Scoping Review of Postpartum Discharge Education Provided by Nurses

Abstract

Objective:

To determine what is known about postpartum education provided by nurses to women before discharge from the hospital after birth and whether current nursing practices are effective to prepare women to identify warning signs of complications, perform self-care (physical and emotional), prepare for parenting a newborn, and establish infant feeding.

Data sources:

We conducted a systematic search of CINAHL Plus and MEDLINE for relevant sources, including peer-reviewed articles, conference presentations, and guidelines from professional organizations, that were published in English from January 2010 through November 30, 2020.

Study selection We included sources if participants were women who had given birth to a healthy, liveborn term infant and were receiving education in whole or in part by a nurse during the maternity hospitalization. We excluded sources with samples of high-risk women or those who gave birth to high-risk infants (preterm, congenital anomalies, neonatal abstinence). Forty-six of the sources met the inclusion criteria.

Data extraction:

We extracted citation, type of document, country of origin, context (prenatal/postpartum or both and inpatient/outpatient or both), aim, participants (mother/father or both, sample characteristics), content of education, who provided it, outcomes or key themes, and main results.

Data synthesis:

Infant topics included breastfeeding and safe sleep, and maternal topics included breastfeeding, postpartum mood, and self-care after birth. Nurses prioritized safety, including safe sleep, preventing infant falls, decreasing infection, screening for postpartum depression, and avoiding adverse outcomes after discharge. Women focused on self-care, pain management, infant care, and parenting. Women and nurses prioritized breastfeeding. Authors of the included sources measured effectiveness by patient satisfaction, chart audit, pre- and post-tests of nurses’ knowledge, and breastfeeding duration. Women reported barriers to postpartum education such as limited nursing time or conflicting information.

Conclusion:

Postpartum education is a priority, but its effectiveness is not well studied. Few maternal or infant health-centered outcomes have been measured beyond breastfeeding duration. Nursing care and nurse expertise are not easily quantified or measured. Research is needed to inform best practices for postpartum education.

Precis

Postpartum education is prioritized by mothers and nurses, but effectiveness has not been well studied. Research is needed to inform best practices for discharge education provided by nurses.

Callouts

1. In the absence of evidence of effectiveness, practices for postpartum discharge education are informed by tradition, the expertise of the nurse, and standardized guidelines.

2. The importance of nursing care was clearly identified by women, even when specific educational or support interventions were not described.

3. Nursing expertise and caring are not easily quantified. Accurate measurement of nursing care using measurable patient-centered outcomes is needed for both research and practice.

Discharge education is an essential part of maternity care and is key to the successful developmental and physical transition of women to becoming a mother (Bernstein et al., 2013; Malagon-Maldonado et al., 2017). The content of this education varies by the expertise of the nurse who delivers it (Suplee et al., 2017), agency protocols, national guidelines, and the discipline of the provider who delivers it (Bajorek & McElroy, 2020). For postpartum nurses, priorities for education include recovery from birth for mother and newborn, infant feeding, family bonding, parenting, and newborn care (Suplee & Janke, 2020). Various factors, including visitors, may compete for a mother’s attention and time while nurses attempt to deliver postpartum education.

The content of postpartum discharge education has been informed by the public health priority to reduce physical and mood-related postpartum complications (U.S. Department of Health and Human Services, 2020). However, unmet needs for education in physical self-care and infant care, breastfeeding initiation, emotional support, and anticipatory guidance are also of concern (Suplee, Kleppel, Santa-Donato, et al. 2016; Tully et al., 2017). Nurses (American Nurses Association, 2021) and other health care providers are charged to provide this critical information during hospital stays that can range from 24 to 72 hours. They are guided by disciplinary best practices and agency protocols and are evaluated by accrediting bodies such as The Joint Commission (2019) and patient satisfaction surveys (Press Ganey Associates LLC, 2020).

