big thing is making sure that they’re aware of their resources and who to call and when to call and why.”
“You’re thinking about how nervous they are going home and how much they don’t know and they’re becoming aware of what they don’t know.”
“First babies…I probably wrongly assume to give them a little more attention and probably wrongly assume with 2nd, 3rd, 4th babies…she’s got this.”
Overcoming Barriers to Effective Discharge Education
Subthemes for this theme included woman, nurse, and system issues. Nurses’ comments reflected that women do not know what they need at the time of discharge and that new mothers are often overwhelmed by the amount of information they are given. Nurse feel challenged to find the time to be intentional and present with new mothers. This may be due to other patient assignment, staffing issues, or finding an appropriate time to converse and personalize discharge teaching.
“I feel like it’s rare that you find a time where you can sit down with them and they don’t have any visitors and they’re receptive to information and they’re able to ask questions. I feel like that is a rare moment.”
“We bombard them with so much stuff and they can’t take it in and then they’re so scared.”
“I think they don’t know what they want from us.”
“…but sometimes we just have to be, okay, it’s time for this to get done.”
“Patients don’t think you’re really doing anything unless you’ve shown them a checklist and that you’ve done it”
“I think a big thing is teaching people that they have power over this and to empower them to feel confident to be going home and I think that’s a big part of what our teaching is supposed to be.”
“…it provides a lot of nurse satisfaction when you’re actually able to have the time to sit down and personalize it and really see where those parents are coming from.”
Implications for Practice
Postpartum nurses are aware of the challenges and distractions in providing education to new families during the brief hospitalization. Women’s responses in the focus group suggest that there is a disconnection between women’s and nurses’ priorities and expectations for care during the postpartum period. It is likely that providing standardized education during this transitional period is not effective and may even detract from meeting needs for rest and connection with family and the health care team. Differences in expectations among patients and nurses was also identified by Tobiano, Marshall, Bucknall & Chaboyer (2016) in a study conducted in Australia that addressed the experience of patient-centered care on a medical unit.
Pressure to accomplish tasks such as completing discharge paperwork and documenting that all essential topics have been ‘covered’ works against a nurse’s ability to provide individualized, client-centered care (Tobiano et al., 2016). These conflicting priorities have the potential to decrease women’s satisfaction as well as nurse satisfaction, as communication with the nurse is a key component of perceived care (Senti & LeMire, 2011). Women’s satisfaction is considered a key element of quality, and measurement of it may even be a requirement for reimbursement. In this environment, perhaps it is time to reevaluate traditional methods for providing discharge teaching. Nurses could bring their expertise in client-centered care to clinical practice committees and address whether changes to discharge procedures and standards are needed.
Improving the experience for women and families during the maternity stay is not the only goal of teaching. Women in the focus groups described a need to have someone help them understand what is normal during the postpartum period for themselves and their infants. In a study of outcomes associated with readiness for postpartum discharge, Bernstein et al. (2013) found that women who were uncertain about maternal and infant symptoms and experienced concern in the first few weeks made more phone calls to health care providers (maternity and pediatric), and lower scores on measures of physical and mental health. Other variables also influenced outcomes independently, including cesarean birth, breastfeeding, poorer maternal physical and mental health, and inadequate health insurance (Bernstein et al., 2013). While families are highly motivated to learn during the postpartum period, the shortage of time during the maternity hospitalization, as well as stress and lack of confidence in negotiating the transition to parenthood, create barriers to learning (Russell, 2006). This suggests that nurses may need to address these barriers prior to providing discharge teaching, recognizing how little information may actually be retained.
While increased health care utilization and thus the cost of care may be considered a negative outcome, it might motivate reconsideration of how postpartum care is provided. Bernstein et al.’s (2013) findings suggests that a short hospitalization does not allow enough time for education and support, particularly for high-risk families. Similarly, our focus group participants identified many distractors and stressors during the first few days postpartum, which made it even more difficult to remember information that was conveyed during discharge teaching (Russell, 2006; Schwabe & Wolf, 2010). Perhaps increased access to health care providers after discharge is desirable, which could free up more time during the hospitalization for rest, bonding, and nurturing. Without multiple tasks to accomplish, nurses could provide more individualized care, improving satisfaction and utilizing nursing time more effectively. Education provided during the hospitalization could focus on only the most essential needs and safety concerns. Access to continued nursing care after discharge, when women and their partners have increased readiness and ability to learn new information, could be a preferable option instead of more intensive teaching during the hospital stay. More research is needed to identify the most critical goals for teaching during hospitalization and the best methods for meeting them.
The findings of this study are limited to small groups of mothers and partners from one hospital in the Northeast. However, there is little evidence measuring outcomes of nurse discharge teaching. There does not appear to be any standard for what outcomes are desirable, and how to measure them (Barkin, Wisner, Bromberger, Beach, & Wisniewski, 2010). Surveys of women’s satisfaction provide some information but are not adequate as an outcome measure of quality nursing care and teaching.
Conclusion
The results of these focus groups support the growing evidence that significant needs for postpartum care are as yet unmet, a finding on which both nurses and childbearing women agree. Addressing the current systems and protocols for providing postpartum care and teaching during the maternity hospitalization and identifying creative ways to extend nursing care post-discharge are needed to better meet the needs of women and to effectively utilize nursing time. Future research measuring woman-centered outcomes beyond maternal satisfaction are needed for evidence-based nursing practice in the fourth trimester.
Clinical Implications.
Maternity care during the postpartum hospitalization blends responsibility for ensuring physical recovery for women, supporting newborns’ transition to extrauterine life, establishing newborn feeding, and educating families on newborn care and safety.
For maternal-child nurses working in the postpartum setting, the importance of meeting the many needs of families creates an urgency around postpartum discharge education
There is often a disconnect between women’s priorities and nurses’ priorities during this time; such conflicting priorities can contribute to decreased satisfaction among women receiving care.
Standardized discharge education may not be effective in meeting the needs of women and their families.
Nursing expertise could be used to extend care beyond discharge.
Callouts.
Women identified many distractors and stressors during the first few days postpartum, which made it even more difficult to remember information that was conveyed during discharge teaching
Access to continued nursing care after discharge, when women and their partners have increased readiness and ability to learn new information, could be a preferable option instead of more intensive teaching during the hospital stay
Acknowledgement
The authors acknowledge financial support from the IDeA Program, NIH Grant No. P20GM103506 (National Institute of General Medical Sciences). The authors wish to acknowledge the contribution of the maternity nurses and childbearing women at Catholic Medical Center who inspire excellence in nursing care and research.
Footnotes
The authors report no conflicts of interest or relevant financial relationships.
Contributor Information
Deborah McCarter, Saint Anselm College, Manchester, NH..
Carrie E. MacLeod, Saint Anselm College, Manchester, NH.
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