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Learning suitable for hospital and learning suitable for home: differences in perception between postpartum… Dean, Susan K. 1992

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cLEARNING SUITABLE FOR HOSPITAL AND LEARNING SUITABLE FOR HOME:DIFFERENCES IN PERCEPTION BETWEEN POSTPARTUM MOTHERS ANDMATERNAL/NEWBORN NURSESBySUSAN KATHERINE DEANB.S.N., The University of Victoria, 1982A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTSFOR THE DEGREE OF MASTER IN SCIENCE OF NURSINGinTHE FACULTY OF GRADUATE STUDIES(School of Nursing)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAJanuary, 1992© Susan Katherine Dean, 1992In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature) Department of  NURSTNGThe University of British ColumbiaVancouver, CanadaDate^\-wckft 9- Neig.DE-6 (2/88)iiABSTRACTThe trend toward early postpartum discharge programs means that much moreof the postpartum teaching traditionally carried out in hospital will need to beconducted at home with visiting nurses. However, before any postpartum educationchanges could be recommended, it was necessary to investigate the perceptions ofthe two groups of people involved in early postpartum education; postpartum mothersand maternal/newborn nurses.The purpose of this study was to identify the postpartum learning needs thatearly discharge mothers and hospital based maternal/newborn nurses regarded aseither more suitably addressed in hospital or more suitably addressed at home and tocompare the perceptions of both groups. Therefore, a factor-searching and relation-searching approach was used to study convenience samples of 89 low risk,primiparous mothers eligible for early discharge and 50 nurses. Each participantcompleted a questionnaire which was developed for the study. Concerns andinterests identified in the literature as important to mothers during the postpartumperiod were included. Topics were assigned to three categories; self, infant, andfamily. Each category contained an "other" option so that both groups would feel freeto identify topics that were not present in the questionnaire.iiiResults of the study suggested that postpartum mothers want learning needsrelated to their infants addressed first, followed by those related to self, and thoserelated to family last. While mothers' and nurses' perceptions of topics suitable forhospital were similar, their perceptions of topics suitable for home differed. Mothersperceived most of the infant topics as more appropriate to discussion in hospital andmost of the family topics as more appropriate to discussion in the home. Most of thenurses perceived only physical care/skill kinds of infant topics as appropriate tohospital and informational topics related to the infant as more appropriate to home.The study also indicated that both groups expected a large portion of postpartumlearning to occur within a 48 hour hospital stay postpartum.The results have implications for nursing practice, education, administration,and research. Strategies aimed at meeting the learning needs of early dischargepostpartum mothers more effectively are identified and described.TABLE OF CONTENTSABSTRACT^ iiTABLE OF CONTENTS ^ivLIST OF TABLES  ^xAcknowledgements  ^xiCHAPTER IINTRODUCTION^ 1Background to the Problem  ^1Statement of the Problem  ^4Purpose of the Study  ^4Conceptual Framework  ^4Andragogy  ^5Self-concept  ^5Experience  ^5Readiness to Learn  ^6Orientation to Learning  ^7Gruis' Developmental Tasks of the Postpartum Period  ^8Physical Restoration  ^8ivVLearning the Infant's Needs  ^8Relating With the Newborn  ^9Accommodating a New Family Member  ^9Research Questions  ^10Significance of the Study  ^11Definition of Terms  ^11Assumptions of the Study  ^12Limitations of the Study  ^13CHAPTER IILITERATURE REVIEW  ^14Overview^ 14Early Postpartum Discharge  ^14Concerns and Interests of Postpartum Mothers  ^18Patients' and Caregivers' Perceptions of Patient Education  ^23Adult Education  ^23Effectiveness of Application of Teaching/Learning Principles . .  ^ 24Patients' and Nurses' Perceptions of Learning Needs ^28Summary^ 31CHAPTER IIIMETHODS^ 33Overview 33Approach  ^33Setting  ^35Participants  ^36Questionnaire  ^36Procedure for Data Collection  ^37Data Analysis  ^39Summary^ 39CHAPTER IVRESULTS AND DISCUSSION  ^41Overview^ 41Results 41Demographic Information  ^41Postpartum Mothers' Perception of Learning More SuitablyAddressed in Hospital  ^46viviiPostpartum Mothers' Perception of Learning More SuitablyAddressed at Home  ^47Maternal/Newborn Nurses' Perception of Learning More SuitablyAddressed in Hospital  ^50Maternal/Newborn Nurses' Perception of Learning More SuitablyAddressed at Home ^50Comparison of the Responses of Both Groups  ^54Distribution of Concerns/Interests Between Hospital and Home^57Discussion^ 58Postpartum Mothers' Perception of Learning More SuitablyAddressed in Hospital  ^58The Impact of Environment  ^60Experience With Newborn Care  ^63Maternal/Newborn Nurses' Perception of Learning More SuitablyAddressed in Hospital  ^64Differences Between Postpartum Mothers' and Maternal/NewbornNurses' Perception of Learning Needs  ^67Distribution of Postpartum Learning Needs Between Hospital and Home^71Summary^ 71viiiCHAPTER VCONCLUSIONS AND IMPLICATIONS  ^73Overview^ 73Conclusions  ^73Implications for Nursing  ^74Nursing Practice  ^74Nursing Education  ^76Nursing Administration  ^77Nursing Research  ^80Summary^ 81REFERENCES 83APPENDICES^ 86Appendix A: The Greater Victoria Hospital SocietyMother/Babe Unit Parent Teaching Sheet  ^86Appendix B: The Greater Victoria Hospital SocietyCriteria for Early Discharge  ^87Appendix C: Postpartum Learning Needs Questionnaire and BackgroundInformation Sheets  ^88Appendix D: Cover Letters  ^101Appendix E: Early Discharge Eligible PostpartumMothers' and Maternal/Newborn Nurses' Responsesto Questionnaire  ^105ixUST OF TABLESI^Early Discharge Eligible Postpartum Mothers:Demographic Information  ^43II^Maternal/Newborn Nurses: Demographic Information  ^45III^Postpartum Mothers' Perception of Learning MoreSuitable for Hospital  ^48IV^Postpartum Mothers' Perception of Learning MoreSuitable for Home  ^49V^Maternal/Newborn Nurses' Perception of LearningMore Suitable for Hospital  ^52VI^Maternal/Newborn Nurses' Perception of LearningMore Suitable for Home  ^53VII^Differences Between Postpartum Mothers' andMaternal/Newborn Nurses'  ^56VIII^Distribution of Concerns/Interests by Category  ^58xxiAcknowledgementsI am grateful to Elaine Carty and Angela Henderson for being so patient andunderstanding with a working, out-of-town student. I am also grateful to the GreaterVictoria Hospital Society and Lynn Stevenson for their generous support andencouragement. I am thankful to the patients and staff of the Mother/Babe Unit whowere willing participants in this study. Lastly, I am fortunate to have friends and peerswho were willing to overlook my periodic bursts of irritability and strange behaviourduring the course of this thesis.1CHAPTER IINTRODUCTIONBackground to the ProblemThe postpartum period is one of change and challenge for first time parents. Notonly is it a time of great physiological change for the mother as her body adapts tothe non pregnant state, it is also a time of great psychosocial change for both motherand partner. The integration of the new family member creates the need for majorreorganization of roles, relationships, and lifestyle patterns. Unfortunately, oureducational system does not prepare young people for parenting (Hall, 1980). Manynew mothers have had little or no experience in caring for a newborn. Because theextended family network is unavailable to a great extent, parents are often deprived ofthe benefit of experience, advice, support, and reassurance (Davis, Brucker, & MacMullen, 1988 ; Hall, 1980). As a result, new mothers have come to rely heavily onhospital nurses for information related to caring for themselves and their babies in theearly postpartum period.Traditionally, postpartum education has been conducted in hospital over a periodof 3-5 days and has tended to follow a nurse organized and initiated schedule (Glover,Houston, Hardy, & Clyne, 1985; Cupoli et al., 1971). Nurses generally spend moretime in demonstrating physical care of mother and baby than in discussing infant2behaviour, infant characteristics or family adaptation (Glover et al., 1985).With today's trend toward a shortened hospital stay of between 6 and 48 hourspostpartum (Jansson, 1985; Lemmer, 1987; Thurston & Dundas, 1985), a differentapproach to postpartum education is required. Shortened length of hospital stayresults in less time to spend on teaching. Nurses generally expect to provide thecontent of a routine teaching package to new mothers in the belief that this approachwill provide information on most of the things new mothers need to know. With lesstime available for teaching, it is evident that the "routine teaching package" approachmust change. A larger proportion of postpartum education must now be provided tomothers after discharge. The ability to identify postpartum learning needs which areimportant to mothers is now becoming essential. Once learning needs have beenidentified, strategies can be developed to address them. Perhaps some can beaddressed in the antenatal period, some can be addressed during hospitalization andothers addressed at home. It is neither possible nor advisable to try to teach acomprehensive educational package during a 48 hour hospital stay postpartum.Organized early postpartum discharge programs generally include nursing homevisits as a part of a comprehensive program (Avery, Fournier, Jones, & Sipovic, 1982;Bradley, Carty, & Hall, 1989; Jansson, 1985; McCarty, 1980; Rush, Chalmers, & Enkin,1989; Thurston & Dundas, 1985). However, there is no consistency among programs3at present. Home followup can range from a phone call, to one or more daily nursingvisits beginning the day after discharge. Visits can be provided by nurses who workon the maternity unit or by community health nurses.Nursing literature stresses the importance of providing individualized patient care(Davis et al., 1988; Gruis, 1977) and the family centered maternity care conceptstresses the importance of parental involvement in decision making concerning care(Bull, 1981). The principles of individualization and involvement should occur in theeducation aspect of patient care as well. If mothers are being exposed to only thosepostpartum topics taught as a matter of routine during hospitalization, they are beingdenied the opportunity to identify the topics that are important to them as individuals.Individualization of learning needs assumes even greater importance given today'strend toward shortened postpartum hospital stay (Bull, 1981; Gruis, 1977). However,nurses have not taken a proactive role in assisting postpartum mothers to identify theirlearning needs (Bradley et al., 1989) and Gruis (1977) warns that mothers may notalways seek out information on their own.It is not clear which learning needs would be more suitably addressed in hospitaland which learning needs would be more suitably addressed at home. Who shoulddetermine what is taught in hospital and what is taught at home? Wouldmaternal/newborn nurses and postpartum mothers make the same or different choices?4Statement of the ProblemThe literature covers a variety of the concerns of postpartum mothers before andafter discharge. Concerns of mothers in the early postpartum period seem to involveinfant care while later concerns seem to involve family relationships. However, there isneither consensus on the part of mothers and nurses regarding which postpartumtopics are most important to mothers nor on recommendations related to which topicsare more suitably addressed in hospital and which topics are more suitably addressedat home.Purpose of the StudyThe purpose of this study was two-fold:1. to identify which learning needs would be more suitably addressed in hospitaland which learning needs would be more suitably addressed at home as perceived bypostpartum mothers and maternal/newborn nurses.2. to compare the perceptions of the two groups.Conceptual FrameworkThe conceptual framework for this study was based on selected concepts fromadult learning theory or andragogy as developed by Malcolm Knowles (1970), andfrom Gruis' (1977) theory of developmental tasks of the postpartum period.5AndragogyAndragogy is based on four important assumptions (Knowles, 1970, 1972) aboutthe characteristics of adult learners. These assumptions relate to self-concept,experience, readiness to learn, and orientation to learning and have implications forthe nurses who are the providers of postpartum education.Self-concept Mature adults see themselves as capable of making their own decisions andmanaging their own lives (Knowles 1970, 1972; Tarnow, 1979). This is the premise ofthe assumption of self-concept (Knowles, 1970).Adults derive fulfillment from various roles such as worker, spouse, or parent.(Knowles, 1970). They experience a deep-seated need to be treated with respect, tohave others see them as capable and self directing (Knowles, 1970). Being told whatto do and what not to do, being talked down to, embarrassed, or judged may causeresistance to learning in an adult. Such treatment is incongruent with his/her self-concept as an autonomous individual (Draves, 1984; Knowles, 1970, 1972).ExperienceThe second assumption involves the life experiences that adults use as buildingblocks for further learning (Knowles, 1970). They have a rich foundation on which torelate new experiences.6Adults are defined by their experience and it establishes their self identity in termsof occupation, achievements, marital status, and other factors (Draves, 1984). Whenin situations where their experience is rejected or minimized, adults may feelpersonally rejected (Knowles, 1970; Tough, 1971). They may carry over perceptionsfrom previous experiences or schooling that they are not very bright. Theseperceptions can prove a barrier to engaging in effective learning (Knowles, 1970).However, adults have also acquired larger numbers of fixed habits and patterns ofthought that tend to make them less open minded (Knowles, 1970).Experience plays a central role in the learning process whereby concepts arederived and continuously modified by experience (Kolb, 1984). Learning is the majorprocess by which adults will adapt to new social and physical environments(Havighurst, 1952). Knowledge will be continuously derived from and tested out in theexperience of the adult involved in change (Havighurst, 1952; Kolb, 1984).Readiness to learnThe third assumption involves a state of mind which Knowles (1970) has termedreadiness to learn. For adults, growth and development is primarily the result of theevolution of social roles and resulting developmental tasks e.g. becoming a parent(Havighurst, 1952).Each of these tasks produces a "readiness to learn" which at its peak produces a7'teachable moment" (Knowles, 1970, p. 45) or "deliberate learning episode" (Tough,1971, p. 7) in which more than half of the individual's intention is to gain and retaincertain knowledge and skill. Knowles (1972) describes readiness to learn as"decreasingly the product of biological development and academic pressure andincreasingly the product of the developmental tasks required for the performance ofevolving social roles" (p. 35).Orientation to LearningThe fourth and last of Knowles' (1970) assumptions relates to the adult'sorientation to learning. Adults are problem-centered and goal-directed learners(Knowles, 1970). There is a perspective of immediacy of application toward most oftheir