Callout 1

In spite of the value of patient education (Bergh et al., 2015), the public health imperative to reduce postpartum complications (U.S. Department of Health and Human Services, 2020), and the stated needs of women (McCarter & MacLeod, 2019; Tully et al., 2017), it is not known whether the education provided to women in the hospital after birth is effective (Gilmer et al., 2016), nor is there a consensus on what outcome measure(s) show whether the education meets the goals of women or health care providers. On the contrary, researchers found that what was taught during the short hospitalization after birth was not retained (McCarter-Spaulding & Shea, 2016) and was more than what was needed in that moment (Buchko et al., 2012).

Limited knowledge about the effectiveness of postpartum education is compounded by a lack of research on outcomes of direct care provided by nurses (Jones, 2016), which includes a significant portion of time spent providing bedside education during the postpartum hospitalization. Nursing time is valuable and should be used wisely (Kemppainen et al., 2013). Thus, it is paramount to determine best practices regarding the content, process, format, and timing of postpartum discharge education and to accurately measure its effectiveness based on the stated goals and identified needs of women and public health priorities. In the absence of such evidence, current practices are informed by tradition, expertise of the individual nurse (Logsdon et al., 2010), and standardized guidelines (The Sullivan Group, 2021). To begin the process of gathering available empirical evidence, we conducted a scoping review to answer the following questions: What is known about postpartum education provided by nurses to women before discharge from the hospital after birth? Are current nursing practices effective to prepare women to identify warning signs of complications, perform self-care (physical and emotional), prepare for parenting a newborn, and establish infant feeding?

Methods

Our four-member research team developed the review protocol based on the research questions, although the protocol was not registered. We included sources if participants were women who had given birth to healthy, liveborn, term infants and received education in whole or in part by a nurse during the maternity hospitalization. The concept examined was any education provided by a nurse during the postpartum hospitalization. We reviewed sources if any educational content, including anticipatory guidance and support, about self-management, parenting, and/or infant care was addressed with mothers only, or concurrently with fathers. To ensure that we reviewed reports of as many educational events provided by nurses in the hospital as possible, sources were retained if the postpartum discharge education described was only one portion of education that also included a prenatal or post-discharge component. We excluded sources with samples of high-risk women or those who gave birth to high-risk infants (preterm, congenital anomalies, neonatal abstinence) because education provided to mothers of preterm or ill infants or those experiencing loss would be expected to be significantly different than education focused on health-promotion for the healthy mother-infant dyad. We included peer-reviewed articles, conference presentations, and guidelines from professional organizations in the search to supplement the limited number of primary research articles. We limited results to those published in English in the past 10 years (January 2010 through November 30, 2020) as we expected that the discharge education protocol would reflect the current standards set by the health care institutions and professional organizations, which change over time and are frequently updated.

Search Strategy

Following the Joanna Briggs Institute (2015) guidelines, we conducted searches in CINAHL Plus and MEDLINE via EBSCO’s interface. First, the entire research team developed a list of possible keywords (see supplemental Table S1) for the concepts within the research questions. We searched CINAHL Plus using the list of keywords to identify corresponding CINAHL Subject Headings, which we identified from relevant article results and CINAHL’s subject index. Similarly, we searched MEDLINE to identify relevant MeSH terms.

We conducted searches in the two databases with keywords and database-specific subject headings that corresponded to all the main concepts of the research questions. We added search terms associated with some exclusionary criteria with the Boolean operator “NOT” (Table S1). Because of the broad nature of scoping reviews, we assessed any published source for inclusion (Joanna Briggs Institute, 2015). CINAHL Plus yielded 72 results, and MEDLINE yielded 275 results. Our reference librarian (H.C.) exported the results to the citation manager Zotero, where she deduplicated them to create an initial set of 330 unique results for screening.

