UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

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

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-ubc_1992_spring_dean_susan.pdf [ 3.81MB ]
Metadata
JSON: 831-1.0086404.json
JSON-LD: 831-1.0086404-ld.json
RDF/XML (Pretty): 831-1.0086404-rdf.xml
RDF/JSON: 831-1.0086404-rdf.json
Turtle: 831-1.0086404-turtle.txt
N-Triples: 831-1.0086404-rdf-ntriples.txt
Original Record: 831-1.0086404-source.json
Full Text
831-1.0086404-fulltext.txt
Citation
831-1.0086404.ris

Full Text

c LEARNING SUITABLE FOR HOSPITAL AND LEARNING SUITABLE FOR HOME: DIFFERENCES IN PERCEPTION BETWEEN POSTPARTUM MOTHERS AND MATERNAL/NEWBORN NURSES By SUSAN KATHERINE DEAN B.S.N., The University of Victoria, 1982  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER IN SCIENCE OF NURSING in THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept this thesis as conforming to the required standard  THE UNIVERSITY OF BRITISH COLUMBIA January, 1992 © Susan Katherine Dean, 1992  In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission.  (Signature)  Department of NURSTNG The University of British Columbia Vancouver, Canada  Date  ^  DE-6 (2/88)  \-wckft 9- Neig.  ii  ABSTRACT The trend toward early postpartum discharge programs means that much more of the postpartum teaching traditionally carried out in hospital will need to be conducted at home with visiting nurses. However, before any postpartum education changes could be recommended, it was necessary to investigate the perceptions of the two groups of people involved in early postpartum education; postpartum mothers and maternal/newborn nurses. The purpose of this study was to identify the postpartum learning needs that early discharge mothers and hospital based maternal/newborn nurses regarded as either more suitably addressed in hospital or more suitably addressed at home and to compare the perceptions of both groups. Therefore, a factor-searching and relationsearching approach was used to study convenience samples of 89 low risk, primiparous mothers eligible for early discharge and 50 nurses. Each participant completed a questionnaire which was developed for the study. Concerns and interests identified in the literature as important to mothers during the postpartum period were included. Topics were assigned to three categories; self, infant, and family. Each category contained an "other" option so that both groups would feel free to identify topics that were not present in the questionnaire.  iii Results of the study suggested that postpartum mothers want learning needs related to their infants addressed first, followed by those related to self, and those related to family last. While mothers' and nurses' perceptions of topics suitable for hospital were similar, their perceptions of topics suitable for home differed. Mothers perceived most of the infant topics as more appropriate to discussion in hospital and most of the family topics as more appropriate to discussion in the home. Most of the nurses perceived only physical care/skill kinds of infant topics as appropriate to hospital and informational topics related to the infant as more appropriate to home. The study also indicated that both groups expected a large portion of postpartum learning 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 discharge postpartum mothers more effectively are identified and described.  iv  TABLE OF CONTENTS ABSTRACT^  ii  TABLE OF CONTENTS  ^iv  LIST OF TABLES  ^x  Acknowledgements  ^xi  CHAPTER I INTRODUCTION^  1  Background to the Problem  ^1  Statement of the Problem  ^4  Purpose of the Study  ^4  Conceptual Framework  ^4  Andragogy  ^5  Self-concept  ^5  Experience  ^5  Readiness to Learn  ^6  Orientation to Learning  ^7  Gruis' Developmental Tasks of the Postpartum Period Physical Restoration  ^8 ^8  V  Learning the Infant's Needs  ^8  Relating With the Newborn  ^9  Accommodating a New Family Member  ^9  Research Questions  ^10  Significance of the Study  ^11  Definition of Terms  ^11  Assumptions of the Study  ^12  Limitations of the Study  ^13  CHAPTER II LITERATURE REVIEW  ^14  Overview^  14  Early Postpartum Discharge  ^14  Concerns and Interests of Postpartum Mothers  ^18  Patients' and Caregivers' Perceptions of Patient Education  ^23  Adult Education  ^23  Effectiveness of Application of Teaching/Learning Principles . . ^24 Patients' and Nurses' Perceptions of Learning Needs Summary^  ^28 31  vi  CHAPTER III METHODS^ Overview^  33 33  Approach  ^33  Setting  ^35  Participants  ^36  Questionnaire  ^36  Procedure for Data Collection  ^37  Data Analysis  ^39  Summary^  39  CHAPTER IV RESULTS AND DISCUSSION  ^41  Overview^  41  Results^  41  Demographic Information  ^41  Postpartum Mothers' Perception of Learning More Suitably Addressed in Hospital  ^46  vii  Postpartum Mothers' Perception of Learning More Suitably Addressed at Home  ^47  Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed in Hospital  ^50  Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed at Home Comparison of the Responses of Both Groups  ^50 ^54  Distribution of Concerns/Interests Between Hospital and Home ^57 Discussion^  58  Postpartum Mothers' Perception of Learning More Suitably Addressed in Hospital  ^58  The Impact of Environment  ^60  Experience With Newborn Care  ^63  Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed in Hospital  ^64  Differences Between Postpartum Mothers' and Maternal/Newborn Nurses' Perception of Learning Needs  ^67  Distribution of Postpartum Learning Needs Between Hospital and Home^71 Summary^  71  viii CHAPTER V CONCLUSIONS AND IMPLICATIONS  ^73 73  Overview^ Conclusions  ^73  Implications for Nursing  ^74  Nursing Practice  ^74  Nursing Education  ^76  Nursing Administration  ^77  Nursing Research  ^80 81  Summary^ REFERENCES^  83  APPENDICES^  86  Appendix A: The Greater Victoria Hospital Society Mother/Babe Unit Parent Teaching Sheet  ^86  Appendix B: The Greater Victoria Hospital Society Criteria for Early Discharge  ^87  Appendix C: Postpartum Learning Needs Questionnaire and Background Information Sheets Appendix D: Cover Letters  ^88 ^101  ix Appendix E: Early Discharge Eligible Postpartum Mothers' and Maternal/Newborn Nurses' Responses to Questionnaire  ^105  x  UST OF TABLES  I^Early Discharge Eligible Postpartum Mothers: Demographic Information II^Maternal/Newborn Nurses: Demographic Information  ^43 ^45  III^Postpartum Mothers' Perception of Learning More Suitable for Hospital  ^48  IV^Postpartum Mothers' Perception of Learning More Suitable for Home  ^49  V^Maternal/Newborn Nurses' Perception of Learning More Suitable for Hospital  ^52  VI^Maternal/Newborn Nurses' Perception of Learning More Suitable for Home  ^53  VII^Differences Between Postpartum Mothers' and Maternal/Newborn Nurses'  ^56  VIII^Distribution of Concerns/Interests by Category  ^58  xi  Acknowledgements I am grateful to Elaine Carty and Angela Henderson for being so patient and understanding with a working, out-of-town student. I am also grateful to the Greater Victoria Hospital Society and Lynn Stevenson for their generous support and encouragement. I am thankful to the patients and staff of the Mother/Babe Unit who were willing participants in this study. Lastly, I am fortunate to have friends and peers who were willing to overlook my periodic bursts of irritability and strange behaviour during the course of this thesis.  1 CHAPTER I INTRODUCTION Background to the Problem The postpartum period is one of change and challenge for first time parents. Not only is it a time of great physiological change for the mother as her body adapts to the non pregnant state, it is also a time of great psychosocial change for both mother and partner. The integration of the new family member creates the need for major reorganization of roles, relationships, and lifestyle patterns. Unfortunately, our educational system does not prepare young people for parenting (Hall, 1980). Many new mothers have had little or no experience in caring for a newborn. Because the extended family network is unavailable to a great extent, parents are often deprived of the benefit of experience, advice, support, and reassurance (Davis, Brucker, & Mac Mullen, 1988 ; Hall, 1980). As a result, new mothers have come to rely heavily on hospital nurses for information related to caring for themselves and their babies in the early postpartum period. Traditionally, postpartum education has been conducted in hospital over a period of 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 more time in demonstrating physical care of mother and baby than in discussing infant  2 behaviour, infant characteristics or family adaptation (Glover et al., 1985). With today's trend toward a shortened hospital stay of between 6 and 48 hours postpartum (Jansson, 1985; Lemmer, 1987; Thurston & Dundas, 1985), a different approach to postpartum education is required. Shortened length of hospital stay results in less time to spend on teaching. Nurses generally expect to provide the content of a routine teaching package to new mothers in the belief that this approach will provide information on most of the things new mothers need to know. With less time available for teaching, it is evident that the "routine teaching package" approach must change. A larger proportion of postpartum education must now be provided to mothers after discharge. The ability to identify postpartum learning needs which are important to mothers is now becoming essential. Once learning needs have been identified, strategies can be developed to address them. Perhaps some can be addressed in the antenatal period, some can be addressed during hospitalization and others addressed at home. It is neither possible nor advisable to try to teach a comprehensive educational package during a 48 hour hospital stay postpartum. Organized early postpartum discharge programs generally include nursing home visits 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 programs  3 at present. Home followup can range from a phone call, to one or more daily nursing visits beginning the day after discharge. Visits can be provided by nurses who work on 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 concept stresses the importance of parental involvement in decision making concerning care (Bull, 1981). The principles of individualization and involvement should occur in the education aspect of patient care as well. If mothers are being exposed to only those postpartum topics taught as a matter of routine during hospitalization, they are being denied the opportunity to identify the topics that are important to them as individuals. Individualization of learning needs assumes even greater importance given today's trend toward shortened postpartum hospital stay (Bull, 1981; Gruis, 1977). However, nurses have not taken a proactive role in assisting postpartum mothers to identify their learning needs (Bradley et al., 1989) and Gruis (1977) warns that mothers may not always seek out information on their own. It is not clear which learning needs would be more suitably addressed in hospital and which learning needs would be more suitably addressed at home. Who should determine what is taught in hospital and what is taught at home? Would maternal/newborn nurses and postpartum mothers make the same or different choices?  