learning because they generally engage in learning as a means of accomplishingsomething that is important to them now (Draves, 1984). When skills and knowledgeare required to accomplish their goals, adults can be highly motivated learners. It isquestionable whether people can motivate other people to learn, whether they canhelp motivate, or whether they are actually powerless in influencing the motivation ofothers (Draves, 1984). Motivation is an internal drive and can be put into operation bythe learner only (Bille, 1981).Knowles' (1970) assumptions were considered an appropriate framework for thisstudy as mothers, during the early postpartum period, are adult learners making8decisions about what they feel are their immediate learning needs. Early dischargeprograms mean that mothers now have to make decisions related to the environmentin which early learning will take place as well.Gruis' Developmental Tasks of the Postpartum PeriodGruis (1977) believes that there are four developmental tasks related to becominga parent which have a relationship to the times during the postpartum period at whichspecific learning needs become evident; physical restoration, learning the infant'sneeds, relating with the newborn, and accommodating a new family member.Physical RestorationAlthough mothers may appear ready and eager to learn in the early postpartumperiod, effective learning may not actually take place because mothers are often tired,sore, and uncomfortable. They require time for their physical and psychological needsto be seen to before they are actually ready to learn.Leamina the Infant's NeedsIn today's society, there are few opportunities formal or informal for people to learnabout infant care through their own experience before actually becoming parents.Through various resources such as literature, their parents and friends, mothers mayhave some perceptions related to infant care but a solid experiential basis is lacking.9Relating With the NewbornA mother needs to learn about and understand her new infant in terms of normalgrowth and development and infant behaviour. A vital component of the mother/infantrelationship is the adaptation between the mother's personality and the personality ofthe baby newly introduced into her environment.Accommodating a New Family MemberDemands of the baby must be regulated with the demands of other familymembers, society, and the mother's own personal needs. The new mother must notonly establish a relationship with her baby, but she must also face the issues involvedin integrating the infant into the larger environment of family and community. Mothersmay feel quite overwhelmed in the early postpartum period.Gruis' (1977) developmental tasks provide a focus for nurses in terms of guidingand facilitating postpartum mothers' learning experiences. Nurses are aware that theearly postpartum period may not be an optimal time for learning therefore they mustcarefully assess each mother's readiness to learn (Knowles, 1970). Gruis (1977)offered no suggestions related to the points at which, or the sequence in whichmothers move through the developmental tasks. However, nurses will recognize thatlearning involves a continuous process of adaptation for mothers: their return to thenon-pregnant state, learning to meet their infants' needs, learning how to relate to their10infants, and learning how to adapt with their infants to the larger environment of familyand community (Gruis, 1977).Research QuestionsThis study was designed to answer the following research questions:1. Which postpartum learning needs do mothers eligible for participation in anearly discharge program perceive as being more suitably addressed during thehospital stay?2. Which postpartum learning needs do mothers eligible for participation in anearly discharge program perceive as being more suitably addressed by visiting nursesin the home?3. Which postpartum learning needs do maternal/newborn nurses perceive asbeing more suitably addressed with short stay mothers in hospital?4. Which postpartum learning needs do maternal/newborn nurses perceive asbeing more suitably addressed with short stay mothers during nursing visits in thehome?5. Are postpartum mothers' perceptions about these questions different than thoseof maternal/newborn nurses'?1 1Significance of the StudyEducation is an important aspect of the role of today's maternal/newborn nurse.At the same time, length of hospital stay postpartum is becoming increasingly shorter.A perceived inability to provide what nurses believe is essential in terms of postpartumteaching leaves them frustrated and demoralized.The information obtained in this study may be of assistance in the development ofmore individualized, cost effective educational programs. Mothers may not expect orwant a lot of information in the first 24 hours postpartum. Perhaps prenatal classescan look at what postpartum material is offered pre delivery and how it can bechanged or adapted. The aim is to ensure that the educational preparation ofpostpartum mothers is consistent with their learning needs and changing trends inmaternity care and to decrease the frustration of maternal/newborn nurses related topostpartum education.Definition of TermsPostpartum learning need: an identified concern or interest requiring information,discussion, or skill on the part of the postpartum mother. Such concerns or interestsmay be related to self, infant, or family.Maternal/newborn nurse: a nurse who provides care for a mother/baby dyad.12Early discharge program: a formal program in which low risk mothers and babies aredischarged within 6-48 hours of delivery. Provisions are made for nursing home visitsbeginning the day after discharge.Short stay eligible mothers: postpartum mothers who are eligible to participate in anearly discharge program.Visiting nurse: a nurse, either hospital or community-based, who will provide follow-upcare in the home for postpartum mothers participating in an early discharge program.Primipara: a postpartum mother who has delivered and will care for her first baby.Multipara: a postpartum mother who has delivered more than one baby and hascared for at least one of those babies.Assumptions of the StudyThe assumptions of the study were as follows:1. Postpartum education is an integral part of postpartum care.2. Mothers are capable of delineating their learning needs early in the postpartumperiod.3. The majority of today's first time mothers have little or no experience withnewborns.13Limitations of the StudyThe limitations of the study were as follows:1. Because the study was descriptive in design, results could not be readilygeneralized.2. The questionnaire used was not subjected to testing for reliability and requiresfurther testing for validity.14CHAPTER IILITERATURE REVIEWOverviewThis study sought information regarding which postpartum learning needs mothersand nurses perceive as suitable to hospital and home. An initial search revealed noliterature in the area. Therefore a literature review was conducted in those areaswhich seemed appropriate to the purpose of the study, the conceptual framework,and research questions; early postpartum discharge, general concerns/interests ofpostpartum mothers, and patients' and caregivers' perceptions of patient education.Literature in these areas may shed some light on the perceptions of both mothers andnurses related to education and learning needs in the early postpartum period.Early Postpartum DischargeMuch of the literature on early discharge deals with the issues of costeffectiveness, patient safety, or patient satisfaction (Cottrell, Pittala, & Hey, 1983;Rollins et al., 1979; Waldenstrom, 1989; Waskerwitz, Fournier, Jones, & Meier, 1985;Yanover, Jones, & Miller, 1976). Postpartum learning needs of early dischargemothers are rarely addressed and then only superficially.In a retrospective evaluation of an early discharge program Avery et al. (1982)wanted to determine if mothers were satisfied with their birth experiences. They15distributed 154 questionnaires to program participants of which 94 were returned. Thecharacteristics of the respondents were not reported. The questionnaire inquiredabout postpartum instruction but related to satisfaction only.Eighty six per cent of the sample indicated satisfaction with the amount ofinstruction received. This program included a teaching sheet in checklist formatcovering both maternal and infant topics, but how and by whom the teaching sheetwas developed was unclear. Although teaching sheets were used both in hospitaland for home visits, whether or not they were individualized for each mother was alsounclear. The topics discussed in hospital and at home were not identified. There isalso no mention of who selected the topics for discussion; nurse or mother.In another retrospective evaluation of early discharge, Sullivan and Beeman (1982)studied the association between satisfaction with care and three areas; parent-infantbonding, reconstructing birth events, and instruction in care of self and baby. Theymailed 3773 questionnaires of which 1900 were returned. Respondents varied widelyin terms of age, ethnic origin, and socio-economic status. Seventeen percent of thesample were actually hospitalized longer than 3 days.The investigators noted that those respondents whose wishes related to bonding,reconstruction of the birth experience, and education were not honored hadsignificantly lower levels of satisfaction with care than did those whose wishes were16honored. Home visits were not offered to early discharge mothers in this study and30% indicated that they would have liked a visit to discuss a variety of concernsrelated to self and baby care, emotional self, and family relationships.Bradley et al. (1988) conducted the only recent randomized, controlled trial of earlypostpartum discharge. In one aspect of the study, they looked at topics raised fordiscussion by postpartum mothers (n = 131) with the home visiting nurse on day 1, 2,3, 5, and 10. Participants were mainly Caucasian, well educated, middle incomemothers with a mean age of 30.16 years. All had unremarkable pregnancies anddeliveries.On day 1, mothers focussed on infant appearance and behaviour and the birthexperience. Mothers on day 2 expressed concerns regarding fatigue. On days 3 and5 mothers interests again returned to infant topics with questions related to infantfeeding and infant behaviour. Both traditional hospital stay mothers and earlydischarge mothers were visited on day 10. The traditional discharge mothers tendedto raise more topics such as infant behaviour, birth experience, and fatigue than didearly discharge mothers. However, mothers participating in the trial had the samevisiting nurse while traditional stay mothers may have had a number of different nursesoffering teaching and information during their stay in hospital. The trial mothers wouldhave experienced more consistency in terms of teaching and information. There was17no significant difference between multiparas and primiparas in the kinds of concernsraised.Martell, Imle, Horwitz, & Wheeler (1989) studied a sample of 42 short stay mothersat 72 hours postpartum. The purpose of their study was to identify information from agiven teaching protocol which mothers in a maternity short stay program thought wasmost important to them in the first three days postpartum. The mean age of thesample was 24.74 years, mean educational was 12.83 years, and all had uneventfulpregnancies and deliveries. All mothers were discharged between 6 and 8 hourspostpartum. Most of the mothers were recruited to the study by telephone after theirfirst 24 hours postpartum and the remainder were recruited when they returned for aclinic visit between 48 and 72 hours postpartum. The researchers collected data witha one way structured Q sort asking mothers to rank 24 items from the teachingprotocol according to the items' importance to them the first 3 days postpartum. Theaverage point at which mothers participated in the study was 57.76 hours postpartum.Results indicated that health threats, infant care, and feeding were of a highdegree of concern for both primiparas and multiparas. Mothers were least concernedabout their own sexuality, family changes, and bowel function.These studies gave no direction as to which learning needs mothers would haveaddressed in hospital or which learning needs they would have addressed at home.18However, it appears that mothers' early (1-3 days postpartum) learning needs have aninfant focus with family relationship topics being of little interest. Some of the studiesindicated that mothers seem to respond more positively to learning experiences whengiven the opportunity to identify their own learning needs.Concerns and Interests of Postpartum MothersThere is a variety of literature available on postpartum mothers' concerns andinterests from 24 hours to 6 weeks postpartum. Methods vary widely. Most of thestudies are descriptive in nature and instruments consist of mainly study-specificquestionnaires and card sorts. Most of the samples were those of convenience. Themajority of studies indicated that mothers' early postpartum concerns involved infantcare topics while concerns related to family relationships appeared later in thepostpartum period. Concerns related to self were never very evident at any timeexcept in Gruis' (1977) study where the topic of most concern was the return of thefigure to normal.Davis et al. (1988) conducted a descriptive study with in-hospital mothers in =117) during their first 3 days postpartum. They designed a 44 item questionnairebased on a comprehensive interview guide developed by Lesser and Keene (1956).The sample was composed of English-speaking mothers who had uneventfuldeliveries and healthy newborns. Mothers were instructed to rate items which they felt19nurses should be teaching in terms of self and baby on a scale of "not very important"to "very important."The maternal care topic of highest priority was postpartum complications and theinfant care topic of highest priority was infant illnesses. These results reflected thepriorities of all age and parity groups. Other priority topics for primiparas wereepisiotomy/stitches in the maternal care category and infant medications, feedingbaby, and cord care in the infant care category. For multiparas, other importantmaternal care topics were the use of medications and stitches/episiotomy.Moss (1981) attempted to identify the concerns of multiparas during the earlypostpartum period in the areas of self, infant care, and family relationships. Shedeveloped and administered a card sort to each of 56 in hospital mothers on the 3rdpostpartum day (defined as between 60 to 72 hours after delivery). The toolconsisted of 61 index cards with each card containing a word or phrase indicatingcommon concerns of new mothers identified in the literature. The mean age ofparticipants was 24.4 years and all had uneventful pregnancies and deliveries.Educational background was varied.Results indicated that concerns related to themselves ranked relatively low exceptfor weight and return of their figures to normal. Baby's safety and how children athome will react to the new baby were among the five highest ranked items. Overall,20mothers' concerns related primarily to items in the family relationships area.Hiser (1987), replicating Moss' (1981) study with a sample of 20 multiparas, cameto the same conclusions. However, when Hiser asked mothers (after they hadcompleted the card sort) to name their concerns, more than half of the participantsnamed their newborns. Less than half of the participants named the family.Bull (1981) conducted a comparative survey to determine