Data Abstraction and Synthesis

The first author (D.M.) screened these 330 sources by abstract and excluded 173, which left 157 for full text screening by the research team. Based on full text screening, we excluded an additional 111 sources because they did not meet inclusion criteria (Figure 1). If there was any ambiguity about whether the source met inclusion criteria, a second author also screened the article. We entered the remaining 46 items into a shared spreadsheet and extracted the following data: source citation, type of research, country of origin, context (prenatal/postpartum or both, inpatient/outpatient, or both), aim, participants (mother/father or both, sample characteristics), content of education addressed and who provided it, outcome measures or key themes, and main results. The three clinical members of the team reviewed a subset of sources: D.M. reviewed research studies, A.L. reviewed clinical practice articles, and K.P. reviewed conference presentations. We did not critically appraise the sources but did categorize the findings by article category. The first author (D.M.) synthesized the results into a narrative that was reviewed by the second author (A.L.).

Figure 1.

Flowchart of item inclusion for scoping review of postpartum discharge education provided by nurses

Results

We included 46 sources in the final synthesis: reports of seven randomized controlled trials (RCTs), one metasynthesis, reports of eight qualitative studies, reports of 19 quantitative studies, and 11 practice articles and/or presentations (see supplemental Table S2).

Randomized Controlled Trials

The seven RCTs were conducted in Canada, Finland, Nepal, Denmark, Jordan, and China. Four of these RCTs (Khresheh et al., 2011; Nilsson et al., 2017; Abbass-Dick & Dennis, 2018; Hu et al., 2020) were focused specifically on interventions for breastfeeding education, and researchers measured breastfeeding knowledge, satisfaction, self-efficacy, and exclusive breastfeeding at varying time points. The interventions evaluated included postpartum care in the hospital and follow-up contact, generally by phone or chat platform. In each case, researchers compared the breastfeeding intervention, provided by in-person visit, videos, and/or written resources, to usual care. Hu et al. (2020) sampled breastfeeding women who gave birth by cesarean and found increased knowledge, satisfaction, and exclusivity to 4 months postpartum in group receiving individualized breastfeeding education and support in the hospital. Nilsson et al. (2017) reported that women who were discharged fewer than 50 hours after birth who received a focused program to support breastfeeding initiation in the hospital had no significant difference in breastfeeding self-efficacy or exclusive breastfeeding compared to women who received usual care, although they did have higher odds of breastfeeding exclusively at 6 months postpartum. Khresheh et al. (2011) did not find any difference in exclusive breastfeeding rates in a sample of primiparous women who gave birth vaginally and had participated in a breastfeeding education and support program initiated in the hospital with two follow-up phone calls after discharge, but they did find significant improvement in knowledge in the intervention group. Abbass-Dick and Dennis (2018) focused specifically on satisfaction with a co-parenting intervention for breastfeeding begun during the postpartum hospitalization, which was well received. In the parent study, Abbass-Dick et al.(2015) found a significant improvement in breastfeeding duration, but not exclusivity at 12 weeks postpartum.

Researchers in three of the RCTs focused on education for infant care. In Finland, Botha et al. (2020) compared a midwife-taught behavioral infant calming technique to standard care, with parenting self-efficacy and satisfaction as the outcome measures. The intervention group was found to have a significant improvement in parenting self-efficacy, but no significant difference in parenting satisfaction at 6-8 weeks postpartum. In Canada, McRury and Zolotor (2020) provided an educational intervention via a 30-minute videotape to be viewed prior to discharge, which included instruction in calming infants. Outcomes were compared to a control group who received a video with instructions on normal newborn care. Researchers measured the effectiveness of the intervention by the hours/day of infant crying, maternal mood, and parental stress at 6 and 12 weeks postpartum, and found no significant difference. In Nepal, Shrestha et al. (2016) reported that when nurses provided structured education about general newborn care at the bedside with follow-up telephone support at 2 weeks postpartum, mothers reported higher knowledge and confidence in infant care, lower anxiety, and fewer sick visits to the health center at 5-6 weeks postpartum, when compared to a control group who received only general information about newborn care prior to hospital discharge.