4 Statement of the Problem  The literature covers a variety of the concerns of postpartum mothers before and after discharge. Concerns of mothers in the early postpartum period seem to involve infant care while later concerns seem to involve family relationships. However, there is neither consensus on the part of mothers and nurses regarding which postpartum topics are most important to mothers nor on recommendations related to which topics are more suitably addressed in hospital and which topics are more suitably addressed at home. Purpose of the Study  The purpose of this study was two-fold: 1. to identify which learning needs would be more suitably addressed in hospital and which learning needs would be more suitably addressed at home as perceived by postpartum mothers and maternal/newborn nurses. 2. to compare the perceptions of the two groups. Conceptual Framework  The conceptual framework for this study was based on selected concepts from adult learning theory or andragogy as developed by Malcolm Knowles (1970), and from Gruis' (1977) theory of developmental tasks of the postpartum period.  5 Andragogy  Andragogy is based on four important assumptions (Knowles, 1970, 1972) about the characteristics of adult learners. These assumptions relate to self-concept, experience, readiness to learn, and orientation to learning and have implications for the nurses who are the providers of postpartum education. Self-concept  Mature adults see themselves as capable of making their own decisions and managing their own lives (Knowles 1970, 1972; Tarnow, 1979). This is the premise of the 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, to have others see them as capable and self directing (Knowles, 1970). Being told what to do and what not to do, being talked down to, embarrassed, or judged may cause resistance to learning in an adult. Such treatment is incongruent with his/her selfconcept as an autonomous individual (Draves, 1984; Knowles, 1970, 1972). Experience  The second assumption involves the life experiences that adults use as building blocks for further learning (Knowles, 1970). They have a rich foundation on which to relate new experiences.  6 Adults are defined by their experience and it establishes their self identity in terms of occupation, achievements, marital status, and other factors (Draves, 1984). When in situations where their experience is rejected or minimized, adults may feel personally rejected (Knowles, 1970; Tough, 1971). They may carry over perceptions from previous experiences or schooling that they are not very bright. These perceptions can prove a barrier to engaging in effective learning (Knowles, 1970). However, adults have also acquired larger numbers of fixed habits and patterns of thought that tend to make them less open minded (Knowles, 1970). Experience plays a central role in the learning process whereby concepts are derived and continuously modified by experience (Kolb, 1984). Learning is the major process by which adults will adapt to new social and physical environments (Havighurst, 1952). Knowledge will be continuously derived from and tested out in the experience of the adult involved in change (Havighurst, 1952; Kolb, 1984). Readiness to learn The third assumption involves a state of mind which Knowles (1970) has termed readiness to learn. For adults, growth and development is primarily the result of the evolution 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 a  7 '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 retain certain knowledge and skill. Knowles (1972) describes readiness to learn as "decreasingly the product of biological development and academic pressure and increasingly the product of the developmental tasks required for the performance of evolving social roles" (p. 35). Orientation to Learning  The fourth and last of Knowles' (1970) assumptions relates to the adult's orientation to learning. Adults are problem-centered and goal-directed learners (Knowles, 1970). There is a perspective of immediacy of application toward most of their learning because they generally engage in learning as a means of accomplishing something that is important to them now (Draves, 1984). When skills and knowledge are required to accomplish their goals, adults can be highly motivated learners. It is questionable whether people can motivate other people to learn, whether they can help motivate, or whether they are actually powerless in influencing the motivation of others (Draves, 1984). Motivation is an internal drive and can be put into operation by the learner only (Bille, 1981). Knowles' (1970) assumptions were considered an appropriate framework for this study as mothers, during the early postpartum period, are adult learners making  8 decisions about what they feel are their immediate learning needs. Early discharge programs mean that mothers now have to make decisions related to the environment in which early learning will take place as well. Gruis' Developmental Tasks of the Postpartum Period  Gruis (1977) believes that there are four developmental tasks related to becoming a parent which have a relationship to the times during the postpartum period at which specific learning needs become evident; physical restoration, learning the infant's needs, relating with the newborn, and accommodating a new family member. Physical Restoration  Although mothers may appear ready and eager to learn in the early postpartum period, effective learning may not actually take place because mothers are often tired, sore, and uncomfortable. They require time for their physical and psychological needs to be seen to before they are actually ready to learn. Leamina the Infant's Needs  In today's society, there are few opportunities formal or informal for people to learn about infant care through their own experience before actually becoming parents. Through various resources such as literature, their parents and friends, mothers may have some perceptions related to infant care but a solid experiential basis is lacking.  9 Relating With the Newborn  A mother needs to learn about and understand her new infant in terms of normal growth and development and infant behaviour. A vital component of the mother/infant relationship is the adaptation between the mother's personality and the personality of the baby newly introduced into her environment. Accommodating a New Family Member  Demands of the baby must be regulated with the demands of other family members, society, and the mother's own personal needs. The new mother must not only establish a relationship with her baby, but she must also face the issues involved in integrating the infant into the larger environment of family and community. Mothers may feel quite overwhelmed in the early postpartum period. Gruis' (1977) developmental tasks provide a focus for nurses in terms of guiding and facilitating postpartum mothers' learning experiences. Nurses are aware that the early postpartum period may not be an optimal time for learning therefore they must carefully assess each mother's readiness to learn (Knowles, 1970). Gruis (1977) offered no suggestions related to the points at which, or the sequence in which mothers move through the developmental tasks. However, nurses will recognize that learning involves a continuous process of adaptation for mothers: their return to the non-pregnant state, learning to meet their infants' needs, learning how to relate to their  10 infants, and learning how to adapt with their infants to the larger environment of family and community (Gruis, 1977). Research Questions  This study was designed to answer the following research questions: 1. Which postpartum learning needs do mothers eligible for participation in an early discharge program perceive as being more suitably addressed during the hospital stay? 2. Which postpartum learning needs do mothers eligible for participation in an early discharge program perceive as being more suitably addressed by visiting nurses in the home? 3. Which postpartum learning needs do maternal/newborn nurses perceive as being more suitably addressed with short stay mothers in hospital? 4. Which postpartum learning needs do maternal/newborn nurses perceive as being more suitably addressed with short stay mothers during nursing visits in the home? 5. Are postpartum mothers' perceptions about these questions different than those of maternal/newborn nurses'?  11 Significance of the Study  Education 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 postpartum teaching leaves them frustrated and demoralized. The information obtained in this study may be of assistance in the development of more individualized, cost effective educational programs. Mothers may not expect or want a lot of information in the first 24 hours postpartum. Perhaps prenatal classes can look at what postpartum material is offered pre delivery and how it can be changed or adapted. The aim is to ensure that the educational preparation of postpartum mothers is consistent with their learning needs and changing trends in maternity care and to decrease the frustration of maternal/newborn nurses related to postpartum education. Definition of Terms  Postpartum learning need: an identified concern or interest requiring information, discussion, or skill on the part of the postpartum mother. Such concerns or interests may be related to self, infant, or family. Maternal/newborn nurse: a nurse who provides care for a mother/baby dyad.  12 Early discharge program: a formal program in which low risk mothers and babies are  discharged within 6-48 hours of delivery. Provisions are made for nursing home visits beginning the day after discharge. Short stay eligible mothers: postpartum mothers who are eligible to participate in an  early discharge program. Visiting nurse: a nurse, either hospital or community-based, who will provide follow-up  care 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 has  cared for at least one of those babies. Assumptions of the Study  The 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 postpartum period. 3. The majority of today's first time mothers have little or no experience with newborns.  13 Limitations of the Study  The limitations of the study were as follows: 1. Because the study was descriptive in design, results could not be readily generalized. 2. The questionnaire used was not subjected to testing for reliability and requires further testing for validity.  