any differences inmaternal concerns after one week at home. A self-administered 50 item questionnairecontaining potential concerns related to the categories of self, baby, husband, family,and community was adapted by the researcher from a checklist developed by Gruis(1977). Mothers were between 18 and 35 years of age, Caucasian, and Englishspeaking. All had at least high school education and all had uneventful pregnanciesand deliveries. Each of 40 mothers completed a questionnaire in hospital onapproximately her 3rd day postpartum and was asked to mail in another completedquestionnaire after approximately one week at home. Thirty of these questionnaireswere returned.Results indicated that both the frequency and intensity of concerns related tophysical discomfort decreased after one week at home, however, the frequency andintensity of concerns related to emotional self increased. The number and intensity ofconcerns related to physical care of the baby decreased after one week at home but21infant behaviour continued to be of "moderate" to "much" concern. Items in thehusband category were consistently ranked as being of "little" or "moderate" concern.Items in the family and community categories were consistently ranked as being of"little" or "no" concern.Sumner and Fritsch (1977) conducted a descriptive survey during the entire monthof October, 1974 to see if there was justification based on consumer volume todevelop education/supportive services for parents of newborns. All calls from eligibleconsumers (those who delivered or had an infant up to 42 days of age during thestudy period) related to postpartum concerns were monitored at the medical facilityinvolved in the study from October 7, 1974 to November 2, 1974. A form wasdeveloped for documentation of data. The number of calls totalled 270. Twenty fivepercent of the multiparas eligible to call did so and 88% of the primiparas eligible tocall did so.The category of most concern was infant feeding, followed by other infant care-related items. In general, the questions were most frequent during the first 2 weekspostpartum, dropping off sharply at 6 weeks. Results were consistent for both paritygroups.In her 1977 study, Gruis surveyed 40 mothers who were one month postpartum.Various mothers were asked to complete a questionnaire listing potential areas of22concern drawn from the literature. Mothers were instructed to identify which of theareas were significant to them during the past month, rank the concerns as major orminor, and note the resources they had used to meet these concerns. Respondents'ages ranged from 18 to 36 and educational background varied. All haduncomplicated pregnancies and deliveries.Gruis (1977) noted that the most frequent major concern raised for both paritygroups a month postpartum (strongest in the multiparous group) was the return oftheir figures to normal. Multiparas also raised regulating family demands, finding timefor self, fatigue, and emotional tension as major concerns. Primiparas raisedregulating family demands, infant behaviour, feeding, and emotional tension. Gruisalso determined that mothers did not seek help for 22% of the concerns theyidentified, probably because help was not readily available.Like the studies on early discharge, the studies related to mothers' postpartumconcerns/interests did not indicate which learning needs mothers perceived as moresuitably addressed in hospital and which learning needs they perceived as moresuitably addressed at home. However, these studies did seem to point to the timesduring which specific concerns appeared. Research conducted in the earlypostpartum period (3 days postpartum) with in-hospital mothers indicated that theirconcerns were generally related to the physical care of themselves and their infants.23At home one week postpartum, concerns were related to the emotional self and infantbehaviour. One month postpartum, concerns turned to family relationship topics.Patients' and Caregivers' Perceptions of Patient EducationAdult EducationMost writers in the field of adult education support Knowles' (1970) conceptsrelated to the adult learner as useful in adult education. Knowles (1970) identifiesthese concepts as assumptions but they have also been called principles of adultlearning, adult education principles, or principles of teaching/learning (Draves, 1984;Honan, Krsnak, Peterson, & Torkelson, 1988; Mooney, 1987; Murdaugh, 1980;Redman, 1984; Tough, 1971). Much practical advice for adult educators is derivedfrom Knowles' (1970) assumptions of self-concept, experience, readiness to learn, andorientation to learning.Educators are cautioned that physical surroundings must be comfortable andconducive to learning (Draves, 1984; Redman, 1984) and more importantly, thepsychological climate should be one in which learners feel accepted, respected, andsupported (Draves, 1984; Knowles, 1970; Redman, 1984). The behaviour of theeducator and the relationship between educator and learner is probably the mostinfluential determinant of the psychological environment (Bille, 1981; Knowles, 1970;Lesser & Keene, 1956). Educators convey in many ways whether their attitudes are24ones of interest in and respect for adults as learners or whether they see such adultsas essentially receiving sets for their educative wisdom (Draves, 1984). Effectivelearning is better served by having goals expressed from the learner's point of view(Bille, 1981; Redman, 1984).Adults will be motivated to learn relative to the participation they have had inidentifying learning needs, planning to meet those needs, and in conducting andevaluating the learning experiences (Arndt & Underwood, 1990; Knowles, 1970).Adults are also more motivated to learn by seeing the relevance of what they arelearning through practical application (Kolb, 1984; Redman, 1984). Learning is alsomore meaningful to adults if the sequence of learning is both logical and important tothem (Knowles, 1970; Tough, 1971).Adult educators must be person-centered and individualize teaching to suit theindividual learner continually timing learning to the learner's pace (Knowles, 1970;Redman, 1984). Adult educators must also be prepared to act as facilitators oflearning rather than teachers, as no one person is capable of "making" another personlearn (Tough, 1971).Effectiveness of Application of Teaching/Leaming PrinciplesThere are some studies which describe differences between caregivers' andpatients' perceptions of patient education both in general and in the area of25maternal/child nursing. The following studies describe both patients' and caregivers'perceptions of patient education in relation to other aspects of service delivery and theeffect that nurses' use of adult education principles appears to have on outcomes inpatient education. In addition, some of these studies describe differences in emphasisplaced on postpartum needs by both mothers and nurses.Elbeik (1986) studied patient education relative to the perception of clients (n =33) and various health care providers including administrators (n = 28), nurses (n =35), and medical staff (n = 21). Demographic data on participants were not reported.A Likert style self-completion survey was administered in random fashion toparticipants in order to elicit information regarding what users and providers felt wasimportant regarding service delivery.Study results revealed that all four groups identified diagnosis/assessment andtreatment as important attributes of care. However, health care providersdemonstrated significantly less concern for education than did clients.Murdaugh (1980) wished to ascertain whether patients would learn more about adisease process and therapeutic regimen if nurses were taught the principles ofteaching/learning. Patient participants included both males and females up to the ageof 75 years. Nurse participants were registered nurses who worked in the CoronaryCare Unit (CCU) on a regular basis. A pretest/posttest static group design was used26for the study. Data were collected from 20 patients in the CCU related to theirknowledge and understanding of specific aspects of their condition on entry to theunit and again just prior to discharge. After these patients were discharged, 18nurses working in the unit participated in a course on the principles ofteaching/learning. Data were collected again from another 20 patients on entry to andjust prior to discharge from the unit.Results indicated a significant difference in knowledge and understanding for thepatients taught by nurses who applied teaching/learning principles. Murdaughconcluded that although nurses without knowledge of teaching/learning principles maybe teaching patients, teaching becomes more effective when nurses know theseprinciples.Mooney (1987) conducted a study to gain information about nurses' use andapplication of the four adult education principles of self-directedness, time perspective,readiness to learn, and experience. The investigator developed a 21 itemquestionnaire which assessed knowledge and application of the adult learningprinciples and administered it to 127 registered nurses from two hospitals. Ninetyeight of the nurses responded. The mean age was 22.4 years and 94% wereemployed full time. Educational preparation included associate degrees (4.1%),diploma graduates (44.5%), and baccalaureate graduates (51%).27Mooney (1987) concluded that the nurses understood all four adult educationprinciples but did not apply them consistently. The principles of time, experience, andreadiness were chosen by the nurses more often than self-directedness. Failure of thenurses to apply the principle of self-directedness would imply that patients were notallowed an active, responsible role in the learning process.Honan et al. (1988) conducted a descriptive study related to selected factors thatmay influence patient teaching; responsibility, priority, knowledge, materials,environment, time/staff, and documentation. Sixty registered nurses completed aquestionnaire which consisted of 28 subjective attitudinal questions. Respondentscould use either a Likert-type scale or a rank order sequence to answer the questions.No demographic information concerning the respondents was reported.The investigators concluded that while nurses believed they had a responsibility forteaching, 85% believed other disciplines needed to be more involved. Only 58.3%believed it was the nurse's responsibility to coordinate multidisciplinary teaching. Datafrom Likert-type questions indicated nurses believed patient teaching was a highpriority. However, a rank order question revealed patient teaching was not a highpriority when ranked with other nursing duties such as patient care, medications, andcharting. It was also ascertained that nurses did not have an adequate enoughknowledge of teaching/learning principles to effectively teach patients. Nurses cited28the adequacy and availability of teaching materials as well as time and staffing asobstacles to patient teaching. The investigators also reported that although formaland informal patient teaching was carried out, it was seldom communicated ordocumented.Patients' and Nurses' Perceptions of Learning NeedsWhile observing and interviewing various postpartum nurses and mothers, Lesserand Keene (1956) studied both postpartum mothers' and nurses' perceptions ofgeneral postpartum needs. They concluded that, as a group, the nurses recognizedall of the needs that mothers themselves revealed. However, the nurses' emphasiswas often very different from that of the mothers'.The nurses saw themselves as performing routine clinical functions and teachingcertain aspects of self care and baby care. Meeting other needs of the mothers wasoften incidental, to be performed if there was time and only if those needs wereforcefully made known. Mothers expressed the need for physical care anddependence and felt that nurses, by and large, failed to recognize these needs. Thebiggest factor for these mothers appeared to be the nurse-patient relationship. If thenurses displayed warmth and personalization of care, the mothers felt greatersatisfaction with their hospital experience as a whole.Cupoli et al. (1971) investigated teaching conducted by nurses in the areas of29infant care, behaviour, and characteristics. Data were collected by non-participantobservation over a two week period. During each shift, randomly selected postpartumand nursery nurses were observed for selected periods of time that would cover suchactivities as infant feeding and patient discharge. Three nurses were educated at thebaccalaureate level, 24 graduated from diploma programs, and 11 were licensedpractical nurses; a total of 21 postpartum and 17 nursery nurses.The investigators concluded that more time is spent teaching about infant carethan either infant behaviour or infant characteristics. They observed that mothersmore often than nurses initiated information exchanges about infant behaviour andthat, while in hospital, mothers seemed to be more concerned about the behaviour oftheir infants than their infants' care. Thus a discrepancy exists between the topics ofinformation exchanges mothers initiate and those nurses initiate.Glover et al. (1985) surveyed postnatal educational programs in 27 BritishColumbia, Alberta, and Saskatchewan hospitals. Their findings indicated that teachingcontent is most often set by nurses alone. The present system of in-hospital postnataleducation seems to be addressing the physical aspects of maternal and infant carebut not the emotional aspects and expectations surrounding this time. Theyquestioned whether teaching is appropriate to consumer needs.Tribotti and Lyons (1987) studied postpartum mothers and nurses (12 = 23630nurse/patient pairs) perceptions related to postpartum problems according to possiblenursing diagnoses. Patient participants were an average of 27 years of age, hadalmost 14 years of education, and were married. Most were between 12 and 72 hourspostpartum and breastfeeding their term infants. Nurse participants were an averageof 35 years of age, 10 years out of nursing school, and had 6 years of experience inobstetrical nursing. The majority were registered nurses without baccalaureatedegrees. Investigators concluded that the major areas of concern to patients werechange in comfort, potential for growth (related to the social and emotional aspects ofparenting), change in body fluids, change in sleep pattern, and change in movement.The major areas of concern to patients as perceived by nurses were change incomfort, potential for growth, lack of knowledge, change in bowels, and change inbody fluids. Findings for both groups were similar but rank order of priority proveddifferent. The one major difference identified was lack of knowledge. Of the nurses,62.3% identified lack of knowledge as a problem while only 32.4% of mothersidentified it as a problem.The studies reviewed did not identify which postpartum learning needs nursesperceived as more suitably addressed in hospital and which learning needs theyperceived as more suitably addressed at home nor was there any clear indication ofwhich postpartum learning needs nurses perceived as important to mothers during31the early postpartum period. Therefore it was not possible to detect any relationshipbetween nurses' and mothers' perceptions of early learning needs. However, thestudies did offer some conclusions worth considering.It would appear that caregivers attach much less importance to patient educationthan do patients. Nurses seem to perceive education as just one more task to beperformed in addition to other care and only attended to when other tasks have beencompleted. There is some