Meta-synthesis

Nilsson et al. (2015) conducted a metasynthesis to investigate women’s experiences of early discharge (fewer than 72 hours postpartum) using 10 studies conducted in Western countries. Postpartum education was addressed among the themes identified, and women described insecurity due to a lack of knowledge about infant care and feeding. Women identified health professionals as a source of information and support but also reported that they received too much information from too many sources. Early discharge from the hospital was not perceived positively if the education received in the hospital was not individualized and the health professional was not cognizant of their level of experience.

Qualitative Studies

We reviewed eight qualitative studies related to education outcomes. While Frei & Mander (2011), Gaboury et al. (2017), Rodrigues et al. (2014), Sell et al. (2012), Thorstensson et al. (2016), and Zadoroznyj et al. (2015) found the relationship with nurses to be important for learning about self and infant care, participants also identified conflicting information from nurses and other professionals as a concern (Chaplin et al., 2016; Gaboury et al., 2017). Gaboury et al. (2017) reported that women did not always feel that the nurses had enough time for them. Chaplin et al. (2016) and Zadoroznyi et al. (2015) reported that participants felt breastfeeding support was inadequate. Sell et al. (2012) reported that participants did not feel they received adequate education about the management of post-operative pain after cesarean birth. Rodrigues et al. (2014) reported that participants did not feel there was adequate attention given to their transition to the role of a mother. Woiski et al. (2015) studied care related to postpartum hemorrhage (PPH) and reported that patients did not feel adequately informed about what they experienced or their risk factors for PPH in a future birth.

Quantitative Studies

We reviewed 19 studies with various quantitative designs. Researchers addressed content, delivery, and outcomes of postpartum education in the hospital in multiple ways, and included education provided by nurses as well as other health care professionals, such as midwives, pediatricians, obstetricians, physical therapists, or the more general category of “hospital services” (Sword et al., 2011). Researchers of only four studies addressed education specifically provided by nurses. Demirtas (2012) measured perception of informational support from nurses for breastfeeding, and reported that mothers desired more practical, individualized support for breastfeeding, and that not receiving such support was a predictor of early supplementation with formula. Grassley et al. (2013) reported on the development of an instrument to measure perception of nursing support for breastfeeding specifically for adolescents, and found that informational, instrumental, and emotional support were the key dimensions of breastfeeding support. McCarter-Spaulding and Shea (2016) provided focused, individualized discharge education about signs of postpartum depression and found that participants in the intervention group had no significant difference in symptoms of depression in the first six months postpartum compared to the usual care group. Oommen et al. (2011) found that women desired and valued support from nurses particularly pertaining to how to handle and feed an infant.

Researchers addressed breastfeeding education in 15 of the 35 research studies reviewed, and 2 of the 11 clinical practice sources, either as the key topic or in conjunction with other infant and maternal care topics. Catala et al. (2018) reported that women were more satisfied with their hospital experience if breastfeeding was initiated in the first hour of life but did not measure or acknowledge the role of nurses in facilitating early initiation. Fontoura Abissulo et al. (2016) evaluated the use of a breast model and baby doll for education about breastfeeding and found it feasible. Almalik (2017) reported that women identified breastfeeding as a key learning need prior to discharge from the hospital. Hildingsson and Sandin-Bojö (2011) addressed participants’ satisfaction with the information and practical instruction for breastfeeding provided postpartum. While support from staff was an important component of satisfaction with care, nursing education was not considered separately from support. Valbø et al. (2011) compared care providers’ and mothers’ perceptions of postpartum care. Health care providers felt they provided more assistance with infant care than mothers did. Yanıkkerem et al. (2018) measured knowledge as one of four subscales of a perceived readiness for discharge. Participants reported that over 50% of the information they received postpartum had been provided by nurses, and most reported being ready for discharge.