14 CHAPTER II LITERATURE REVIEW Overview This study sought information regarding which postpartum learning needs mothers and nurses perceive as suitable to hospital and home. An initial search revealed no literature in the area. Therefore a literature review was conducted in those areas which seemed appropriate to the purpose of the study, the conceptual framework, and research questions; early postpartum discharge, general concerns/interests of postpartum mothers, and patients' and caregivers' perceptions of patient education. Literature in these areas may shed some light on the perceptions of both mothers and nurses related to education and learning needs in the early postpartum period. Early Postpartum Discharge Much of the literature on early discharge deals with the issues of cost effectiveness, 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 discharge mothers 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. They  15 distributed 154 questionnaires to program participants of which 94 were returned. The characteristics of the respondents were not reported. The questionnaire inquired about postpartum instruction but related to satisfaction only. Eighty six per cent of the sample indicated satisfaction with the amount of instruction received. This program included a teaching sheet in checklist format covering both maternal and infant topics, but how and by whom the teaching sheet was developed was unclear. Although teaching sheets were used both in hospital and for home visits, whether or not they were individualized for each mother was also unclear. The topics discussed in hospital and at home were not identified. There is also 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-infant bonding, reconstructing birth events, and instruction in care of self and baby. They mailed 3773 questionnaires of which 1900 were returned. Respondents varied widely in terms of age, ethnic origin, and socio-economic status. Seventeen percent of the sample 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 had significantly lower levels of satisfaction with care than did those whose wishes were  16 honored. Home visits were not offered to early discharge mothers in this study and 30% indicated that they would have liked a visit to discuss a variety of concerns related to self and baby care, emotional self, and family relationships. Bradley et al. (1988) conducted the only recent randomized, controlled trial of early postpartum discharge. In one aspect of the study, they looked at topics raised for discussion 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 income mothers with a mean age of 30.16 years. All had unremarkable pregnancies and deliveries. On day 1, mothers focussed on infant appearance and behaviour and the birth experience. Mothers on day 2 expressed concerns regarding fatigue. On days 3 and 5 mothers interests again returned to infant topics with questions related to infant feeding and infant behaviour. Both traditional hospital stay mothers and early discharge mothers were visited on day 10. The traditional discharge mothers tended to raise more topics such as infant behaviour, birth experience, and fatigue than did early discharge mothers. However, mothers participating in the trial had the same visiting nurse while traditional stay mothers may have had a number of different nurses offering teaching and information during their stay in hospital. The trial mothers would have experienced more consistency in terms of teaching and information. There was  17 no significant difference between multiparas and primiparas in the kinds of concerns raised. Martell, Imle, Horwitz, & Wheeler (1989) studied a sample of 42 short stay mothers at 72 hours postpartum. The purpose of their study was to identify information from a given teaching protocol which mothers in a maternity short stay program thought was most important to them in the first three days postpartum. The mean age of the sample was 24.74 years, mean educational was 12.83 years, and all had uneventful pregnancies and deliveries. All mothers were discharged between 6 and 8 hours postpartum. Most of the mothers were recruited to the study by telephone after their first 24 hours postpartum and the remainder were recruited when they returned for a clinic visit between 48 and 72 hours postpartum. The researchers collected data with a one way structured Q sort asking mothers to rank 24 items from the teaching protocol according to the items' importance to them the first 3 days postpartum. The average 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 high degree of concern for both primiparas and multiparas. Mothers were least concerned about their own sexuality, family changes, and bowel function. These studies gave no direction as to which learning needs mothers would have addressed in hospital or which learning needs they would have addressed at home.  18 However, it appears that mothers' early (1-3 days postpartum) learning needs have an infant focus with family relationship topics being of little interest. Some of the studies indicated that mothers seem to respond more positively to learning experiences when given the opportunity to identify their own learning needs. Concerns and Interests of Postpartum Mothers  There is a variety of literature available on postpartum mothers' concerns and interests from 24 hours to 6 weeks postpartum. Methods vary widely. Most of the studies are descriptive in nature and instruments consist of mainly study-specific questionnaires and card sorts. Most of the samples were those of convenience. The majority of studies indicated that mothers' early postpartum concerns involved infant care topics while concerns related to family relationships appeared later in the postpartum period. Concerns related to self were never very evident at any time except in Gruis' (1977) study where the topic of most concern was the return of the figure 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 questionnaire based on a comprehensive interview guide developed by Lesser and Keene (1956). The sample was composed of English-speaking mothers who had uneventful deliveries and healthy newborns. Mothers were instructed to rate items which they felt  19 nurses 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 the infant care topic of highest priority was infant illnesses. These results reflected the priorities of all age and parity groups. Other priority topics for primiparas were episiotomy/stitches in the maternal care category and infant medications, feeding baby, and cord care in the infant care category. For multiparas, other important maternal care topics were the use of medications and stitches/episiotomy. Moss (1981) attempted to identify the concerns of multiparas during the early postpartum period in the areas of self, infant care, and family relationships. She developed and administered a card sort to each of 56 in hospital mothers on the 3rd postpartum day (defined as between 60 to 72 hours after delivery). The tool consisted of 61 index cards with each card containing a word or phrase indicating common concerns of new mothers identified in the literature. The mean age of participants 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 except for weight and return of their figures to normal. Baby's safety and how children at home will react to the new baby were among the five highest ranked items. Overall,  20 mothers' concerns related primarily to items in the family relationships area. Hiser (1987), replicating Moss' (1981) study with a sample of 20 multiparas, came to the same conclusions. However, when Hiser asked mothers (after they had completed the card sort) to name their concerns, more than half of the participants named their newborns. Less than half of the participants named the family. Bull (1981) conducted a comparative survey to determine any differences in maternal concerns after one week at home. A self-administered 50 item questionnaire containing 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 English speaking. All had at least high school education and all had uneventful pregnancies and deliveries. Each of 40 mothers completed a questionnaire in hospital on approximately her 3rd day postpartum and was asked to mail in another completed questionnaire after approximately one week at home. Thirty of these questionnaires were returned. Results indicated that both the frequency and intensity of concerns related to physical discomfort decreased after one week at home, however, the frequency and intensity of concerns related to emotional self increased. The number and intensity of concerns related to physical care of the baby decreased after one week at home but  21 infant behaviour continued to be of "moderate" to "much" concern. Items in the husband 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 month of October, 1974 to see if there was justification based on consumer volume to develop education/supportive services for parents of newborns. All calls from eligible consumers (those who delivered or had an infant up to 42 days of age during the study period) related to postpartum concerns were monitored at the medical facility involved in the study from October 7, 1974 to November 2, 1974. A form was developed for documentation of data. The number of calls totalled 270. Twenty five percent of the multiparas eligible to call did so and 88% of the primiparas eligible to call did so. The category of most concern was infant feeding, followed by other infant carerelated items. In general, the questions were most frequent during the first 2 weeks postpartum, dropping off sharply at 6 weeks. Results were consistent for both parity groups. In her 1977 study, Gruis surveyed 40 mothers who were one month postpartum. Various mothers were asked to complete a questionnaire listing potential areas of  22 concern drawn from the literature. Mothers were instructed to identify which of the areas were significant to them during the past month, rank the concerns as major or minor, and note the resources they had used to meet these concerns. Respondents' ages ranged from 18 to 36 and educational background varied. All had uncomplicated pregnancies and deliveries. Gruis (1977) noted that the most frequent major concern raised for both parity groups a month postpartum (strongest in the multiparous group) was the return of their figures to normal. Multiparas also raised regulating family demands, finding time for self, fatigue, and emotional tension as major concerns. Primiparas raised regulating family demands, infant behaviour, feeding, and emotional tension. Gruis also determined that mothers did not seek help for 22% of the concerns they identified, probably because help was not readily available. Like the studies on early discharge, the studies related to mothers' postpartum concerns/interests did not indicate which learning needs mothers perceived as more suitably addressed in hospital and which learning needs they perceived as more suitably addressed at home. However, these studies did seem to point to the times during which specific concerns appeared. Research conducted in the early postpartum period (3 days postpartum) with in-hospital mothers indicated that their concerns were generally related to the physical care of themselves and their infants.  