evidence to suggest that patients perceive the nurse-patient relationship as an extremely important aspect of their care and respond withbetter education outcomes when nurses use an adult oriented approach. It has beensuggested that nurses' emphasis on postpartum learning needs differs from mothers'but evidence is inconclusive.SummaryThe literature on early discharge, with the exception of one study, is virtuallynon-existent on the subject of postpartum learning needs. The literature onpostpartum mothers' concerns and interests presents a variety of topics that seem tobe important to postpartum mothers. However, no clear direction regarding whichtopics mothers perceived as being addressed in hospital or at home was apparent.There was some evidence to suggest that infant concerns are a priority for bothprimiparous and multiparous mothers in the early postpartum period.32Although the application of adult learning principles appears accepted as asuitable educational approach, it would appear that they are applied inconsistently, ifat all, in patient education. Perspectives on the importance of patient education seemto differ between nurses and patients, the latter placing a great deal more emphasison learning. The postpartum learning needs on which nurses focus seem to differ frommothers' actual learning needs, although evidence is inconclusive.33CHAPTER IIIMETHODSOverviewThe information presented in Chapter III provides an explanation of the methodsused to investigate both mothers' and nurses' perceptions of which postpartumlearning needs were more suitably addressed in hospital and which postpartumlearning needs were more suitably addressed at home. The investigation alsoincluded the identification of differences in responses between the two groups.Approach, setting, participants, questionnaire, procedure for data collection, and dataanalysis will be described.ApproachThis study reflected two levels of inquiry; factor-searching and relation-searching(Diers, 1979). A factor-searching approach identified those learning needs which bothpostpartum mothers and nurses perceived as being more appropriately learned inhospital and those which both groups perceived as being more appropriately learnedat home. A relation-searching approach compared the perceptions of the two groups.Factor-searching studies are at the first level of inquiry and begin with researchquestions as opposed to hypotheses (Diers, 1979). The questions are very generaland, instead of naming variables or relationships, they may just indicate areas for34inquiry. This approach literally looks for ways to classify information on a givensituation in order to produce sets of categories which, when taken together, willdescribe the whole situation (Diers, 1979). Diers (1979) believes that a factor-searchingapproach is useful when a researcher wants to take a new look at an old situation orwhen there is no usable and/or available information about a particular phenomenon.The aim is description rather than hypothesis-testing and often the data are put in theform of categories after they are collected (Diers, 1979).Although there were some data available on mothers' learning needs in the earlypostpartum period, there were no data available on either mothers' or nurses'perceptions of which learning needs should be addressed in hospital and whichlearning needs should be addressed at home. Therefore, a factor-searchingapproach was considered appropriate. However, through the work of Gruis (1977),specific categories into which the majority of postpartum learning needs seem to fithave already been suggested; self, infant, and family. As a result, data for this studywere collected in relation to these three categories.Relation-searching studies are at the second level of inquiry and are concernedwith problems in which relationships among given factors are unspecified or unknown(Diers, 1979). Diers (1979) suggests that relation-searching studies should beconducted when a situation is new or when there is a search to see if a relationship35found in one context will also be found in others. As with factor-searching studies,relation-searching studies do not have hypotheses and their purpose is not togeneralize findings to other populations or samples, but simply to describerelationships found (Diers, 1979).A number of writers suggest that the relationship between educator and learner iscrucial and that, if the learning objectives of educator and learner differ, learning willbe inhibited (Draves, 1984; Knowles; 1970; Redman, 1984). However, there are nodata available on the relationship between mothers' and nurses' perceptions of whichpostpartum learning needs are more appropriately addressed in hospital and whichpostpartum learning needs are more appropriately addressed at home. The lack ofsuch data indicated a need for a relation-searching approach.SettingThe setting was the Maternal\Newborn unit in an acute care hospital on VancouverIsland which averages approximately 3500 deliveries a year. Presently, postpartumteaching is conducted according to topics set out in a parent teaching sheet. Thisteaching sheet becomes a part of the permanent health record of each postpartummother (see Appendix A). A pilot early discharge program has recently beendeveloped in which selected groups of low risk vaginally delivered mothers and babiesand low risk Caesarean delivered mothers and babies are discharged at36approximately 48 hours and 4 days postpartum respectively. Nursing follow up in thehome begins the next day.ParticipantsDuring a seven week period, a convenience sample of all vaginally deliveredprimiparas meeting the criteria for early discharge (see Appendix B) and who werejudged eligible for inclusion in the study, were asked to participate. Of 126 primiparaseligible, 89 chose to participate.For the purposes of this study primiparas were targeted because, given theirassumed lack of experience, nursing staff tend to give them priority in terms ofteaching time and effort. Vaginally delivered primiparas were also believed to producea more homogeneous perspective on what would be considered normal postpartumlearning needs.All maternal/newborn nurses providing mother/baby care including relatedteaching were judged eligible for inclusion in the study. Of 72 nurses eligible, 50chose to participate.QuestionnaireData were collected with a questionnaire based on those postpartum concernsand interests evident in the literature as important to mothers (see Appendix C).Concerns and interests were assigned to content categories congruent with Gruis'37(1977) developmental tasks of postpartum mothers; self, infant, and family.A relation-searching approach implies that comparisons are to be made. Wherecomparisons are to be made, it is necessary to retrieve exactly the same informationfrom each sample unit (Diers, 1979). Because mothers' and nurses' responses inrelation to postpartum learning needs were to be compared, the same questionnairewas distributed to both groups. Participants were asked to assign concerns andinterests to either of two areas; learning suitable to hospital or learning suitable tohome.To ensure the clarity and content validity of the questionnaire, a pilot study wasconducted with five maternal/newborn nurses and five primiparas eligible for earlydischarge. All participants reported that the questionnaire was logical, comprehensive,and easy to understand and follow. The questionnaire was also reviewed by the HeadNurse and the Clinical Teacher of the Maternal/Newborn unit. The only change was toadd frequency of feeds under bottle feeding concerns which eight out of tenrespondents in the pilot study felt should be included. The revised questionnaire wasthen used to collect data for the actual study.Procedure for Data CollectionOver a seven week period, questionnaires were distributed to all vaginallydelivered primiparas who were 24-72 hours postpartum and met the criteria for early38discharge. Completed questionnaires were placed in envelopes, sealed, and returnedto the nursing staff or the unit clerks who dropped them into a return box located at aneutral location on the unit. This return box was used to collect both mothers' andnurses' questionnaires.During the same seven week period, the investigator presented the purpose andobjectives of the study at a maternal/newborn nurses' staff meeting to invite nurseparticipation. Subsequently, notices inviting participation were placed on the nursingcommunication boards of each patient care area on the unit. A number ofquestionnaires were left at each patient care area and replenished by the investigatoras necessary. Completed questionnaires were placed in envelopes, sealed, anddropped by participating nurses into the return box.Both nurses and mothers received identical questionnaires. The only differencewas the attached demographic information sheets (see Appendix C). Included witheach questionnaire was an explanatory letter delineating the purpose and objectives ofthe study and outlining subject rights relative to scientific investigation (see AppendixD). Consent to participate in the study was assumed by the return of a completedquestionnaire.39Data AnalysisFrequencies were determined for each concern/interest on the questionnaire andeach category on the background information sheets for both groups. Frequencieswere computed in proportions and then converted to percentages for tabularpresentation (see Appendix E). Concerns/interests were then listed according to theten topics which each group chose most frequently as learning more suitable tohospital and/or learning more suitable to home. On those occasions where topics tiedfor tenth place, they were included in the list.Chi-square analysis was performed for each group on completed backgroundinformation sheets in order to detect any trends related to background informationdata and participants' responses to items on the questionnaire.To determine if differences existed between the responses of the two groups, theChi-square statistic was also applied to both groups' responses for each postpartumconcern/interest covered in the questionnaire. A two-tailed t-test, as a measure ofproportion, was also used to further validate any significant differences reported byChi-square.SummaryFor this study, a factor-searching approach was used to identify mothers' andnurses' perceptions of which postpartum learning needs were more suitably40addressed in hospital and which postpartum learning needs were more suitablyaddressed at home. A relation-searching approach was used to compare theresponses of both groups.Eighty nine early discharge eligible mothers and 50 maternal/newborn nurses froman acute care hospital on Vancouver Island chose to participate in the study. Bothgroups completed and returned identical questionnaires. The questionnaire coveredpostpartum concerns and interests gathered from the literature. Concerns andinterests were separated into three categories reflecting Gruis' (1977) developmentaltasks of the postpartum period; self, infant, and family. Included with eachquestionnaire was a cover letter and background information sheet specific to eithermother or nurse.Frequencies were determined for each response for both groups and reported aspercentages. Responses of both groups were then listed according to the concernsand interests which each chose most frequently as learning suitable to hospital andhome. Significant differences in responses for both groups were identified using theChi-square statistic. Two-tailed t-tests were used to validate identified differences.Background information was also examined for trends in relation to both groups'responses using the Chi-square statistic.41CHAPTER IVRESULTS AND DISCUSSIONOverviewDemographic information related to the samples will be presented first. Followingthis, the postpartum concerns/interests which postpartum mothers' and nurses'perceived as more suitably addressed either in hospital or at home will be identifiedand the responses of both groups compared. The distribution of postpartumconcerns/interests between hospital and home will also be delineated. Finally resultswill be discussed in relation to the conceptual framework and the literature review.ResultsDemographic InformationOf 126 eligible postpartum mothers, 89 returned completed questionnaires and of72 eligible maternal/newborn nurses, 50 returned completed questionnaires; a returnrate of 70.6% and 69.4% respectively. The majority of mothers were 25-29 years ofage, had completed high school, and had a total family income of $45,000 or more(see Table 1).The demographic information also revealed that 11 % of mothers felt the helpavailable to them after discharge would not be adequate to meet their needs. Thisgroup of mothers chose to breast feed their infants, were 25-29 years of age, had42completed college/university or postgraduate studies, and had a total family income of$35,000-$45,000 or more. Two mothers did not respond to this question stating that,as they didn't know what to expect, they couldn't predict whether the help available tothem after discharge would meet their needs or not.Six mothers did not supply information regarding total family income. All chose tobreast feed, were generally aged 20-24, were from all education levels with theexception of the post graduate studies category, and all believed the help available tothem after discharge would be adequate to meet their needs.Mothers who had completed post graduate studies chose to have the majority oftheir learning needs met at home. However, as there were only 3 mothers in thatcategory, statistical analysis could not be performed.Demographic information items, when subjected to Chi-square analysis in relationto individual responses on the questionnaire, revealed no significant trends for eithergroup.43Table 1Early Discharge Eligible Postpartum Mothers: Demographic Information  (rj = 89)1. Age:19 or below^2%^20 - 24^21 %25 - 29^45% 30 - 34^23%35 - 39^9%^40 or over 0%2. Education:Some high school^ 1%Completed high school 38%Some college/university^ 32%Completed college/university 25%Completed post graduate studies^4%3. Total family income:$14,000 or less^4%^$15,000 - $24,000 20%$25,000 - $34,000 5%^$35,000 - $44,000 35%$45,000 or more 37%4. I am planning to:breast feed^97%bottle feed^3%5. I expect that the help available to me after discharge will meet my needs forassistance at home.Yes 89%^No 11%44The majority of the nurses who participated in this study were in the 45-49 agegroup (see Table 2 ). Only one nurse did not supply age. Most were prepared at thediploma level and have been in nursing for well over 15 years. Fourteen percent of thesample had post basic preparation related to maternal/child nursing such as midwiferyor the British Columbia Institute of Technology's (BCIT) low risk obstetrics program.45Table 2Maternal/Newborn Nurses: Demographic Information (n = 50)1. Age:24 or below^0%^ 25 - 29^8%30 - 34^12% 35 - 39 25%40 - 44^14%^ 45 - 49^29%50 or over^12%2. Years in nursing:2 or below^2%^ 3 - 4^ 2%5 - 9^14% 10 - 14 12%15- 19^18%^ 20 - 24^18%25 - 29^20% 30 or more 14%3. Educational preparation:RN diploma^ 86%Post basic baccalaureate in nursing^ 14%Generic baccalaureate in nursing 0%Baccalaureate in other than nursing^ 0%Master's in nursing^ 0%Master's in other than nursing^ 0%4. Other post basic preparation related to maternal/child nursing e.g. midwifery:Midwifery^ 10%BCIT low risk obstetric program^ 4%46In analyzing the data, the intent was to report results accurately and consistently.For instance, if one mother checked a concern/interest as suitable to both hospitaland home, the total number of responses for that