CALLOUT 2

Several researchers addressed women’s perception of unmet education needs in the early postpartum period. Almalik (2017) reported that at 6-8 weeks postpartum, participants felt they had not received adequate information about physical changes postpartum, signs of complications after cesarean birth, breastfeeding, new baby care, and family planning. Similarly, Hildingsson and Sandin-Bojö (2011) reported that at 2 months after discharge, women felt they had not received enough information and practical help about their own physical and emotional changes, breastfeeding, infant care, and intimate life. Oommen et al. (2011) reported that at the time of discharge, mothers felt they needed more information and practical support about maternal and infant care topics, and Sword et al. (2011) identified unmet learning needs as one of 11 predictors of symptoms of depression at 6 weeks postpartum as measured by a score of 12 or higher on the Edinburg Postnatal Depression Scale. Valbø et al. (2011) found that while mothers were satisfied with the content and quality of the care they received, staff felt it was more adequate than mothers did. Yanıkkerem et al., 2018 reported that women who received more education felt better prepared for hospital discharge. Zheng et al., 2018 did not measure discharge education but reported that women recruited in their study during the postpartum hospitalization had low levels of self-efficacy in managing infant first aid when measured at 6 and 12 weeks postpartum. Before hospital discharge, Logsdon et al. (2018) measured women’s knowledge about risk factors for maternal mortality and found that participants could not identify all the warning signs of complications and did not know that symptoms could occur up to 6 weeks or more after discharge.

Other than breastfeeding, infant care topics were not precisely defined in the studies we reviewed with the exception of Cruz et al. (2014), who compared adherence to infant massage based on whether education was provided prenatally or during the postpartum hospitalization, finding no difference between groups.

Conference Presentations & Clinical Practice

We reviewed 11 published sources including six conference presentations and five clinical practice articles. Authors reported on educational topics, including preventing of infant falls (Hantske, 2015; Wallace, 2015), safe sleep (Abney-Roberts, 2015), decreasing post-operative infection (Holland et al., 2015), postpartum depression (Cravens et al., 2020), individualization of discharge planning (Horgan et al., 2014), medication education (Rovell et al., 2012), avoiding adverse events after discharge (Simpson, 2017), breastfeeding (Papautsky, 2019; Wood, 2018), and interpreting newborn cues (Karl and Keefer,2011). When effectiveness was measured, it was documented by patient satisfaction surveys (Horgan et al., 2014; Rovell et al., 2012), chart-audits (Cravens et al., 2020; Wallace, 2015), or observation of practice (Abney-Roberts, 2015) .

Discussion

Content of Discharge Education

We found that breastfeeding was the most common topic addressed during postpartum discharge education This was a priority for mothers and nurses and thus is likely to account for significant portion of nursing time, although time was not measured specifically. Effectiveness of breastfeeding education was measured by rates of initiation, duration, and exclusivity, breastfeeding knowledge, parenting self-efficacy, perception of support, problems with breastfeeding, or satisfaction with discharge education. The priority placed on breastfeeding is likely due to the consistent health promotion effort to increase the rate of breastfeeding initiation, duration, and exclusivity (Brown, 2017; Centers for Disease Control and Prevention, 2013) and the corresponding desire from women for assistance in meeting their breastfeeding goals (Brown, 2018). Outcome measures that most directly reflect the effectiveness of education by nurses during maternity hospitalization would likely be breastfeeding self-efficacy (McQueen et al., 2011), perception of breastfeeding support (Balogun et al., 2016), and satisfaction with discharge education (Abbass-Dick & Dennis, 2018). The Ten Steps to Successful Breastfeeding (Baby-Friendly USA, 2022) provide guidelines to inform hospital nursing practice.

Infant care was also a frequently addressed topic during the postpartum hospitalization but described in general rather than by specific skills except in two trials of an infant soothing intervention (Botha et al., 2020; McRury & Zolotor, 2020) and one study of infant massage (Cruz et al., 2014). While women reported the need for more infant care education retrospectively (Almalik,2017), it could not be determined what women felt was lacking. It may be that participants experienced a lack of self-efficacy as new parents (Beach Copeland & Harbaugh, 2017) and attributed it to insufficient infant care support during the hospital stay (Oommen et al., 2011). Nurses focused on safety as an educational priority, specifically safe sleep (Kellams et al., 2017) and preventing infant falls (Hantske, 2015; Wallace, 2015), which reflected the influence of national safety initiatives on nursing practice (Bittle et al., 2019; Bombard et al., 2018). What remains unknown is how much infant care education was provided after birth but not retained given that nurses reported providing more education than parents perceived (Valbø et al., 2011).