23 At home one week postpartum, concerns were related to the emotional self and infant behaviour. One month postpartum, concerns turned to family relationship topics. Patients' and Caregivers' Perceptions of Patient Education Adult Education  Most writers in the field of adult education support Knowles' (1970) concepts related to the adult learner as useful in adult education. Knowles (1970) identifies these concepts as assumptions but they have also been called principles of adult learning, 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 derived from Knowles' (1970) assumptions of self-concept, experience, readiness to learn, and orientation to learning. Educators are cautioned that physical surroundings must be comfortable and conducive to learning (Draves, 1984; Redman, 1984) and more importantly, the psychological climate should be one in which learners feel accepted, respected, and supported (Draves, 1984; Knowles, 1970; Redman, 1984). The behaviour of the educator and the relationship between educator and learner is probably the most influential determinant of the psychological environment (Bille, 1981; Knowles, 1970; Lesser & Keene, 1956). Educators convey in many ways whether their attitudes are  24 ones of interest in and respect for adults as learners or whether they see such adults as essentially receiving sets for their educative wisdom (Draves, 1984). Effective learning 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 in identifying learning needs, planning to meet those needs, and in conducting and evaluating the learning experiences (Arndt & Underwood, 1990; Knowles, 1970). Adults are also more motivated to learn by seeing the relevance of what they are learning through practical application (Kolb, 1984; Redman, 1984). Learning is also more meaningful to adults if the sequence of learning is both logical and important to them (Knowles, 1970; Tough, 1971). Adult educators must be person-centered and individualize teaching to suit the individual learner continually timing learning to the learner's pace (Knowles, 1970; Redman, 1984). Adult educators must also be prepared to act as facilitators of learning rather than teachers, as no one person is capable of "making" another person learn (Tough, 1971). Effectiveness of Application of Teaching/Leaming Principles  There are some studies which describe differences between caregivers' and patients' perceptions of patient education both in general and in the area of  25 maternal/child nursing. The following studies describe both patients' and caregivers' perceptions of patient education in relation to other aspects of service delivery and the effect that nurses' use of adult education principles appears to have on outcomes in patient education. In addition, some of these studies describe differences in emphasis placed 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 to participants in order to elicit information regarding what users and providers felt was important regarding service delivery. Study results revealed that all four groups identified diagnosis/assessment and treatment as important attributes of care. However, health care providers demonstrated significantly less concern for education than did clients. Murdaugh (1980) wished to ascertain whether patients would learn more about a disease process and therapeutic regimen if nurses were taught the principles of teaching/learning. Patient participants included both males and females up to the age of 75 years. Nurse participants were registered nurses who worked in the Coronary Care Unit (CCU) on a regular basis. A pretest/posttest static group design was used  26 for the study. Data were collected from 20 patients in the CCU related to their knowledge and understanding of specific aspects of their condition on entry to the unit and again just prior to discharge. After these patients were discharged, 18 nurses working in the unit participated in a course on the principles of teaching/learning. Data were collected again from another 20 patients on entry to and just prior to discharge from the unit. Results indicated a significant difference in knowledge and understanding for the patients taught by nurses who applied teaching/learning principles. Murdaugh concluded that although nurses without knowledge of teaching/learning principles may be teaching patients, teaching becomes more effective when nurses know these principles. Mooney (1987) conducted a study to gain information about nurses' use and application of the four adult education principles of self-directedness, time perspective, readiness to learn, and experience. The investigator developed a 21 item questionnaire which assessed knowledge and application of the adult learning principles and administered it to 127 registered nurses from two hospitals. Ninety eight of the nurses responded. The mean age was 22.4 years and 94% were employed full time. Educational preparation included associate degrees (4.1%), diploma graduates (44.5%), and baccalaureate graduates (51%).  27  Mooney (1987) concluded that the nurses understood all four adult education principles but did not apply them consistently. The principles of time, experience, and readiness were chosen by the nurses more often than self-directedness. Failure of the nurses to apply the principle of self-directedness would imply that patients were not allowed an active, responsible role in the learning process. Honan et al. (1988) conducted a descriptive study related to selected factors that may influence patient teaching; responsibility, priority, knowledge, materials, environment, time/staff, and documentation. Sixty registered nurses completed a questionnaire which consisted of 28 subjective attitudinal questions. Respondents could 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 for teaching, 85% believed other disciplines needed to be more involved. Only 58.3% believed it was the nurse's responsibility to coordinate multidisciplinary teaching. Data from Likert-type questions indicated nurses believed patient teaching was a high priority. However, a rank order question revealed patient teaching was not a high priority when ranked with other nursing duties such as patient care, medications, and charting. It was also ascertained that nurses did not have an adequate enough knowledge of teaching/learning principles to effectively teach patients. Nurses cited  28 the adequacy and availability of teaching materials as well as time and staffing as obstacles to patient teaching. The investigators also reported that although formal and informal patient teaching was carried out, it was seldom communicated or documented. Patients' and Nurses' Perceptions of Learning Needs  While observing and interviewing various postpartum nurses and mothers, Lesser and Keene (1956) studied both postpartum mothers' and nurses' perceptions of general postpartum needs. They concluded that, as a group, the nurses recognized all of the needs that mothers themselves revealed. However, the nurses' emphasis was often very different from that of the mothers'. The nurses saw themselves as performing routine clinical functions and teaching certain aspects of self care and baby care. Meeting other needs of the mothers was often incidental, to be performed if there was time and only if those needs were forcefully made known. Mothers expressed the need for physical care and dependence and felt that nurses, by and large, failed to recognize these needs. The biggest factor for these mothers appeared to be the nurse-patient relationship. If the nurses displayed warmth and personalization of care, the mothers felt greater satisfaction with their hospital experience as a whole. Cupoli et al. (1971) investigated teaching conducted by nurses in the areas of  29 infant care, behaviour, and characteristics. Data were collected by non-participant observation over a two week period. During each shift, randomly selected postpartum and nursery nurses were observed for selected periods of time that would cover such activities as infant feeding and patient discharge. Three nurses were educated at the baccalaureate level, 24 graduated from diploma programs, and 11 were licensed practical nurses; a total of 21 postpartum and 17 nursery nurses. The investigators concluded that more time is spent teaching about infant care than either infant behaviour or infant characteristics. They observed that mothers more often than nurses initiated information exchanges about infant behaviour and that, while in hospital, mothers seemed to be more concerned about the behaviour of their infants than their infants' care. Thus a discrepancy exists between the topics of information exchanges mothers initiate and those nurses initiate. Glover et al. (1985) surveyed postnatal educational programs in 27 British Columbia, Alberta, and Saskatchewan hospitals. Their findings indicated that teaching content is most often set by nurses alone. The present system of in-hospital postnatal education seems to be addressing the physical aspects of maternal and infant care but not the emotional aspects and expectations surrounding this time. They questioned whether teaching is appropriate to consumer needs. Tribotti and Lyons (1987) studied postpartum mothers and nurses (12 = 236  30  nurse/patient pairs) perceptions related to postpartum problems according to possible nursing diagnoses. Patient participants were an average of 27 years of age, had almost 14 years of education, and were married. Most were between 12 and 72 hours postpartum and breastfeeding their term infants. Nurse participants were an average of 35 years of age, 10 years out of nursing school, and had 6 years of experience in obstetrical nursing. The majority were registered nurses without baccalaureate degrees. Investigators concluded that the major areas of concern to patients were change in comfort, potential for growth (related to the social and emotional aspects of parenting), 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 in comfort, potential for growth, lack of knowledge, change in bowels, and change in body fluids. Findings for both groups were similar but rank order of priority proved different. 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 mothers identified it as a problem. The studies reviewed did not identify which postpartum learning needs nurses perceived as more suitably addressed in hospital and which learning needs they perceived as more suitably addressed at home nor was there any clear indication of which postpartum learning needs nurses perceived as important to mothers during  31 the early postpartum period. Therefore it was not possible to detect any relationship between nurses' and mothers' perceptions of early learning needs. However, the studies did offer some conclusions worth considering. It would appear that caregivers attach much less importance to patient education than do patients. Nurses seem to perceive education as just one more task to be performed in addition to other care and only attended to when other tasks have been completed. There is some evidence to suggest that patients perceive the nursepatient relationship as an extremely important aspect of their care and respond with better education outcomes when nurses use an adult oriented approach. It has been suggested that nurses' emphasis on postpartum learning needs differs from mothers' but evidence is inconclusive. Summary The literature on early discharge, with the exception of one study, is virtually non-existent on the subject of postpartum learning needs. The literature on postpartum mothers' concerns and interests presents a variety of topics that seem to be important to postpartum mothers. However, no clear direction regarding which topics 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 both primiparous and multiparous mothers in the early postpartum period.  32 Although the application of adult learning principles appears accepted as a suitable educational approach, it would appear that they are applied inconsistently, if at all, in patient education. Perspectives on the importance of patient education seem to differ between nurses and patients, the latter placing a great deal more emphasis on learning. The postpartum learning needs on which nurses focus seem to differ from mothers' actual learning needs, although evidence is inconclusive.  