concern/interest was considered tobe 90 as opposed to 89. If a concern/interest was not checked at all, the totalnumber of responses was considered to be 88. The same rule was applied to thenurses' responses. Because only three mothers chose to bottle feed, items related tothat concern/interest were deleted for both groups as results would not be statisticallyvalid. Topics from the self, infant, and family categories were identified in theappropriate tables by the letters S, I, or F placed beside the corresponding topic.Postpartum Mothers' Perception of Learning More Suitably Addressed in HospitalThe majority of concerns/interests which mothers perceived as being more suitablyaddressed in hospital involved the infant category. Most were related to the physicalcare of the infant. Only one topic reflected a need for knowledge alone as opposedto a need for knowledge attached to a skill (see Table 3). Concerns related to selfconstituted only three items of the ten topics which mothers chose most often aslearning more suitably addressed in hospital. There were no items listed in relation tothe family category.Topics which few mothers would choose to have addressed in hospital cameprimarily from two categories; family (regulating demands of partner, housework, and47job) and emotional self (feelings of guilt/ambivalence about returning to work andfeeling tied down).Postpartum Mothers' Perception of Learning More Suitably Addressed at HomeThe majority of concerns/interests which mothers perceived as being more suitablyaddressed at home were from the family category (see Table 4). These were followedclosely by concerns related to the emotional self. Only two items involved the infantcategory and those reflected a need for knowledge.Under "other topics/concerns" in the self category, one mother wished to know thelocation of the nearest emergency services and to discuss concerns related to"physical conditions".Topics which few mothers would choose to have addressed at home came fromthe infant category such as cord care and infant feeding.48Table 3Postpartum Mothers' Perception of Learning More Suitable for Hospital  (rj = 89)Concerns/Interests ActualCord care (I) 99 (89)Handling/holding infant (I) 98 (88)Blood flow (S) 97 (86)Episiotomy/stitches (S) 97 (85)Infant appearance (I) 96 (87)Attaching/removing infant at breast (I) 96 (86)Frequency of feeds (I) 96 (85)Positioning infant at breast (I) 95 (86)Bathing infant (I) 94 (85)Infant skin care (I) 94 (84)Hemorrhoids (S) 94 (82)Note.^S = self;^I = infant;^F = family.49Table 4Postpartum Mothers' Perception of Learning More Suitable for Home (ri = 89)Concerns/Interests % ActualRegulating demands (F) 99 (88)Kinds of solids to introduce (I) 99 (86)Child care (S) 99 (86)When to introduce solids (I) 98 (87)Changes in lifestyle (F) 98 (88)Feelings of guilt/ambivalence (when returning to work) (S) 98 (85)Feeling tied down (S) 97 (86)Finding time together (F) 97 (85)Family planning (F) 97 (83)Sharing household responsibilities (F) 97 (85)Home management (when returning to work) (S) 97 (84)Note.^S = self;^I = infant;^F = family.50Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed inHospitalThe majority of concerns/interests which the nurses perceived as more suitablyaddressed in hospital were from the infant category, particularly in area ofbreastfeeding (see Table 5). There were no infant items listed which called for theprovision of knowledge alone. Three concerns involved the self category. There wereno concerns listed from the family category.Topics which none of the nurses would address in hospital came from all threecategories: when/kinds of solids to introduce to the infant, immunization (infant); childcare, home management (self); regulating demands of partner, housework, and joband changes in lifestyle (family).Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed at HomeThe majority of the concerns/interests which nurses perceived as being moresuitably addressed at home were from the infant category and reflected a need forknowledge (see Table 6). Three concerns were from the self category (emotionalself) and there were also three concerns from the family category.Under "other topics/concerns" in the self category, one nurse would provide phonenumbers of LaLeche League, lactation consultants, and breast pump distributors.Under "other topics/concerns" in the infant category, one nurse would address infantgrowth spurts.Topics which none of the nurses would address at home were from the infantcategory; aspects of infant feeding and cord care.5152Table 5Maternal/Newborn Nurses' Perception of Learning More Suitable for Hospital (3 = 50)Concerns/Interests % ActualCord care (I) 100 (50)Attaching/removing infant at breast (I) 100 (50)Positioning infant at breast (I) 100 (50)Frequency of feeds (I) 100 (50)Breast/nipple care (I) 100 (50)Episiotomy/stitches (S) 98 (49)Hemorrhoids (S) 98 (50)Infant skin care (I) 98 (49)Handling/holding infant (I) 96 (48)Blood flow (S) 96 (50)Note.^S = Self;^I = infant; F = family.53Table 6Maternal/Newborn Nurses' Perception of Learning More Suitable for Home  in = 50)Concerns/Interests % ActualRegulating demands (F) 100 (50)Kinds of solids to introduce (I) 100 (50)When to introduce solids (I) 100 (50)Home management (when returning to work) (S) 100 (50)Child care (when returning to work) (S) 100 (50)Changes in lifestyle (F) 100 (49)Immunizing infant (I) 100 (48)Feeling tied down (S) 98 (50)Weaning infant (I) 98 (49)Finding time together (F) 98 (49)Vit/fluoride supplements (I) 96 (48)Note.^S = self;^I = infant;^F = family.54Comparison of the Responses of Both GroupsWhen Tables 3 and 5 were compared, both mothers and nurses generallyidentified the same concerns/interests as learning more suitable to hospital. A majortopic for nurses which did not appear on the mothers' table was breast/nipple care.Likewise two major topics for mothers did not appear on the nurses' table; infantappearance and infant bathing. However, over 90% of both groups perceived thesethree topics as more suitably addressed in hospital (see Appendix E). Therefore, onthe whole, both groups would appear to perceive infant care and self care topics aslearning more suitable to hospital.When Tables 4 and 6 were compared, there were some differences betweenmothers' and nurses' choices for learning at home. Three major topics for motherswhich did not appear on the nurses' table were feelings of guilt/ambivalence aboutreturning to work, family planning, and sharing household responsibilities. Over 90%of nurses perceived two of these topics as appropriate for home; feelings ofguilt/ambivalence about returning to work and sharing household responsibilities (seeAppendix E). However, less than 90% of nurses chose family planning as a topicappropriate for home (see Appendix E).Three major topics for nurses which did not appear on the mothers' table wereimmunizing the infant, weaning the infant, and vitamin/fluoride supplements. All three55topics were chosen by less than 90% of mothers as appropriate for home (seeAppendix E). Therefore, more mothers than nurses chose topics from the familycategory as suitable for home while more nurses than mothers chose topics from theinfant category as suitable for home. These observations were borne out statistically.The majority of significant differences between mothers' and nurses' responsesoccurred in the home environment with the infant and family categories.The most significant differences (p<.001) in responses between the two groupsoccurred with the topics of growth and development, family planning, andimmunization (see Table 7). Both groups perceived these topics as learning moresuitable to home. However, more mothers than nurses chose family planning (familycategory) and more nurses than mothers chose growth and development andimmunization (infant category).The only two topics which differed significantly for the two groups in terms of themore suitable environment for learning, hospital or home, were recognizing the unwellinfant and providing a safe environment for the infant. Nurses were evenly split as towhether recognizing the unwell infant was a topic more appropriate for hospital orhome.56Table 7Differences Between Postpartum Mothers' and Maternal/Newborn Nurses' Responsesp-valueConcerns/InterestsMothers^Nurses(n = 89)^L = 50)Hosp. Home^Hosp. Home t-testGrowth and development (I)Family planning (F)Immunization (I)Resuming sexual relations (F)Weaning (I)Vitamin/fluoride supplements (I)Contraception (F)Recognizing unwell infant (I)Safe environment (I)Exercise regime (S)34 66 8 92 <.02 <.0013 97 17 83 =.05 <.00118 82 0 100 <.05 <.0017 93 29 71 <.02 <.00216 84 2 98 <.10 <.00219 81 4 96 <.10 <.018 92 25 75 cs.05 <.0270 30 50 50 v.10 <.0543 57 63 37 =.10 =.058 92 20 80 z.10 =.05Note.^S = self;^I = infant;^F = family.57While more mothers perceived this topic as more appropriate for hospital.More nurses perceived that providing a safe environment for the infant was informationmore suitable to hospital while more mothers perceived such information as moreappropriate for home. Results for both were not significant when analyzed using Chi-square. However when analyzed using a t-test, there was moderate evidence (p<.05)to suggest that mothers' and nurses' responses were different for recognizing theunwell infant and some evidence (p:$.05) to suggest the same for providing a safeenvironment for the infant. Of the concerns/interests for which significant differenceswere identified between the responses of mothers and nurses only one, exerciseregime, came from the self category.It is worth noting that there were no topics which all mothers identified as learningmore suitable to either hospital or home i.e. topics that 100% of mothers assigned tohospital and 0% assigned to home or vice versa. On the other hand, there were anumber of topics that all nurses perceived as learning more suitable to either hospitalor home i.e. topics that 100% of nurses assigned to hospital and 0% assigned tohome and vice versa. (see Appendix E).Distribution of Concerns/Interests Between Hospital and HomeThe relationship to the hospital and home environment among the three categoriesof concerns/interests is depicted in Table 8. Both groups perceived that the majoritySelf 39%Infant 68%Family 6%37%^61 %^63%63% 32% 37%12%^94%^88%58of family topics should be addressed at home. However both groups also perceivedover 30% of self care and over 60% of infant care topics as being more suitablyaddressed during a hospital stay of 48 hours.Table 8Distribution of Concems/Interests by CategoryHospital^ HomeCategory^Mothers^Nurses^Mothers^Nurses(n = 89)^(n =50)^(n = 89)^(n = 50)DiscussionPostpartum Mothers' Perception of Learning More Suitably Addressed in HospitalPostpartum mothers' perception of learning needs more suitably addressed inhospital were similar to other studies which describe mothers' early (24-72 hours)postpartum learning needs. Mothers in this study were most interested in learning59about the physical care of the infant and infant feeding. Some specific infant topicswhich elicited a high degree of concern in other studies of early postpartum learningneeds such as infant illness, (Davis et al., 1988) infant behaviour, (Bradley et al., 1988)and infant safety (Moss, 1981) were not major in hospital choices for mothers in thisstudy.Self care topics chosen by the majority of mothers for learning in hospital werefew; maternal blood flow, episiotomy/stitches, and hemorrhoids. These resultsreflected the findings of Davis et al. (1988) and Bull (1981). Emotional self topics ofmuch concern in other studies such as fatigue and discussion of the birth experience(Bradley et al., 1988) did not appear as major choices for in-hospital discussion withmothers in this study.Family and emotional self items, demonstrated in the studies of Martell et al.(1989) and Bull (1981) as being of little concern for early learning, were not oftenchosen as in-hospital topics by mothers in this study either. These results are inmarked contrast to those of Hiser (1987) and Moss (1981) who found a high degreeof concern related to family and emotional self items in the early postpartum period.Many differences noted among studies could be attributed to differences insample sizes, methods, and demographic characteristics of the participants. On theother hand, some differences may be attributable to other factors such as the60psychological impact of both hospital and home environments on mothers'perceptions and their level of experience with newborn care.The impact of environment. Studies, such as Davis et al. (1988), conducted inhospital within 72 hours postpartum indicated that mothers appeared to be mostconcerned with infant care and infant feeding. However, studies carried out in thehome environment within the same time span, most notably Bradley et al. (1988),indicated a shift towards other concerns such as the birth experience, fatigue, andinfant behaviour. These researchers also noted that the concerns expressed bytraditional discharge mothers at 10 days postpartum mirrored those expressed byearly discharge mothers at a much earlier point in the postpartum period.Family items and items related to the emotional self were chosen most often aslearning more suitable for home by the mothers in this study although the study wasconducted in the hospital. These results are very consistent with those of Gruis (1977)who conducted her study with mothers who were a month postpartum and at home.The results of this study, in relation to other studies describing mothers'postpartum learning needs, suggest that a change in mothers' learning needs occursnot only as a result of time but also as a result of environment. Mothers in thishospital study clearly perceived infant care, infant feeding, and self care topics asmore appropriate for discussion in hospital and emotional self and family topics as61more appropriate for discussion at home. Therefore mothers' perception of thephysical environment may have an impact on their choices (Knowles, 1970; Tarnow,1979).Although attempts have been made to improve the physical environment ofmaternity units to provide a more home like setting, the atmosphere remains artificial.The sights, sounds, and procedures evident on postpartum units may serve toreinforce mothers' perceptions that hospitals are very hands on, task oriented placesand that learning should be approached in the same way. However, when mothersthink of home, their thoughts turn to family and community and what that will mean tothem in relation to their new role. The focus for learning would appear dependent tosome degree on the meaning that each environment has for the postpartum mother.That mothers perceived the majority of their learning needs in hospital to berelated to infant care and feeding would suggest "rooming in" as an appropriateeducational strategy. Immediate application of learning related to their infants shouldmake the learning experience more meaningful and relevant to them (Knowles, 1970;Kolb, 1984; Tarnow, 1979). However, when rooming in, mothers know that nursingassistance is immediately available to them. They also know that they do not need tobe concerned about such things as meals, laundry, and other household tasks thatthey would be involved in at home. If motivation is an internal drive based on a62perceived need for information (Bille, 1981), mothers may feel a more urgent need tolearn at home by exploring their own methods and alternatives available to them in anenvironment that does not ensure the physical presence of a nurse.The perception of their relationship with caregivers may have had an impact onmothers' choices