Nov 04, 2014
By Carolyn Crowley, RN, MN

Addressing a gap in postpartum care

Newborn Baby
Mikhail Tchkheidze/iStockphoto/Thinkstock

Canadian women spend, on average, 2.1 days in hospital after a vaginal birth and 3.8 days in hospital after caesarean deliveries (Public Health Agency of Canada, 2009). Current guidelines call for mother/baby dyad care on postpartum units. Nurses must therefore be competent in caring for both populations and be able to share a large amount of information in a short amount of time to prepare mothers for their discharge home. They must also ensure that the patient’s personal learning needs have been met and that she has developed enough knowledge about the key topics to be safely discharged home.

Although teaching and support related to breastfeeding take priority, other topics nurses must discuss before discharge include bathing, car seat safety, jaundice, safe sleep, postpartum mood disorders and maternal nutrition.

Public health departments in many regions offer community-based postpartum support, but at-home postpartum followup is not the norm across Canada. Support from family members may also be lacking for many women. The gaps in support, or perceived difficulties in how to receive support, may create an even greater pressure on nurses to teach a mother everything she needs to know before she leaves the hospital.

Over the course of several years, data from patient satisfaction surveys at Hôpital Montfort, in Ottawa, showed that approximately 50 per cent of the new mothers who responded said they had received enough information about their discharge home, despite good overall satisfaction ratings. Little information had been collected about what they felt was missing or how the teaching could be improved.

Individualized teaching tool
With the support of the Family Birthing Centre’s multidisciplinary Quality Committee, our nursing staff initiated the development of a postpartum teaching tool, covering both maternal and newborn care. Beginning with a list of relevant topics, we compiled information from expert sources such as the Canadian Paediatric Society, the Society of Obstetricians and Gynaecologists of Canada and the World Health Organization and presented it to the Quality Committee, the centre’s staff nurses (RNs and registered practical nurses) and physicians for review.

In the brainstorming stages of developing the tool, we surveyed the nurses to understand their perceptions of the level of teaching they were able to offer and get their input on how to improve our teaching practices. Our survey consisted of eight Likert-type quantitative questions and an open-ended qualitative question. Forty-six out of the 100 nurses working in the centre responded. This group confirmed there was a gap in teaching, and they provided valuable insight into what was needed to address it.

Survey results
Sixty-eight per cent of respondents felt that patients had not received enough teaching on postpartum maternal care while in hospital, and 41.5 per cent felt that patients had not received enough teaching on newborn care. This information was consistent with the data from the patient satisfaction surveys. Most respondents agreed that they themselves possessed enough knowledge about postpartum maternal care (86.2%) and about newborn care (82.6%).

Respondents suggested improvements in two main areas: the need for better written information to give to patients (87.5% of responses) and for standardized information for nurses to refer to (31.25% of responses). Respondents noted that although postpartum information packages were routinely being given to patients after delivery, several important topics were missing in the handouts and that information was spread out over several documents.

Tools for nurses
We produced a double-sided checklist, available in English and French, for our patients. Listed on one side are the topics related to maternal postpartum care; on the other, the topics related to the care of newborns. A one- or two-sentence overview is included for each topic. The checklist format allows patients to personalize their learning based on what they feel they need to know. With this new tool, nurses continue to do their regular teaching but are better equipped to discuss postpartum and newborn care with the patient and together determine if her learning needs are being met. The document also includes a list of symptoms to alert patients and their families to when to contact their doctor or midwife urgently.

To ensure that all nurses provide consistent information on each of the topics, we also developed pamphlets containing more detailed information. We introduced the teaching tool and the updated information in the pamphlets to staff in in-service sessions in February 2013. We printed the pamphlets and posted them on the hospital’s website, making them available for nurses and patients alike.

Evaluation and next steps
One month after implementation, we recirculated the survey and received responses from 20 nurses. This time, 31.5 per cent of respondents felt that patients had not received enough maternal postpartum teaching; 26.3 per cent felt that patients had not received enough teaching regarding newborn care. Although the sample size was small and we could not determine if those who responded to the second survey had responded to the first one, the data pointed to a positive impact on nurses’ perceptions of postpartum teaching with the implementation of the new material. Nurses had positive comments on the new materials and made further suggestions: additional training for staff in order to better standardize the information shared when teaching, and translating the text into languages other than English and French.

Although the patient satisfaction survey covers multiple aspects of hospital care, our patients were not specifically asked about the teaching tool. However, when we compared results from surveys completed in April through June 2013 with those completed over the same period in 2012, we noted that an additional 14 per cent of respondents felt they had received enough information about their recovery.

Getting input from nurses on the front lines of care during the development, implementation and post-implementation phases helped foster support for the project. For example, they confirmed that the format of the teaching tool was appropriate and that using the tool would not add to their current workload.

The teaching tool is facilitating better partnerships between nurse and family. Whether nurses are new to the Family Birthing Centre or have more experience, they can now be assured that what they are teaching patients and their families is based on current research.

Recognizing that there is still room for improvement, we will continue to evaluate our ability to meet patients’ learning needs after delivery. Future plans to evaluate the impact of the new tool include speaking directly with patients, during leader-patient rounds, to ensure that their postpartum teaching needs are being met.

Public Health Agency of Canada. (2009). What Mothers Say: The Canadian Maternity Experiences Survey.

Carolyn Crowley, RN, MN, is Clinical Manager, Family Birthing Centre AT Hôpital Montfort, Ottawa.

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