33  CHAPTER III METHODS Overview The information presented in Chapter III provides an explanation of the methods used to investigate both mothers' and nurses' perceptions of which postpartum learning needs were more suitably addressed in hospital and which postpartum learning needs were more suitably addressed at home. The investigation also included the identification of differences in responses between the two groups. Approach, setting, participants, questionnaire, procedure for data collection, and data analysis will be described. Approach  This study reflected two levels of inquiry; factor-searching and relation-searching (Diers, 1979). A factor-searching approach identified those learning needs which both postpartum mothers and nurses perceived as being more appropriately learned in hospital and those which both groups perceived as being more appropriately learned at 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 research questions as opposed to hypotheses (Diers, 1979). The questions are very general and, instead of naming variables or relationships, they may just indicate areas for  34 inquiry. This approach literally looks for ways to classify information on a given situation in order to produce sets of categories which, when taken together, will describe the whole situation (Diers, 1979). Diers (1979) believes that a factor-searching approach is useful when a researcher wants to take a new look at an old situation or when 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 the form of categories after they are collected (Diers, 1979). Although there were some data available on mothers' learning needs in the early postpartum period, there were no data available on either mothers' or nurses' perceptions of which learning needs should be addressed in hospital and which learning needs should be addressed at home. Therefore, a factor-searching approach was considered appropriate. However, through the work of Gruis (1977), specific categories into which the majority of postpartum learning needs seem to fit have already been suggested; self, infant, and family. As a result, data for this study were collected in relation to these three categories. Relation-searching studies are at the second level of inquiry and are concerned with problems in which relationships among given factors are unspecified or unknown (Diers, 1979). Diers (1979) suggests that relation-searching studies should be conducted when a situation is new or when there is a search to see if a relationship  35 found 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 to generalize findings to other populations or samples, but simply to describe relationships found (Diers, 1979). A number of writers suggest that the relationship between educator and learner is crucial and that, if the learning objectives of educator and learner differ, learning will be inhibited (Draves, 1984; Knowles; 1970; Redman, 1984). However, there are no data available on the relationship between mothers' and nurses' perceptions of which postpartum learning needs are more appropriately addressed in hospital and which postpartum learning needs are more appropriately addressed at home. The lack of such data indicated a need for a relation-searching approach. Setting  The setting was the Maternal\Newborn unit in an acute care hospital on Vancouver Island which averages approximately 3500 deliveries a year. Presently, postpartum teaching is conducted according to topics set out in a parent teaching sheet. This teaching sheet becomes a part of the permanent health record of each postpartum mother (see Appendix A). A pilot early discharge program has recently been developed in which selected groups of low risk vaginally delivered mothers and babies and low risk Caesarean delivered mothers and babies are discharged at  36 approximately 48 hours and 4 days postpartum respectively. Nursing follow up in the home begins the next day. Participants  During a seven week period, a convenience sample of all vaginally delivered primiparas meeting the criteria for early discharge (see Appendix B) and who were judged eligible for inclusion in the study, were asked to participate. Of 126 primiparas eligible, 89 chose to participate. For the purposes of this study primiparas were targeted because, given their assumed lack of experience, nursing staff tend to give them priority in terms of teaching time and effort. Vaginally delivered primiparas were also believed to produce a more homogeneous perspective on what would be considered normal postpartum learning needs. All maternal/newborn nurses providing mother/baby care including related teaching were judged eligible for inclusion in the study. Of 72 nurses eligible, 50 chose to participate. Questionnaire  Data were collected with a questionnaire based on those postpartum concerns and 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. Where comparisons are to be made, it is necessary to retrieve exactly the same information from each sample unit (Diers, 1979). Because mothers' and nurses' responses in relation to postpartum learning needs were to be compared, the same questionnaire was distributed to both groups. Participants were asked to assign concerns and interests to either of two areas; learning suitable to hospital or learning suitable to home. To ensure the clarity and content validity of the questionnaire, a pilot study was conducted with five maternal/newborn nurses and five primiparas eligible for early discharge. All participants reported that the questionnaire was logical, comprehensive, and easy to understand and follow. The questionnaire was also reviewed by the Head Nurse and the Clinical Teacher of the Maternal/Newborn unit. The only change was to add frequency of feeds under bottle feeding concerns which eight out of ten respondents in the pilot study felt should be included. The revised questionnaire was then used to collect data for the actual study. Procedure for Data Collection  Over a seven week period, questionnaires were distributed to all vaginally delivered primiparas who were 24-72 hours postpartum and met the criteria for early  38 discharge. Completed questionnaires were placed in envelopes, sealed, and returned to the nursing staff or the unit clerks who dropped them into a return box located at a neutral location on the unit. This return box was used to collect both mothers' and nurses' questionnaires. During the same seven week period, the investigator presented the purpose and objectives of the study at a maternal/newborn nurses' staff meeting to invite nurse participation. Subsequently, notices inviting participation were placed on the nursing communication boards of each patient care area on the unit. A number of questionnaires were left at each patient care area and replenished by the investigator as necessary. Completed questionnaires were placed in envelopes, sealed, and dropped by participating nurses into the return box. Both nurses and mothers received identical questionnaires. The only difference was the attached demographic information sheets (see Appendix C). Included with each questionnaire was an explanatory letter delineating the purpose and objectives of the study and outlining subject rights relative to scientific investigation (see Appendix D). Consent to participate in the study was assumed by the return of a completed questionnaire.  39 Data Analysis Frequencies were determined for each concern/interest on the questionnaire and each category on the background information sheets for both groups. Frequencies were computed in proportions and then converted to percentages for tabular presentation (see Appendix E). Concerns/interests were then listed according to the ten topics which each group chose most frequently as learning more suitable to hospital and/or learning more suitable to home. On those occasions where topics tied for tenth place, they were included in the list. Chi-square analysis was performed for each group on completed background information sheets in order to detect any trends related to background information data and participants' responses to items on the questionnaire. To determine if differences existed between the responses of the two groups, the Chi-square statistic was also applied to both groups' responses for each postpartum concern/interest covered in the questionnaire. A two-tailed t-test, as a measure of proportion, was also used to further validate any significant differences reported by Chi-square. Summary For this study, a factor-searching approach was used to identify mothers' and nurses' perceptions of which postpartum learning needs were more suitably  40 addressed in hospital and which postpartum learning needs were more suitably addressed at home. A relation-searching approach was used to compare the responses of both groups. Eighty nine early discharge eligible mothers and 50 maternal/newborn nurses from an acute care hospital on Vancouver Island chose to participate in the study. Both groups completed and returned identical questionnaires. The questionnaire covered postpartum concerns and interests gathered from the literature. Concerns and interests were separated into three categories reflecting Gruis' (1977) developmental tasks of the postpartum period; self, infant, and family. Included with each questionnaire was a cover letter and background information sheet specific to either mother or nurse. Frequencies were determined for each response for both groups and reported as percentages. Responses of both groups were then listed according to the concerns and interests which each chose most frequently as learning suitable to hospital and home. Significant differences in responses for both groups were identified using the Chi-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.  41 CHAPTER IV RESULTS AND DISCUSSION Overview Demographic information related to the samples will be presented first. Following this, the postpartum concerns/interests which postpartum mothers' and nurses' perceived as more suitably addressed either in hospital or at home will be identified and the responses of both groups compared. The distribution of postpartum concerns/interests between hospital and home will also be delineated. Finally results will be discussed in relation to the conceptual framework and the literature review. Results Demographic Information  Of 126 eligible postpartum mothers, 89 returned completed questionnaires and of 72 eligible maternal/newborn nurses, 50 returned completed questionnaires; a return rate of 70.6% and 69.4% respectively. The majority of mothers were 25-29 years of age, 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 help available to them after discharge would not be adequate to meet their needs. This group of mothers chose to breast feed their infants, were 25-29 years of age, had  42 completed 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 to them after discharge would meet their needs or not. Six mothers did not supply information regarding total family income. All chose to breast feed, were generally aged 20-24, were from all education levels with the exception of the post graduate studies category, and all believed the help available to them after discharge would be adequate to meet their needs. Mothers who had completed post graduate studies chose to have the majority of their learning needs met at home. However, as there were only 3 mothers in that category, statistical analysis could not be performed. Demographic information items, when subjected to Chi-square analysis in relation to individual responses on the questionnaire, revealed no significant trends for either group.  