Nurses identified recognizing symptoms and identifying women at risk for postpartum mood disorders as an important educational priority, and providing anticipatory guidance is considered best practice (Suplee & Janke, 2020). However, it has not been determined if mothers find education about postpartum mood during the maternity stay to be timely or helpful or whether it improves maternal outcomes after discharge (McCarter-Spaulding & Shea, 2016).

Several researchers (Almalik, 2017; Gaboury et al., 2017; Rodrigues et al., 2014; Sell et al., 2012), reported that women identified an unmet need for education about their own physical recovery and self-care, but no researchers measured maternal self-care education. It may be that that education about self-care (Holland et al., 2015) and managing pain (Sell et al., 2012) is so integrated into nursing care at the bedside (Suplee & Janke, 2020) that is not considered separately. Research is needed to determine best practices education about maternal self-care.

While women did not identify learning about warning signs of complications as an important focus of discharge education, it is recommended that nurses improve this area of education (Suplee, Kleppel, & Bingham, 2016) based on the public health imperitive to decrease mortalilty and morbidity. Future research is needed to determine the most effective educational strategy to support the goal of reducing mortality and morbidity.

Nursing care during the postpartum hospitalization is clearly important to women and is a key element in patient satisfaction (Karaca & Durna, 2019). Nursing discharge education may be so integrated into other nursing care activities (Bergh et al., 2015) that is not described or evaluated separately, unless motivated by standards determined by an external entity such as The Joint Commission (2019), the QSEN institute (2020) or a professional organization such as AWHONN (Suplee & Janke, 2020). More research is needed which isolates the role of nurses in patient outcomes.

Effectiveness

We also sought to determine whether current discharge education about warning signs of post-discharge complications, self-care (physical and emotional), parenting, and establishing infant feeding was effective, but measures of effectiveness varied widely. Measuring satisfaction with care as an outcome (Abbass-Dick & Dennis, 2018; Nilsson et al., 2015) assumes that satisfaction reflects effectiveness of education provided by nurses. However, nursing-specific interventions were not measured directly, and in many of the RCT’s, nurses were involved in both the intervention and the usual care condition. Additionally, the relationship between satisfaction and a person’s ability to retrieve and apply the information received has not been measured. Women were generally satisfied and felt ready at time of discharge in contrast to retrospective reports of unmet learning needs (Martin et al., 2014; Tully et al., 2017). It is likely that women cannot fully anticipate their needs before discharge. Almalik (2017) suggested that increasing education in the hospital will meet the stated (unmet) needs of women, but it is not known if this would be desired, retained, or effective in changing outcomes post-discharge.

We could not determine the effectiveness of any specific format for education (in-person, written, electronic) by our scoping review. Interventions frequently involved in-person and written or media resources or included post-discharge follow-up (Khresheh et al., 2011; Shrestha et al., 2016), which made it impossible to isolate the effect of only the postpartum education provided by nurses in the hospital.

More research is needed to determine what outcomes, from the points of view of women and nurses, accurately reflect effectiveness. Future research should be focused on outcomes amenable to nursing intervention, such as self-efficacy in infant care, parenting (Botha et al., 2020) and breastfeeding (McQueen et al., 2011), which may better predict health outcomes (Sheeran et al. (2016).

Nurse knowledge, judgement, and expertise (Manetti, 2019; Suplee et al., 2017) and women’s needs, and characteristics influence outcomes. Effective nursing care (Manetti, 2019) requires individualization within the broader context of hospital protocols and practice standards. Such individualized care is an outcome of the clinical judgment of the nurse, which is difficult to measure. Isolating the effect of nursing care from other variables in the postpartum hospital experience (e.g., other health care providers, nurse staffing, mode of birth) will be needed to better measure effectiveness of nursing practice interventions.