of which topics were more suitable for hospital. Patients tend toperceive hospital nurses as experts in their areas of practice (Redman, 1984). Ifmothers see hospitals and hospital personnel as very procedure and task oriented,they may believe that task oriented learning supported by nursing expertise isavailable to them only during their hospital stay. The fact that mothers feel themajority of infant topics and a large portion of self topics should be addressed duringthe hospital stay would seem to support this assumption. At the same time, whilemothers may have recognized nurses (including nurses in the community) as expertresources in the area of task-oriented care, they may not have perceived nurses asresources in areas such as emotional self and family relationship topics. Gruis (1977)indicated in her study that mothers did not seek help for 22% of the concerns theyidentified, probably because they believed that help was not readily available.The approaches of different nurses to the "rooming in" experience may also beproblematic. When mothers do call for assistance with an infant concern, somenurses may act as facilitators and assist mothers to work through their concern.63Others may remove the baby, advising mothers that the nursing staff will look after theproblem. Removing the baby may not be helpful. These nurses may beunintentionally giving mothers the message that they are not competent to look aftertheir babies. This message will negatively affect mothers' self concept and couldhinder the learning process (Knowles, 1970; Tough, 1971).Experience with newborn care. The kinds of learning experiences the mothersin this study perceived as suitable to hospital may have been appropriate to their levelof experience with newborn care. One of the assumptions of this study was thatprimiparous mothers have little or no stores of past experiences with newborns uponwhich to build. Therefore, it could be expected that these mothers would be moreoriented to infant care and infant feeding.In Sumner and Fritsch's 1977 telephone survey, results indicated that the majorityof callers concerns centered around infant feeding and infant care. This was true forboth multiparas and primiparas. However only 25% of the multiparas eligible to calldid so, while 88% of the primiparas eligible to call did so. Fewer calls from multiparasmay indicate that these mothers had a larger store of experience with which toaddress infant feeding and infant care concerns before they would feel the need toseek help.Moss (1981) and Hiser (1987) reported that family topics were the major concerns64for the mothers in their studies. However, their studies were conducted with multiparasexclusively. These mothers' past experience with a newborn may have decreasedtheir perceived need for instruction related to infant care.Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed inHospitalNurses' perception of postpartum learning needs more suitably addressed inhospital appeared to mirror those of postpartum mothers. The topics nurses chosemost often as appropriate to hospital were from the infant care and self carecategories.Nurses, like mothers, chose physical topics which require "hands on" skill as moreappropriate for hospital. The apparent tendency of nurses to focus on "hands on"topics related to postpartum education is supported by the findings of Cupoli et al.(1971) and Lesser and Keene (1956). Hospital nurses have been educated to work inan environment of policies, procedures, and duty-related tasks which are routinelycarried out in the course of providing patient care.As a result, nurses may view patient education activities as just one more task toperform and so concentrate on physical/skill content rather than informational content(Glover et al., 1985). There is literature to suggest that, in relation to other identifiedtasks, education is not a priority for most nurses (Elbeik, 1986; Honan et al., 1988).65Nurses may be saying that unless patient education is attached to some physicalaspect of care, it may not have as much relevance for them as their other duty-relatedtasks. It is possible that, in their view, covering physical/skill related care topics withmothers is both appropriate and logical. Mothers, exposed to this approach, mighthave their own perception of the physical environment of the hospital reinforced whichserves to further reinforce nurses' perception of which topics they should beaddressing.It is interesting to note that most mothers chose two very visual in-hospital topicsrelated to the infant; cord care and infant appearance. To mothers, the sight of a rawstump of a clamped cord instead of a navel and an infant with an elongated head,newborn rash, or an excess of body hair is outside of their experience with what is"normal". However, although all nurses chose to address cord care in hospital, fewerchose to address infant appearance. Nurses know that there is nothing abnormalabout either the cord or the initial appearance of the newborn. They see these kindsof things all the time. However, the cord is associated with a physical aspect of infantcare while infant appearance, a purely informational topic, may not have as muchrelevance for nurses as it does for mothers.Given this scenario, mothers may have their learning expectations met but may notnecessarily have their learning needs met. Nurses may not be individualizing66postpartum education by being sensitive to mothers and allowing them to choosetopics which are important to them. This may undermine mothers' attempts to provethemselves competent and self directing (Draves, 1984; Knowles, 1970).In this study, mothers did not perceive any of the topics listed as suitable only forhospital or suitable only for home. However, nurses perceived someconcerns/interests as appropriate only to hospital or appropriate only to home (seeAppendix E). Again, this suggests that nurses may not be providing mothers withindividualized patient education. To take an active role in their own learning requiresthat mothers be permitted to identify their own learning needs (Knowles, 1970;Redman, 1984).Another interesting aspect of this study was some unsolicited direction receivedrelated to responsibility for postpartum education. Three nurses commented thatsome topics in the infant category, vitamin/floride supplements, when to introducesolids, and what kinds of solids to begin feeding, should also be the physician'sresponsibility. Two nurses felt that information in the area of sexuality should also bea part of the physician's responsibility and one nurse felt information on resumingsexual relations to be solely the physician's responsibility. These results supported thefindings of Honan et al. (1988) which suggested that, although nurses believe theyhave a responsibility for education, they believe other disciplines have a responsibility67as well.Differences Between Postpartum Mothers' and Matemal/Newbom Nurses' Perceptionof Learning NeedsAlthough nurses continued to view infant concerns/interests as more suitable fordiscussion at home, there was one significant difference. Their focus shifted fromphysical care /skill kinds of topics to those which were informational in nature.Postpartum mothers identified family items for discussion at home.The nurses' continued emphasis on the infant category may indicate that nursesperceive mothers, particularly inexperienced primiparas, to be focused on infantlearning longer than they actually may be. The shift in focus could indicate thatnurses may believe physical care/skill oriented infant topics are more important tocover in hospital to make the best use of their expertise. Other informational infanttopics can wait for home. On the other hand, nurses may believe their knowledgerelated to informational topics in the infant category to be lacking so feeluncomfortable discussing them (Cupoli et al., 1971). This discomfort may also apply totopics in the self and family categories as well. Many of these topics, particularly inthe family category, are more appropriate to discussion as opposed to physicaldemonstration. Most of the nurses in this study completed their basic nursingeducation when tasks and procedures were still the focus. Areas such as family68theory had yet to be introduced into nursing programs.The organizational climate may influence nurses' attitudes as well. If they perceivetheir leaders to be more interested in physical, task oriented activities, they will bemore inclined to focus on physical activities. Hospital nurses may also perceive topicsinvolving information or discussion to be the province of community health nurses.That differences existed between mothers' and nurses' responses to a number ofinfant and family items on the questionnaire was supported by statistical analysis (seetable 5). Although both groups felt the majority of these topics would be moresuitably learned at home, more mothers felt that way about family topics and morenurses felt that way about infant topics. So it would seem that some mothers maywant to have more infant topics addressed in hospital. They were interested in suchtopics as growth and development and immunization; informational topics as opposedto physical care/skill kinds of topics. By identifying these topics, mothers may havebeen signifying that, in hospital, they perceived their infants to be their immediateconcern.However, nurses may be trying to provide some education in hospital on topicsthat mothers are not ready for; most notably family planning and resuming sexualrelations. Mothers had not yet experienced their infants in relation to the family setting,therefore may not have perceived topics about emotional self or the family as urgent69or relevant while in the hospital setting (Knowles, 1970; Redman, 1984).There were two topics about which mothers and nurses disagreed in terms of themore suitable environment for discussion; recognizing the unwell infant and providinga safe environment for the infant. Mothers wanted information on the unwell infantduring their hospital stay while nurses were evenly split between hospital and home.Mothers perceived information on infant safety to be more appropriate to home whilenurses perceived such information as more appropriate to hospital.Given their possible perception of the hospital environment and the functions ofhospital nurses as caring for the ill, mothers may feel that the hospital environment is amore appropriate one in which to gain information related to recognizing an ill infant.Because nurses are capable of recognizing the unwell infant and view thisresponsibility as part of their job, they may perceive this informational topic asirrelevant unless aware of mothers' concern. In order to be aware of mothers'concerns, nurses need to plan learning experiences with them (Knowles, 1970;Redman, 1984). Nurses may also believe that education related to infant illness is aphysician responsibility (Honan et al., 1988).Mothers probably believe the hospital is a safe environment for their infants and,having yet to experience the home environment with them, do not yet see learningabout providing a safe environment as relevant (Knowles, 1970; Redman, 1984). On70the other hand, nurses in this study routinely provide such information whileperforming a demonstration infant bath for mothers. Nurses probably associate theinformational topic of providing a safe environment for the infant with the physicalactivity of demonstrating infant bathing. Safety measures is also a topic in the babycare category on the standard form used by unit nurses to document teachingactivities (see Appendix A). If such associations did not exist, they may not be as likelyto provide mothers with information on infant safety. Without identifying with mothersthat infant safety is a concern, nurses may be making an incorrect assumption aboutthe importance the topic holds for mothers while they are in hospital (Knowles, 1970).The learning choices made by mothers in this study in relation to hospital andhome reflected Gruis' (1977) developmental tasks of the postpartum period. Mothersappeared to want care/information related to the physical aspects of self and infantfirst, followed by knowledge related to their interactions with their infants, and finally,information related to emotional self and family relationships. However, progressionthrough Gruis' (1977) tasks may not always be clear cut, as hospital stay postpartumbecomes increasingly shorter. If choice of learning needs is indeed a product ofenvironment as well as time, early discharge mothers may require information neededto deal with family relationship items before they can learn to relate to their infants.They may even require assistance in dealing with a combination of developmental71tasks that come up together.Distribution of Postpartum Learning Needs Between Hospital and HomeIn light of the trend toward a shorter hospital stay postpartum, it would be difficult,if not impossible, to provide education related to over 60% of the infant topics andover 30% of the self topics in 48 hours or less. It may be that, at present, bothmothers and nurses remain oriented to the traditional hospital stay in terms ofeducational expectations. Both groups assumed that the bulk of postpartum learningneeds should be met in hospital. It is possible that neither group believes adequateresources exist in the community relative to their respective educational expectationsfor the postpartum period. Perhaps if nurses acted more as facilitators rather thanproviders of information or instruction, mothers could be assisted to identify their ownstrengths and learn to rely more on themselves. They may then feel more confident intheir ability to problem solve their way through postpartum learning experiences(Draves, 1984; Knowles, 1970; Redman, 1984; Tough, 1971).SummaryMothers' perception of postpartum learning needs suitable to hospital and homewere generally similar to those identified in the literature as of concern to new mothersin the early and late postpartum period. If postpartum learning needs are viewed interms of Gruis' (1977) developmental tasks of the postpartum period, mothers'72priorities seemed to focus first on infant care/infant feeding and to a lesser degree thephysical care of self followed by family relationships and to a lesser degree theemotional care of self.Both mothers and nurses chose physical care/skill topics related to the infant asmore appropriate for hospital. Both groups may have been influenced in their choicesby the physical and psychological environment of the hospital. Nurses may have beenfurther influenced by their basic nursing education. Most of the nurses in this studywere educated at a time when programs were task and procedure focused; suchcourses as family theory had yet to be introduced.Even though in hospital, mothers choices of topics for home reflected family andemotional self; choices perhaps influenced by their perception of the homeenvironment. Nurses choices of topics for home remained infant focused, possiblyrelated to the continuing influence of their work environment and their perception ofwhat primiparous mothers needed to know. Nurses tended to avoid informationaltopics. They may have believed them to be irrelevant in hospital or perhaps, due to aperceived lack of knowledge, may have felt uncomfortable discussing them.73CHAPTER VCONCLUSIONS AND IMPLICATIONSOverviewThis chapter will present the major findings of the study and the implications ofthose findings for nursing practice, education, administration, and research.Conclusions1. Postpartum mothers chose infant care/feeding and some self care topics asappropriate