43 Table 1  Early 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 for assistance at home. Yes 89%^No 11%  44 The majority of the nurses who participated in this study were in the 45-49 age group (see Table 2 ). Only one nurse did not supply age. Most were prepared at the diploma level and have been in nursing for well over 15 years. Fourteen percent of the sample had post basic preparation related to maternal/child nursing such as midwifery or the British Columbia Institute of Technology's (BCIT) low risk obstetrics program.  45  Table 2 Maternal/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%  46 In 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 hospital and home, the total number of responses for that concern/interest was considered to be 90 as opposed to 89. If a concern/interest was not checked at all, the total number of responses was considered to be 88. The same rule was applied to the nurses' responses. Because only three mothers chose to bottle feed, items related to that concern/interest were deleted for both groups as results would not be statistically valid. Topics from the self, infant, and family categories were identified in the appropriate tables by the letters S, I, or F placed beside the corresponding topic. Postpartum Mothers' Perception of Learning More Suitably Addressed in Hospital  The majority of concerns/interests which mothers perceived as being more suitably addressed in hospital involved the infant category. Most were related to the physical care of the infant. Only one topic reflected a need for knowledge alone as opposed to a need for knowledge attached to a skill (see Table 3). Concerns related to self constituted only three items of the ten topics which mothers chose most often as learning more suitably addressed in hospital. There were no items listed in relation to the family category. Topics which few mothers would choose to have addressed in hospital came primarily from two categories; family (regulating demands of partner, housework, and  47 job) and emotional self (feelings of guilt/ambivalence about returning to work and feeling tied down). Postpartum Mothers' Perception of Learning More Suitably Addressed at Home  The majority of concerns/interests which mothers perceived as being more suitably addressed at home were from the family category (see Table 4). These were followed closely by concerns related to the emotional self. Only two items involved the infant category and those reflected a need for knowledge. Under "other topics/concerns" in the self category, one mother wished to know the location 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 from the infant category such as cord care and infant feeding.  48  Table 3 Postpartum Mothers' Perception of Learning More Suitable for Hospital (rj = 89)  Actual  Concerns/Interests  Cord 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.  49 Table 4 Postpartum Mothers' Perception of Learning More Suitable for Home (ri = 89)  Concerns/Interests  %  Actual  Regulating 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.  50 Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed in Hospital  The majority of concerns/interests which the nurses perceived as more suitably addressed in hospital were from the infant category, particularly in area of breastfeeding (see Table 5). There were no infant items listed which called for the provision of knowledge alone. Three concerns involved the self category. There were no concerns listed from the family category. Topics which none of the nurses would address in hospital came from all three categories: when/kinds of solids to introduce to the infant, immunization (infant); child care, home management (self); regulating demands of partner, housework, and job and changes in lifestyle (family). Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed at Home  The majority of the concerns/interests which nurses perceived as being more suitably addressed at home were from the infant category and reflected a need for knowledge (see Table 6). Three concerns were from the self category (emotional self) and there were also three concerns from the family category. Under "other topics/concerns" in the self category, one nurse would provide phone numbers of LaLeche League, lactation consultants, and breast pump distributors. Under "other topics/concerns" in the infant category, one nurse would address infant  51 growth spurts. Topics which none of the nurses would address at home were from the infant category; aspects of infant feeding and cord care.  52 Table 5 Maternal/Newborn Nurses' Perception of Learning More Suitable for Hospital (3 = 50)  Concerns/Interests  %  Actual  Cord 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.  53 Table 6 Maternal/Newborn Nurses' Perception of Learning More Suitable for Home  Concerns/Interests  %  in =  50)  Actual  Regulating 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.  54 Comparison of the Responses of Both Groups  When Tables 3 and 5 were compared, both mothers and nurses generally identified the same concerns/interests as learning more suitable to hospital. A major topic 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; infant appearance and infant bathing. However, over 90% of both groups perceived these three topics as more suitably addressed in hospital (see Appendix E). Therefore, on the whole, both groups would appear to perceive infant care and self care topics as learning more suitable to hospital. When Tables 4 and 6 were compared, there were some differences between mothers' and nurses' choices for learning at home. Three major topics for mothers which did not appear on the nurses' table were feelings of guilt/ambivalence about returning to work, family planning, and sharing household responsibilities. Over 90% of nurses perceived two of these topics as appropriate for home; feelings of guilt/ambivalence about returning to work and sharing household responsibilities (see Appendix E). However, less than 90% of nurses chose family planning as a topic appropriate for home (see Appendix E). Three major topics for nurses which did not appear on the mothers' table were immunizing the infant, weaning the infant, and vitamin/fluoride supplements. All three  55 topics were chosen by less than 90% of mothers as appropriate for home (see Appendix E). Therefore, more mothers than nurses chose topics from the family category as suitable for home while more nurses than mothers chose topics from the infant category as suitable for home. These observations were borne out statistically. The majority of significant differences between mothers' and nurses' responses occurred in the home environment with the infant and family categories. The most significant differences (p<.001) in responses between the two groups occurred with the topics of growth and development, family planning, and immunization (see Table 7). Both groups perceived these topics as learning more suitable to home. However, more mothers than nurses chose family planning (family category) and more nurses than mothers chose growth and development and immunization (infant category). The only two topics which differed significantly for the two groups in terms of the more suitable environment for learning, hospital or home, were recognizing the unwell infant and providing a safe environment for the infant. Nurses were evenly split as to whether recognizing the unwell infant was a topic more appropriate for hospital or home.  56 Table 7 Differences Between Postpartum Mothers' and Maternal/Newborn Nurses' Responses  Mothers^Nurses  p-value  (n = 89)^L = 50) t-test  Concerns/Interests  Hosp. Home^Hosp. Home  Growth and development (I)  34  66  8  92  <.02  <.001  Family planning (F)  3  97  17  83  =.05  <.001  Immunization (I)  18  82  0  100  <.05  <.001  Resuming sexual relations (F)  7  93  29  71  <.02  <.002  Weaning (I)  16  84  2  98  <.10  <.002  Vitamin/fluoride supplements (I)  19  81  4  96  <.10  <.01  Contraception (F)  8  92  25  75  cs.05  <.02  Recognizing unwell infant (I)  70  30  50  50  v.10  <.05  Safe environment (I)  43  57  63  37  =.10  =.05  Exercise regime (S)  8  92  20  80  z.10  =.05  Note.^S = self;^I = infant;^F = family.  57 While more mothers perceived this topic as more appropriate for hospital. More nurses perceived that providing a safe environment for the infant was information more suitable to hospital while more mothers perceived such information as more appropriate for home. Results for both were not significant when analyzed using Chisquare. However when analyzed using a t-test, there was moderate evidence (p<.05) to suggest that mothers' and nurses' responses were different for recognizing the unwell infant and some evidence (p:$.05) to suggest the same for providing a safe environment for the infant. Of the concerns/interests for which significant differences were identified between the responses of mothers and nurses only one, exercise regime, came from the self category. It is worth noting that there were no topics which all mothers identified as learning more suitable to either hospital or home i.e. topics that 100% of mothers assigned to hospital and 0% assigned to home or vice versa. On the other hand, there were a number of topics that all nurses perceived as learning more suitable to either hospital or home i.e. topics that 100% of nurses assigned to hospital and 0% assigned to home and vice versa. (see Appendix E). Distribution of Concerns/Interests Between Hospital and Home  The relationship to the hospital and home environment among the three categories of concerns/interests is depicted in Table 8. Both groups perceived that the majority  58 of family topics should be addressed at home. However both groups also perceived over 30% of self care and over 60% of infant care topics as being more suitably addressed during a hospital stay of 48 hours.  