Women reported wanting more time with nurses (Gaboury et al., 2017). Nursing time is affected by patient acuity and staffing levels, which affect the time spend in discharge education, but nursing time was not measured directly. The adequacy of nurse staffing related to patient acuity should be measured as a variable that influences the quality and effectiveness of discharge education in addition to patient satisfaction with care.

Implications for Nursing

Clinical Practice

Women value nursing support postpartum, especially for breastfeeding, which contributes to their satisfaction with the hospital experience. Hospital practices based on the Ten Steps to Successful Breastfeeding (Baby Friendly USA, 2020) will support clinical judgment, desired breastfeeding outcomes, and adequate infant nutrition. Women also want more attention on self-care, including pain management, particularly after cesarean birth. In addition, education about warning signs of postpartum complications should be a standard of practice based on public health priorities.

CALLOUT 3

Women want more education about infant care and parenting. However, in the hospital, safety is a priority of care (The Joint Commission, 2019). Education about infant safety, including safe sleep, preventing falls, managing crying, and accessing/ensuring well-baby follow-up will take precedence over other infant care topics. Education about infant care and parenting may be already integrated into discharge education, but women may not retain the information provided in the first days postpartum. Despite the identified need, there is currently no systematic approach for caring for mothers and infants after hospital discharge.

Research

More evidence is needed to determine the effectiveness of nursing practice in discharge education, including identifying what is the most essential content, and how to accurately establish effectiveness. It will be important to isolate the influence of nurses from that of other professionals and measure nurse knowledge, expertise, clinical judgement, and time. A commitment to improved funding of nursing research (Kiely & Wysocki, 2020) will be needed to accomplish this goal. While patient satisfaction may be a measure for nurse care (Karlsson & Pennbrant, 2020), it is not known if it is an accurate or useful measure of the effectiveness of education provided by nurses before hospital discharge after childbirth. Measuring patient-focused variables amenable to nursing intervention may better reflect nursing effectiveness. Research is also needed to determine best practices for how, when, and by whom this education could be provided.

Policy

Standardized protocols are helpful in ensuring key safety initiatives are met but are not a substitute for individualized assessment and provision of patient-centered care. While standardizing educational content may avoid the issue of conflicting information, this has not been measured. Nurse practice committees are needed to evaluate practice and incorporate new knowledge as it becomes available, to improve outcomes for patients, and to better describe the contribution of nurses in promoting maternal and newborn health. Evaluation of nurse performance and quality of care will need to go beyond patient satisfaction to include institutional variables such as nurse staffing and the availability of continuing education to inform evidence-based practice.

Limitations

The scoping review methodology (Joanna Briggs Institute, 2015) does not include a formal assessment of the quality of the studies. Studies were not compared based on their level of evidence. We only reviewed English-language articles, although no countries were excluded in the search. We did not include discharge education if not provided by nurses, although nurses may have been involved in reinforcing information provided by others or referring women to another provider for additional information. We reviewed sources if discharge education in the hospital was one component of a comprehensive intervention including prenatal and/or post-discharge education, so it was not possible to isolate the effects of only the in-hospital portion of the education. We did not address whether breastfeeding education was different in a Baby Friendly hospital (Baby-Friendly USA, 2022).While the research team developed the guidelines for the scoping review, only one author (D.M.) screened the articles for inclusion.

Conclusion

Women identified nursing care and education as an important part of the maternity hospitalization experience. Breastfeeding was the primary focus of postpartum discharge education and nursing support. Women wanted more education on self-care, infant care, and parenting, although no specific content was identified as lacking. Nurses focused on infant safety and educating women about warning signs of postpartum complications. Nursing care was seldom addressed separately from other variables.

We could not determine the most effective content, timing, or format of the education and support that women and nurses identified as important. More accurate measures are needed for research and practice that take in to account nursing expertise, individualized patient needs, and the care environment. Nursing research which identifies outcomes sensitive to nursing intervention and is more focused on women’s identified needs is needed to inform practice.