to hospital.2. Postpartum mothers chose family and some emotional self topics asappropriate to home.3. Maternal/newborn nurses chose infant care/feeding and some self care topicsas appropriate to hospital.4. Maternal/newborn nurses chose informational topics related to the infant asappropriate for home.5. Mothers' and nurses' perceptions of topics appropriate to hospital were similar.6. Mothers' and nurses' perceptions of topics appropriate to home were different.7. Both mothers' and nurses' perceived that over 60% of infant topics and over30% of topics related to self should be addressed in a 48 hour hospital staypostpartum.74Implications for NursingNursing PracticeShortened length of stay postpartum has become an established practice. Nursesare going to have to accommodate that reality. Information gathered in this study mayassist nurse managers and nurses of Maternal/Newborn units to assess and adapttheir teaching materials and methods. Using the topics that most mothers chose asappropriate for hospital as a guide, nurses can provide mothers with some directionregarding which infant topics they may wish to address during their stay. At the sametime they need to reassure mothers that other topics will be addressed at home.However, nurses must remain open to the fact that mothers may have other burningissues that they are more interested in. Learning must be tailored to suit whatindividual mothers identify as their needs. To ensure that expectations remain withinreasonable limits, negotiation and prioritization are paramount. Nurses must begin toact as facilitators of learning rather than simply providers of information andinstruction. Assisting mothers to identify and prioritize their learning needs willencourage them to take control of their own learning experiences.Discussion or demonstration can be augmented by written materials so thatmothers have something to refer to at home. Videos can also be made available ontopics related to all three categories. Perhaps a loan mechanism could be developed75giving mothers at home access to them as well.Nurses must be encouraged to examine and discuss their beliefs and attitudes interms of postpartum education. The study indicated that mothers want to discussfamily and emotional-self topics at home. Nurses perceptions are different. Perhapsnurses should be provided with the opportunity to leave the hospital environment andaccompany the visiting nurse on some home visits. This experience will give them anopportunity to observe mothers in the home environment and promote someunderstanding about how and why their learning needs change and progress.Observing the visiting nurse will also give them an opportunity to enlarge on their ownknowledge and skills in their interactions with mothers. Increased contact with thevisiting nurse and increased knowledge about care in the home will promote bettercommunication and dialogue between hospital and community nurses related todischarge concerns and issues. Hospitals may want to consider developing their owncommunity postpartum followup programs. Hospital nurses following mothers intotheir homes would provide mothers with continuity and consistency of care. Thechance to follow through in the home with hospital initiated postpartum care andteaching would not only provide hospital nurses with an opportunity to enlarge ontheir knowledge and skills in their interactions with mothers, but would also providethem with increased feelings of accomplishment and job satisfaction.76Since mothers in this study identified physical care/skill infant topics in this studyas appropriate for hospital, experiential learning should be a must. In this waymothers can begin to develop their own problem-solving and coping skills instead ofbeing discharged continuing to rely heavily on nursing knowledge and expertise.Nursing EducationEducators of nurses whether in academic surroundings or in the workplace needto instill and encourage in nurses a commitment to and an understanding of theimportant role they play as facilitators of patient learning. Continuing education formaternal/newborn nurses, whether in hospital or in a college or university setting,needs to focus on the family and community. Nurses must broaden their scope ofknowledge and understanding related to family dynamics in order to view the family asa whole in their community as opposed to one brief snapshot of mother and baby inhospital.To increase the sensitivity of practice nurses to the needs of adult learnersrequires that they be educated to Knowles' (1970) assumptions regarding thecharacteristics of adult learners. Such education must involve not only theoreticalknowledge but concrete examples of how adherence to these principles benefits bothnurses and patients in terms of time spent on educational activities and satisfactionwith teaching/learning experiences. Nurses, like any adult learners, must be able to77see the relevance of what they are learning as applied to their own practice. Hospitalnurse educators can also use the results of this study to assess nurses' learningneeds particularly in relation to the infant informational topics which many mothersperceived should be addressed in hospital. Perhaps broadening nurses' knowledgein this area will allow them to feel more comfortable in discussing these topics withmothers.Schools of nursing can use the results to demonstrate to students mothers'perception of their postpartum learning needs in relation to hospital and home. Thiswill enable them to develop more time specific interventions in terms of postpartummothers' infant, self, and family learning needs. Perhaps schools of nursing also needto review the manner in which the concept of community is presented to students.Patient education will not be improved and enhanced by hospital and communitynurses who view themselves as unique, with separate responsibilities and who, as aresult, may not communicate very effectively. Hospital and home are both a part ofevery patient's community. Community needs to be seen as a whole withcomplementary components not separate components.Nursing AdministrationNurse managers in the hospital environment need to be aware of the philosophyof their institution related to patient education. Where a relatively low priority has been78assigned to patient education, the nurse manager who is committed to patienteducation must lobby for change. Nurse managers can provide the leadershipnecessary, by word and action, to help nurses see that education is a part of everyinteraction with a patient and not a separate task.Where nurses perceive that certain topics, such as family planning and sexuality,are not their responsibility, nurse managers must provide clear guidelines in terms oftheir expectations related to these topics. Perhaps the introduction of a nursing orinterdisciplinary patient care model would assist nurses to view patient education as apart of comprehensive patient care and not as just another task or someone else'sresponsibility. Nurse managers also need to be aware of factors related to both theorganizational structure and the patient population which block nurses in theirattempts to provide individualized educational experiences and investigate ways ofdealing with those factors.Given the tendency to decreasing length of hospital stay postpartum, nursemanagers of both hospital and community perinatal programs must workcollaboratively to ensure that resources and supports necessary to continue thelearning process for postpartum mothers will be available in the community. Perhapshospital and/or community nurse representatives, through prenatal classes, couldbegin to prepare expectant parents for the short hospital stay experience.79Parents need to be advised that it will not be possible to learn everything theyneed to know in hospital but that the learning process will continue once they arehome. They could also be encouraged to begin thinking about the kinds of resourcesthey may need after discharge and ensure that these resources are available to them.Study results may also be useful to prenatal educators. In collaboration withhospital and community nurse representatives, postpartum topics included in prenatalclasses could be reviewed and adapted to reflect more of the informational infanttopics mothers are interested in having addressed in hospital. Information on physicalcare/skill kinds of infant topics, such as cord care, will mean more to mothers whenthey are actually learning the skill. Since these are the kinds of topics most mothersappear to want addressed in hospital anyway, it may be more efficient to addresssuch topics as infant growth and development in the prenatal period. What mothershave already learned can then be reinforced or enhanced either in hospital or athome. At the same time, learning about their infants may only have meaning formothers when the infants become a visual and tactile presence. Given thisperspective, it is possible that mothers' motivation to learn about infant care andbehavior would not be very strong.80Nursing ResearchSeveral questions arise as a result of the study which require investigation.1. Is the perception of postpartum learning needs relative to home or hospitalenvironment different for nurses who had family theory as a part of their basic nursingeducation?2. How do nurses perceive postpartum educational activities in relation to theirother job related duties?3. Why do nurses appear to emphasize physical care/skill kinds of topics relatedto the postpartum period as opposed to informational topics during mothers' hospitalstay?4. Which topics do nurses perceive as their responsibility in the area ofpostpartum education?5. Do beliefs about the hospital environment and the nurses in that environmenthave an impact on postpartum mothers' perception of postpartum learning needs?6. Do nurses use principles of adult learning when conducting educationalactivities?7. Why do both mothers and nurses perceive the need to have such a largeproportion of postpartum learning needs addressed during a 48 hour hospital staypostpartum?818. How would both mothers and nurses have answered if they had been asked toprioritize the ten topics each group identified as more suitably addressed in hospitaland the ten topics each group identified as more suitably addressed at home?SummaryThe results of the study suggested that postpartum mothers wanted learningneeds related to their infants addressed first, followed by those related to self, andthose related to family last. Mothers perceived most of the infant topics as moreappropriate to hospital and most of the family topics as more appropriate to home.The findings indicated that, while mothers' and nurses' perceptions of topics suitablefor hospital were similar, their perceptions of topics suitable for home differed. Most ofthe mothers perceived infant topics as more appropriate to hospital and family topicsas more appropriate to home. Most of the nurses perceived only physical care/skillkinds of infant topics as appropriate to hospital and informational topics related to theinfant as more appropriate to home. 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Early discharge as voluntary and involuntary alternatives to alonger postpartum stay in hospital--effects on mothers' experiences andbreastfeeding. Journal of Midwifery. 5(4), 189-196.Waskerwitz, S., Fournier, L., Jones, P., & Meier, W. (1985). A comparitive analysis ofnewborn outcome in a hospital-based birthing centre. Clinical Pediatrics. 24(5),273-277.Yanover, M.J., Jones, D., & Miller, M.D. (1976). Perinatal care of low risk mothers andinfants: early discharge with home care. The New England Journal of Medicine.294(13), 702-705.= = =••■••■■••■=■■••^■••^•■•i■ im•■^ NM,OM^■••• AM'WIN AM!•1■1.^INE^IN=MI•IW MMI ■•■GREATER VICTORIAHOSPITAL SOCIETY APPENDIX AThe Greater Victoria Hospital Society Mother/Babe Unit Parent Teaching Sheet MATERNITY PARENT TEACHING SHEET86SUBJECT D/M/Y REMARKSA. BREAST FEEDING1. Nipple care- -- • • •••• ••••• ••■■••••• 11111 WM.2. Demand feeding3. Positioning & burping4. Timing5 .Expressing milk6. Engorgement7. Storage of EBMB. FORMULA FEEDS1. Amount first few days2. Demand feeding3. Formula prep.4. Positioning6 .BurpingC. BABY CARE^•1. Bath procedure2. Cord care3. Care of genitalia4. Axilla temp5. Clothing6. Safety Measures •D. HYGIENE1. Pen care2. Sitz bath3. Normal changes in flow1. Nutritional educ.E. PATIENT INFO.•2. Family planning3. Physiotherapy4. Community resources5. Guide to parenting booklet-..')01 - 01 - 0969 - 0L1.11LJALI-A.87The Greater Victoria Hospital Society Maternity Department Criteria for Early Postpartum Discharge QUALITY UTILIZATION MANAGEMENTGVHS/CRD POST-PARTUMHOME FOLLOW-UP PROGRAMADMISSION DATE: ^DISCHARGE DATE: DISCHARGE TIME:PT. TELEPHONE NI: DISCHARGED WITH HOME FOLLOW-UP PROGRAM:YES ^ NO ^ANTENATAL HISTORY RECORD:Program Inclusion Note Documented:^YES^^ NO ^Program Exclusion Note Documented: YES^^ NO ^DELIVERY:DELIVERY DATE:DELIVERY TIME:PHYSICIAN(S):^ Vaginal(24 hr. clock)^ Caesarian SectionDISCHARGE CRITERIA:^Please CIRCLE the number/s) of the criteria that were NOT MET:MOTHER ::.:BABY:1. 37 + Weeks pregnancy2. Uncomplicated delivery3. Healing incision or episiotomy4. Stable hemodynamic system5. Rhogam given, if indicated6. Single birth7. No 4th degree tear (or tubal ligation)8. No Identified Social Problems9. No voiding problems10. Can communicate in English1. Birthweight more than 2500 grams2. Normal temperature control,respiratory rate, heart rateand colour3. Feeding well, voiding normally4. Circumcision 6 hours or moreprior to discharge5. No congenital defects requiringmedical management6. Absence of increasedHyperbilirubinemiaBARRIERS TO DISCHARGE WITH PROGRAM:^ Late Discharge^ Reside outside Program catchment area^ Other:^ Other:MSA# 1 diMDP-HFUP.FrmPlease return to MEDICAL STAFF AFFAIRS on completion.88Appendix CPostpartum Learning Needs Questionnaire and BackgroundInformation Sheets Postpartum Learning Needs QuestionnaireThe questionnaire reflects concerns and interests that have been identified bypostpartum mothers as important learning needs. They are divided into three areas;self, infant, and family. Please indicate, by checking the appropriate box, where youbelieve each concern or interest would be more suitably addressed; during a 48 hourhospital stay or at home with visiting nurses.Example:Concern/Interest^During Hospital Stay^With Visiting Nurse Strategies for dealing with fatigue^0^ 0Concern/Interest^During Hospital Stay^With Visiting NurseSELF1. Information on nutrition/diet:- for regaining figure^0^ 0- while breastfeeding infant^0 02. Information about an exercise regime 0^ 089Concern/Interest^During Hospital Stay^With Visiting Nurse3. Understanding the labour anddelivery experience^0^ 04. Strategies for dealing with fatigue^0 05. What to expect regarding blood flow 0 06. What to expect with changes tobreasts^ 0^ 07. How to deal with postpartumdiscomforts:- episiotomy/stitches^0^ 0- hemorrhoids 0 0- constipation^ 0^ 08. How to deal with emotional swings:- irritability^ 0^ 0- tension 0 0- the baby "blues"^0^ 09. How to deal with feelings associatedwith becoming a new mother:- feeling isolated^ 0^ 090Concern/Interest^During Hospital Stay^With Visiting Nurse- feeling tied down^0^ 0- questioning ability to bea "good mother"^0^ 0- needing time for self^0 0- finding other mothers withwhom to share experiences^0^ 010. How to prepare for returningto work:- child care arrangements^0^ 0- home management^0 0- feelings (e.g. guilt, ambivalence)^0 011. When to call the doctor or publichealth nurse about health problems(mother's health problems notinfant's)^ 0^ 012. Other