Table 8 Distribution of Concems/Interests by Category  Hospital^ Category  ^  Home  Mothers^Nurses^Mothers^Nurses  (n = 89)^(n =50)^(n = 89)^(n = 50) Self  39%  37%^61 %^63%  Infant  68%  63%^32%^37%  Family  6%  12%^94%^88%  Discussion Postpartum Mothers' Perception of Learning More Suitably Addressed in Hospital  Postpartum mothers' perception of learning needs more suitably addressed in hospital were similar to other studies which describe mothers' early (24-72 hours) postpartum learning needs. Mothers in this study were most interested in learning  59 about the physical care of the infant and infant feeding. Some specific infant topics which elicited a high degree of concern in other studies of early postpartum learning needs 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 this study. Self care topics chosen by the majority of mothers for learning in hospital were few; maternal blood flow, episiotomy/stitches, and hemorrhoids. These results reflected the findings of Davis et al. (1988) and Bull (1981). Emotional self topics of much 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 with mothers 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 often chosen as in-hospital topics by mothers in this study either. These results are in marked contrast to those of Hiser (1987) and Moss (1981) who found a high degree of concern related to family and emotional self items in the early postpartum period. Many differences noted among studies could be attributed to differences in sample sizes, methods, and demographic characteristics of the participants. On the other hand, some differences may be attributable to other factors such as the  60 psychological 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 in  hospital within 72 hours postpartum indicated that mothers appeared to be most concerned with infant care and infant feeding. However, studies carried out in the home environment within the same time span, most notably Bradley et al. (1988), indicated a shift towards other concerns such as the birth experience, fatigue, and infant behaviour. These researchers also noted that the concerns expressed by traditional discharge mothers at 10 days postpartum mirrored those expressed by early discharge mothers at a much earlier point in the postpartum period. Family items and items related to the emotional self were chosen most often as learning more suitable for home by the mothers in this study although the study was conducted 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 occurs not only as a result of time but also as a result of environment. Mothers in this hospital study clearly perceived infant care, infant feeding, and self care topics as more appropriate for discussion in hospital and emotional self and family topics as  61 more appropriate for discussion at home. Therefore mothers' perception of the physical environment may have an impact on their choices (Knowles, 1970; Tarnow, 1979). Although attempts have been made to improve the physical environment of maternity units to provide a more home like setting, the atmosphere remains artificial. The sights, sounds, and procedures evident on postpartum units may serve to reinforce mothers' perceptions that hospitals are very hands on, task oriented places and that learning should be approached in the same way. However, when mothers think of home, their thoughts turn to family and community and what that will mean to them in relation to their new role. The focus for learning would appear dependent to some degree on the meaning that each environment has for the postpartum mother. That mothers perceived the majority of their learning needs in hospital to be related to infant care and feeding would suggest "rooming in" as an appropriate educational strategy. Immediate application of learning related to their infants should make the learning experience more meaningful and relevant to them (Knowles, 1970; Kolb, 1984; Tarnow, 1979). However, when rooming in, mothers know that nursing assistance is immediately available to them. They also know that they do not need to be concerned about such things as meals, laundry, and other household tasks that they would be involved in at home. If motivation is an internal drive based on a  62 perceived need for information (Bille, 1981), mothers may feel a more urgent need to learn at home by exploring their own methods and alternatives available to them in an environment that does not ensure the physical presence of a nurse. The perception of their relationship with caregivers may have had an impact on mothers' choices of which topics were more suitable for hospital. Patients tend to perceive hospital nurses as experts in their areas of practice (Redman, 1984). If mothers see hospitals and hospital personnel as very procedure and task oriented, they may believe that task oriented learning supported by nursing expertise is available to them only during their hospital stay. The fact that mothers feel the majority of infant topics and a large portion of self topics should be addressed during the hospital stay would seem to support this assumption. At the same time, while mothers may have recognized nurses (including nurses in the community) as expert resources in the area of task-oriented care, they may not have perceived nurses as resources 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 they identified, probably because they believed that help was not readily available. The approaches of different nurses to the "rooming in" experience may also be problematic. When mothers do call for assistance with an infant concern, some nurses may act as facilitators and assist mothers to work through their concern.  63 Others may remove the baby, advising mothers that the nursing staff will look after the problem. Removing the baby may not be helpful. These nurses may be unintentionally giving mothers the message that they are not competent to look after their babies. This message will negatively affect mothers' self concept and could hinder the learning process (Knowles, 1970; Tough, 1971). Experience with newborn care. The kinds of learning experiences the mothers  in this study perceived as suitable to hospital may have been appropriate to their level of experience with newborn care. One of the assumptions of this study was that primiparous mothers have little or no stores of past experiences with newborns upon which to build. Therefore, it could be expected that these mothers would be more oriented to infant care and infant feeding. In Sumner and Fritsch's 1977 telephone survey, results indicated that the majority of callers concerns centered around infant feeding and infant care. This was true for both multiparas and primiparas. However only 25% of the multiparas eligible to call did so, while 88% of the primiparas eligible to call did so. Fewer calls from multiparas may indicate that these mothers had a larger store of experience with which to address infant feeding and infant care concerns before they would feel the need to seek help. Moss (1981) and Hiser (1987) reported that family topics were the major concerns  64 for the mothers in their studies. However, their studies were conducted with multiparas exclusively. These mothers' past experience with a newborn may have decreased their perceived need for instruction related to infant care. Maternal/Newborn Nurses' Perception of Learning More Suitably Addressed in Hospital  Nurses' perception of postpartum learning needs more suitably addressed in hospital appeared to mirror those of postpartum mothers. The topics nurses chose most often as appropriate to hospital were from the infant care and self care categories. Nurses, like mothers, chose physical topics which require "hands on" skill as more appropriate 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 in an environment of policies, procedures, and duty-related tasks which are routinely carried out in the course of providing patient care. As a result, nurses may view patient education activities as just one more task to perform 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 identified tasks, education is not a priority for most nurses (Elbeik, 1986; Honan et al., 1988).  65 Nurses may be saying that unless patient education is attached to some physical aspect of care, it may not have as much relevance for them as their other duty-related tasks. It is possible that, in their view, covering physical/skill related care topics with mothers is both appropriate and logical. Mothers, exposed to this approach, might have their own perception of the physical environment of the hospital reinforced which serves to further reinforce nurses' perception of which topics they should be addressing. It is interesting to note that most mothers chose two very visual in-hospital topics related to the infant; cord care and infant appearance. To mothers, the sight of a raw stump 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, fewer chose to address infant appearance. Nurses know that there is nothing abnormal about either the cord or the initial appearance of the newborn. They see these kinds of things all the time. However, the cord is associated with a physical aspect of infant care while infant appearance, a purely informational topic, may not have as much relevance for nurses as it does for mothers. Given this scenario, mothers may have their learning expectations met but may not necessarily have their learning needs met. Nurses may not be individualizing  66 postpartum education by being sensitive to mothers and allowing them to choose topics which are important to them. This may undermine mothers' attempts to prove themselves competent and self directing (Draves, 1984; Knowles, 1970). In this study, mothers did not perceive any of the topics listed as suitable only for hospital or suitable only for home. However, nurses perceived some concerns/interests as appropriate only to hospital or appropriate only to home (see Appendix E). Again, this suggests that nurses may not be providing mothers with individualized patient education. To take an active role in their own learning requires that mothers be permitted to identify their own learning needs (Knowles, 1970; Redman, 1984). Another interesting aspect of this study was some unsolicited direction received related to responsibility for postpartum education. Three nurses commented that some topics in the infant category, vitamin/floride supplements, when to introduce solids, and what kinds of solids to begin feeding, should also be the physician's responsibility. Two nurses felt that information in the area of sexuality should also be a part of the physician's responsibility and one nurse felt information on resuming sexual relations to be solely the physician's responsibility. These results supported the findings of Honan et al. (1988) which suggested that, although nurses believe they have a responsibility for education, they believe other disciplines have a responsibility  67 as well. Differences Between Postpartum Mothers' and Matemal/Newbom Nurses' Perception of Learning Needs  Although nurses continued to view infant concerns/interests as more suitable for discussion at home, there was one significant difference. Their focus shifted from physical 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 nurses perceive mothers, particularly inexperienced primiparas, to be focused on infant learning longer than they actually may be. The shift in focus could indicate that nurses may believe physical care/skill oriented infant topics are more important to cover in hospital to make the best use of their expertise. Other informational infant topics can wait for home. On the other hand, nurses may believe their knowledge related to informational topics in the infant category to be lacking so feel uncomfortable discussing them (Cupoli et al., 1971). This discomfort may also apply to topics in the self and family categories as well. Many of these topics, particularly in the family category, are more appropriate to discussion as opposed to physical demonstration. Most of the nurses in this study completed their basic nursing education when tasks and procedures were still the focus. Areas such as family  68  theory had yet to be introduced into nursing programs. The organizational climate may influence nurses' attitudes as well. If they perceive their leaders to be more interested in physical, task oriented activities, they will be more inclined to focus on physical activities. Hospital nurses may also perceive topics involving information or discussion to be the province of community health nurses. That differences existed between mothers' and nurses' responses to a number of infant and family items on the questionnaire was supported by statistical analysis (see table 5). Although both groups felt the majority of these topics would be more suitably learned at home, more mothers felt that way about family topics and more nurses felt that way about infant topics. So it would seem that some mothers may want to have more infant topics addressed in hospital. They were interested in such topics as growth and development and immunization; informational topics as opposed to physical care/skill kinds of topics. By identifying these topics, mothers may have been signifying that, in hospital, they perceived their infants to be their immediate concern. However, nurses may be trying to provide some education in hospital on topics that mothers are not ready for; most notably family planning and resuming sexual relations. 