topics or areas of concern:(please specify)^ 0^ 091Concern/Interest^During Hospital Stay^With Visiting NurseINFANT1. Information about infant'sappearance (e.g. shape of head,skin color)^ 0^ 02. Information about infant'sbehaviour:- crying^ 0^ 0- sleep/wake states^0 0- facial expressions^0^ 0- use of senses (e.g. sight,hearing)^ 0^ 03. Instruction regarding breast feeding:(to be completed by breast feedingmothers and nursing staff)- attaching and removing infant^0^ 0- positioning infant^0 0- breast and nipple care^0^ 0- managing breast engorgement^0 092Concem/Interest^During Hospital Stay^With Visiting Nurse- medications and breast feeding^0 0- storing and freezing breast milk^0 0- instruction regarding bottle feedingfor mothers who plan to give theodd bottle feed (water, expressedbreast milk, or formula)^0^ 0- weaning infant^ 0 04. Instruction regarding bottle feeding:(to be completed by bottle feedingmothers and nursing staff)- feeding technique^0^ 0- amount of formula to feed^0 0- kind of formula to use^0^ 0- kind of bottles/nipples to use^0 0- formula preparation^0^ 0- care of bottles/nipples^0 093Concem/Interest^During Hospital Stay^With Visiting Nurse5. Information on infant nutrition:- knowing when infant is satisfiedwith feeds^ 0^ 0^normal voiding and stool pattern 0 0vitamin and fluoride supplements 0^ 0- when to introduce solids^0 0- kinds of solids to begin feeding^0 06. Information on infant care:- handling/holding the infant^0^ 0- bathing the infant^0 0- dressing the infant^0^ 0- how to care for the cord^0 0- skin care^ 0^ 0- dressing the infant for theweather and comfort^0^ 0- providing a safe environmentfor the infant^ 0^ 094Concem/Interest^During Hospital Stay^With Visiting Nurse7. Information on infant health/illness:- how to take an infant'stemperature^ ()^ 0- recognizing when an infant isunwell^ 0^ 0- when to call the doctor or publichealth nurse about an infant'shealth problems^0^ 0- immunizing an infant^0 08. Information on how infants growand develop^ 0^ 09. Other topics or areas of concern:(please specify)^ 0^ 095Concern/Interest^During Hospital Stay^With Visiting NurseFAMILY1. Information about changingrelationships between partners:- helping a partner who mayfeel "left out"^ ()^ 0sharing household responsibilities 0 0sharing child care responsibilities 0^ 0- finding time to be together^0 02. Regulating the demands of partner,housework, and job^0^ 03. Adapting to changes in lifestyle^0 04. Dealing with "advice" from friendsand family^ 0^ 05. Information in the area of sexuality:- when to resume sexual relations^0 0- methods of contraception^0^ 0- family planning^ () 096Concern/Interest^During Hospital Stay^With Visiting Nurse6. Other topics or areas ofconcern: (please specify)^0^ 0Background InformationEarly Discharge Eligible Postpartum Mothers1. Age:19 or below^0^20 - 24^025 - 29^0^30 - 34^035 - 39^0^40 or over 02. Education:Some high school^0Completed high school^0Some college/university^0Completed college/university^0Completed post graduate studies^03. Total family income:$14,000 or less^0^$15,000 - $24,000^0$25,000 - $34,000^0^$35,000 - $44,000^0$45,000 or more^04. I am planning to: (check one)breast feed^0bottle feed^0975. I expect that the help available to me after discharge will meet my needs forassistance at home.Yes^0No^098Background InformationMatemaVNewbom Nurses1. Age:24 or below^0 25 - 29^030 - 34^0 35 - 39^040 - 44^0^ 45 - 49^050 or over^02. Years in nursing:2 or below^0 3- 4^05 - 9^0 10 - 14^015 - 19^0^ 20 - 24^025 - 29^0 30 or more^03. Educational preparation: (check one only)RN diploma^ 0Post basic baccalaureate in nursing^0Generic baccalaureate in nursing 0Baccalaureate in other than nursing^0Master's in nursing^ 0Master's in other than nursing^ 0994. Other post basic preparation related to maternal/child nursing e.g. midwifery:100(please specify)101Appendix DCover lettersDear Staff Member,Maternal/newborn nurses are increasingly concerned that shortened length of stayprovides little time for teaching. The Maternity department has introduced a pilot earlydischarge program in which a small group of physicians and their patients areparticipating. Low risk, vaginally delivered mothers and infants are discharged at 48hours with nursing follow up in the home the next day. My question is, given earlydischarge with follow up in the home, are there some postpartum learning needs thatare more suitably addressed in hospital and others that would be more suitablyaddressed in the home environment? For my Master's thesis, I would like to comparethe views of staff and a selected group of vaginally delivered primiparas eligible for theearly discharge program on the subject.Over the next two months, I will be asking all the nurses on the Mother/Babe Unitto assist me by participating in this study. Your participation would involve aquestionnaire which will take approximately 15 minutes to complete. Postpartummothers who agree to participate will be completing the same questionnaire. Allinformation is confidential and will be used for the purposes of this study only. If youchoose to participate, place a completed questionnaire in the envelope provided and102drop it into the labelled container in the C.C. Conference Room on either the A or Bside. Questionnaires are to be returned unsigned and there will be no identifyingmarks on either questionnaire or envelope. You may withdraw your participation anytime you wish. If you do not wish to give information in a particular category or area,feel free to leave it blank. Consent to participate will be assumed by the return of acompleted questionnaire.Your assistance is important to me. The delivery of maternal/newborn care haschanged dramatically in recent years. As the professionals charged with meeting theeducation needs of new mothers, your assistance will be invaluable in helping todevelop postpartum education programs that will continue to meet mothers' needsthrough change and over time.Once the study has been completed, I will share the results at a staff meeting andattach a summary of the results to the minutes. Please feel free to contact me if youhave any questions. Thank you for your consideration.Yours truly,Sue Dean^ Elaine Carty, Associate ProfessorMSN Student, U.B.C. School of Nursing^UBC School of Nursing727-4212, L 5211^ Thesis Supervisor, 228-7444103Dear New Mother,Today's trend toward shortened length of hospital stay postpartum has an impacton the teaching that maternal/newborn nurses can provide. The Maternity departmenthas recently commenced a trial early discharge program involving a small group ofphysicians and their patients. The program involves discharging vaginally delivered,healthy mothers and babies at 48 hours postpartum and providing nursing follow upin the home the next day. You may or may not be participating in this program atpresent. However, the advent of shortened length of stay postpartum signifies a needto adapt current methods of providing postpartum education. To accomplish thisrequires the assistance of those most involved with postpartum education; newmothers and their nurses. For my Master's thesis, I would like to compare the viewsof maternal/newborn nurses and first time mothers on which postpartum learningneeds would be more suitably addressed in hospital and which postpartum learningneeds would be more suitably addressed at home with the visiting nurse of the earlydischarge program.Over the next two months, I will be asking all vaginally delivered first time motherslike yourself if they wish to participate in the study. Your participation would involve aquestionnaire which will take approximately 15 minutes to complete.Maternal/newborn nurses who agree to participate will be completing the samequestionnaire. All information is confidential and will be used for the purposes of thisstudy only. If you choose to participate, place a completed questionnaire in theenvelope provided. Questionnaires are to be returned unsigned and there will be noidentifying marks on either questionnaire or envelope. You may withdraw yourparticipation any time you wish. If you do not wish to give information in a particular104category or area, feel free to leave it blank. Refusal to participate will in no waycompromise your care while a patient on the Mother/Babe Unit. Consent to participatewill be assumed by the return of a completed questionnaire. Please return yourcompleted questionnaire to the main nursing station (Communication Centre) or give itto your nurse. If you have any questions, please contact me.More flexible methods of providing postpartum education must be developed inorder to meet the needs of today's new mothers. Your input will be valuable inhelping nursing plan toward meeting those needs. Thank you for your assistance.Yours truly,Sue Dean^ Elaine Carty, Associate ProfessorMSN Student, UBC School of Nursing^UBC School of Nursing727-4212, L 5211^ Thesis Supervisor228-7444105Appendix EEarly Discharge Eligible Postpartum Mothers' andMatemal/Newbom Nurses' Responses to QuestionnaireMothers' Responses to Questionnairen = 89Concem/Interest^Hospital^HomeA.^Self8 *(7) **7092(82)301. Nutrition/dieta. regain figureb. while breastfeeding(63) (27)2. Exercise regime 8 92(7) (82)3. Labour and delivery experience 76 24(68) (21)4. Fatigue 35 65(32) (60)5. Blood flow 97 3(86) (3)6. Changes in breasts 83 17(75) (15)106Concern/Interest7. Postpartum discomfortsa. episiotomy/stitchesb. hemorrhoidsc. constipation8. Emotional swingsa. irritabilityb. tensionc. baby "blues"9. Feelings as a new mothera. isolationb. tied downc. ability to be a "good mother"d. time for selfHospital Home97 3(85) (3)94 6(82) (5)74 26(66) (23)20 80(18) (72)16 84(14) (76)34 66(31) (59)11 89(10) (79)3 97(3) (86)12 88(11) (78)4 96(4) (85)107Concern/Interest Hospital Homee. share experiences with other mothers 10 90(9) (81)10. Returning to worka. child care 1 99(1) (86)b. home management 3 97(3) (84)c. feelings of guilt/ambivalence 2 98(2) (85)11. When to call doctor/P.H. nurse(mother's health) 75 25(68) (23)12. Community support systems 30 70(27) (63)13. Other topics/concerns:location of nearest emergency services (1)concerns/questions re physicalconditions(1)B. Infant1. Infant appearance 96 4(87) (4)108Concern/Interest2. Infant behavioura. cryingb. sleep/wake statesc. facial expressionsd. use of senses3. Breast feedinga. attaching/removing infantb. positioning infantc. frequency of feedsd. breast/nipple caree. breast engorgementf. medication and breast feedingHospital Home87 13(79) (12)82 18(74) (16)64 36(59) (33)55 45(51) (41)96 4(86) (4)95 5(86) (5)96 4(86) (4)92 8(84) (7)87 13(78) (12)77 23(69) (21)109Concern/Interestg. storing/freezing breast milk. bottle feeding instructioni. weaning infant4. Bottle feedinga. feeding techniqueb. amount to feedc. frequency of feedsd. kind of formulae. kind of bottles/nipplesf. formula preparationg. care of bottles/nipples5. Infant nutritiona. satisfaction with feedsb. voiding/stool patternc. vitamin/fluoride supplementsHospital Home41 59(38) (54)53 47(48) (42)16 84(14) (74)(3) (0)(3) (0)(3) (0)(3) (0)(3) (0)(3) (0)(3) (0)87 13(78) (12)91 9(82) (8)19 81(17) (72)110Concern/Interestd. introducing solidse. kinds of solids to introduce6. Infant carea. handling/holdingb. bathingc. dressingd. cord caree. skin caref. dressing for weather/comfortg. providing safe environment7. Infant illnessa. taking infant's temperatureHospital Home2 98(2) (87)1 99(1) (86)98 2(88) (2)94 6(85) (5)93 7(84) (6)99 1(89) (1)94 6(84) (5)49 51(45) (46)43 57(39) (52)76 24(68) (21)Concern/Interestb. recognizing an unwell infantc. when to call doctor/P.H. nurse(infant health)d. immunization8. Growth and development9. Other topics/concerns:Hospital111Home70 30(62) (27)66 34(59) (30)18 82(16) (73)34 66(31) (59)C. Family1. Changing relationshipsa. the partner who is feeling "left out"b. sharing household responsibilitiesc. sharing child care responsibilitiesd. finding time to be together10 90(9) (79)3 97(3) (85)8 92(7) (81)3 97(3) (85)112Concem/Interest Hospital Home2. Regulating demands 1 99(1) (88)3. Changes in lifestyle 2 98(2) (88)4. Dealing with "advice" 10 90(9) (80)5. Sexualitya.^resuming sexual relations 7 93(6) (82)b.^contraception 8 92(7) (80)c.^family planning 3 97(3) (83)6. Other topics/concerns:Note.^* = percent; ** = actual113Matemal/Newbom Nurses' Responses to QuestionnaireConcern/Interest^ Hospital^HomeA. Self1. Nutrition/dieta. regain figure 14 * 86(7) ** (44)b. while breastfeeding 76 24(39) (12)2. Exercise regime 20 80(10) (39)3. Labour and delivery experience 74 26(37) (13)4. Fatigue 30 70(16) (38)5. Blood flow 96 4(50) (2)6. Changes in breasts 92 8(48) (4)114Concern/Interest7. Postpartum discomfortsa. episiotomy/stitchesb. hemorrhoidsc. constipation8. Emotional swingsa. irritabilityb. tensionc. baby "blues"9. Feelings as a new mothera. isolationb. tied downc. ability to be a "good mother"d. time for selfHospital Home98 2(50) (1)98 2(50) (1)76 24(38) (12)8 92(4) (46)6 94(3) (47)26 74(13) (37)6 94(3) (48)2 98(1) (50)14 86(7) (44)6 94(3) (48)115Concern/Interest Hospital Homee.^share experiences with other mothers 8 92(4) (47)10. Returning to work (0) (50)b. home management 0 100(0) (50)c. feelings of guilt/ambivalence 6 94(3) (45)11. When to call doctor/P.H. nurse(mother's health) 82 18(41) (9)12. Community support systems 31 69(16) (36)13. Other topics/concerns:phone numbers of LaLeche League,lactation consultants, breastpump distributors (1)B. Infant1. Infant appearance 94 6(48) (3)2. Infant behavioura.^crying 89 11(49) (6)116d. breast/nipple caree. breast engorgementf. medication and breast feedingg. storing/freezing breast milkHospital Home87 13(46) (7)64 36(32) (18)46 54(24) (28)100 0(50) (0)100 0(50) (0)100 0(50) (0)100 0(50) (0)80 20(43) (11)78 22(42) (12)47 53(25) (28)Concern/Interestb. sleep/wake statesc. facial expressionsd. use of senses3. Breast feedinga. attaching/removing infantb. positioning infantc. frequency of feeds117h. bottle feeding instructioni. weaning infant4. Bottle feedinga. feeding techniqueb. amount to feedc. frequency of feedsd. kind of formulae. kind of bottles/nipplesf. formula preparationg. care of bottles/nipples5. Infant nutritiona. satisfaction with feedsb. voiding/stool patternc. vitamin/fluoride supplementsd. introducing solidsHospital Home53 47(27) (24)2 98(1) (49)(50) (0)(49) (0)(49) (0)(47) (2)(44) (4)(43) (5)(40) (7)87 13(47) (7)94 6(48) (3)4 96(2) (48)0 100(0) (50)Concern/Interest118e. kinds of solids to introduce6. Infant carea. handling/holdingb. bathingc. dressingd. cord caree. skin caref. dressing for weather/comfortg. providing safe environment7. Infant illnessa. taking infant's temperatureb. recognizing an unwell infantHospital Home0 100(0) (50)96 4(48) (2)92 8(46) (4)92 8(46) (4)100 0(50) (0)98 2(49) (1)63 37(33) (19)63 37(35) (21)75 25(39) (13)50 50(27) (27)Concern/Interest119Concern/Interest Hospital Homec. when to call doctor/P.H. nurse(infant health) 55 45(29) (24)d. immunization 0 100(0) (48)8. Growth and development 8 92(4) (48)9. Other topics/concerns:-^growth spurts:agesdealing withfeeding behaviour (1)C. Family1. Changing relationshipsa.^the partner who is feeling "left out" 14 86(7) (44)b.^sharing household responsibilities 8 92(4) (48)c.^sharing child care responsibilities 10 90(5) (45)120Concern/Interest Hospital Homed.^finding time to be together 2(1)98(49)2. Regulating demands 0 100(0) (50)3. Changes in lifestyle 0 100(0) (49)4. Dealing with "advice" 19 81(10) (42)5. Sexualitya. resuming sexual relations 29 71(15) (36)b. contraception 25 75(13) (39)c.^family planning 17 83(9) (44)6. Other topics/concerns:Note. * = percent; ** = actual

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