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 urgent  69  or relevant while in the hospital setting (Knowles, 1970; Redman, 1984). There were two topics about which mothers and nurses disagreed in terms of the more suitable environment for discussion; recognizing the unwell infant and providing a safe environment for the infant. Mothers wanted information on the unwell infant during their hospital stay while nurses were evenly split between hospital and home. Mothers perceived information on infant safety to be more appropriate to home while nurses perceived such information as more appropriate to hospital. Given their possible perception of the hospital environment and the functions of hospital nurses as caring for the ill, mothers may feel that the hospital environment is a more appropriate one in which to gain information related to recognizing an ill infant. Because nurses are capable of recognizing the unwell infant and view this responsibility as part of their job, they may perceive this informational topic as irrelevant 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 a physician 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 learning about providing a safe environment as relevant (Knowles, 1970; Redman, 1984). On  70 the other hand, nurses in this study routinely provide such information while performing a demonstration infant bath for mothers. Nurses probably associate the informational topic of providing a safe environment for the infant with the physical activity of demonstrating infant bathing. Safety measures is also a topic in the baby care category on the standard form used by unit nurses to document teaching activities (see Appendix A). If such associations did not exist, they may not be as likely to provide mothers with information on infant safety. Without identifying with mothers that infant safety is a concern, nurses may be making an incorrect assumption about the 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 and home reflected Gruis' (1977) developmental tasks of the postpartum period. Mothers appeared to want care/information related to the physical aspects of self and infant first, followed by knowledge related to their interactions with their infants, and finally, information related to emotional self and family relationships. However, progression through Gruis' (1977) tasks may not always be clear cut, as hospital stay postpartum becomes increasingly shorter. If choice of learning needs is indeed a product of environment as well as time, early discharge mothers may require information needed to 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 developmental  71 tasks that come up together. Distribution of Postpartum Learning Needs Between Hospital and Home  In 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 and over 30% of the self topics in 48 hours or less. It may be that, at present, both mothers and nurses remain oriented to the traditional hospital stay in terms of educational expectations. Both groups assumed that the bulk of postpartum learning needs should be met in hospital. It is possible that neither group believes adequate resources exist in the community relative to their respective educational expectations for the postpartum period. Perhaps if nurses acted more as facilitators rather than providers of information or instruction, mothers could be assisted to identify their own strengths and learn to rely more on themselves. They may then feel more confident in their ability to problem solve their way through postpartum learning experiences (Draves, 1984; Knowles, 1970; Redman, 1984; Tough, 1971). Summary Mothers' perception of postpartum learning needs suitable to hospital and home were generally similar to those identified in the literature as of concern to new mothers in the early and late postpartum period. If postpartum learning needs are viewed in terms of Gruis' (1977) developmental tasks of the postpartum period, mothers'  72 priorities seemed to focus first on infant care/infant feeding and to a lesser degree the physical care of self followed by family relationships and to a lesser degree the emotional care of self. Both mothers and nurses chose physical care/skill topics related to the infant as more appropriate for hospital. Both groups may have been influenced in their choices by the physical and psychological environment of the hospital. Nurses may have been further influenced by their basic nursing education. Most of the nurses in this study were educated at a time when programs were task and procedure focused; such courses as family theory had yet to be introduced. Even though in hospital, mothers choices of topics for home reflected family and emotional self; choices perhaps influenced by their perception of the home environment. Nurses choices of topics for home remained infant focused, possibly related to the continuing influence of their work environment and their perception of what primiparous mothers needed to know. Nurses tended to avoid informational topics. They may have believed them to be irrelevant in hospital or perhaps, due to a perceived lack of knowledge, may have felt uncomfortable discussing them.  73  CHAPTER V CONCLUSIONS AND IMPLICATIONS Overview This chapter will present the major findings of the study and the implications of those findings for nursing practice, education, administration, and research.  Conclusions 1. Postpartum mothers chose infant care/feeding and some self care topics as appropriate to hospital. 2. Postpartum mothers chose family and some emotional self topics as appropriate to home. 3. Maternal/newborn nurses chose infant care/feeding and some self care topics as appropriate to hospital. 4. Maternal/newborn nurses chose informational topics related to the infant as appropriate 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 over 30% of topics related to self should be addressed in a 48 hour hospital stay postpartum.  74  Implications for Nursing Nursing Practice  Shortened length of stay postpartum has become an established practice. Nurses are going to have to accommodate that reality. Information gathered in this study may assist nurse managers and nurses of Maternal/Newborn units to assess and adapt their teaching materials and methods. Using the topics that most mothers chose as appropriate for hospital as a guide, nurses can provide mothers with some direction regarding which infant topics they may wish to address during their stay. At the same time 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 burning issues that they are more interested in. Learning must be tailored to suit what individual mothers identify as their needs. To ensure that expectations remain within reasonable limits, negotiation and prioritization are paramount. Nurses must begin to act as facilitators of learning rather than simply providers of information and instruction. Assisting mothers to identify and prioritize their learning needs will encourage them to take control of their own learning experiences. Discussion or demonstration can be augmented by written materials so that mothers have something to refer to at home. Videos can also be made available on topics related to all three categories. Perhaps a loan mechanism could be developed  75  giving mothers at home access to them as well. Nurses must be encouraged to examine and discuss their beliefs and attitudes in terms of postpartum education. The study indicated that mothers want to discuss family and emotional-self topics at home. Nurses perceptions are different. Perhaps nurses should be provided with the opportunity to leave the hospital environment and accompany the visiting nurse on some home visits. This experience will give them an opportunity to observe mothers in the home environment and promote some understanding about how and why their learning needs change and progress. Observing the visiting nurse will also give them an opportunity to enlarge on their own knowledge and skills in their interactions with mothers. Increased contact with the visiting nurse and increased knowledge about care in the home will promote better communication and dialogue between hospital and community nurses related to discharge concerns and issues. Hospitals may want to consider developing their own community postpartum followup programs. Hospital nurses following mothers into their homes would provide mothers with continuity and consistency of care. The chance to follow through in the home with hospital initiated postpartum care and teaching would not only provide hospital nurses with an opportunity to enlarge on their knowledge and skills in their interactions with mothers, but would also provide them with increased feelings of accomplishment and job satisfaction.  76 Since mothers in this study identified physical care/skill infant topics in this study as appropriate for hospital, experiential learning should be a must. In this way mothers can begin to develop their own problem-solving and coping skills instead of being discharged continuing to rely heavily on nursing knowledge and expertise. Nursing Education  Educators of nurses whether in academic surroundings or in the workplace need to instill and encourage in nurses a commitment to and an understanding of the important role they play as facilitators of patient learning. Continuing education for maternal/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 of knowledge and understanding related to family dynamics in order to view the family as a whole in their community as opposed to one brief snapshot of mother and baby in hospital. To increase the sensitivity of practice nurses to the needs of adult learners requires that they be educated to Knowles' (1970) assumptions regarding the characteristics of adult learners. Such education must involve not only theoretical knowledge but concrete examples of how adherence to these principles benefits both nurses and patients in terms of time spent on educational activities and satisfaction with teaching/learning experiences. Nurses, like any adult learners, must be able to  77  see the relevance of what they are learning as applied to their own practice. Hospital nurse educators can also use the results of this study to assess nurses' learning needs particularly in relation to the infant informational topics which many mothers perceived should be addressed in hospital. Perhaps broadening nurses' knowledge in this area will allow them to feel more comfortable in discussing these topics with mothers. Schools of nursing can use the results to demonstrate to students mothers' perception of their postpartum learning needs in relation to hospital and home. This will enable them to develop more time specific interventions in terms of postpartum mothers' infant, self, and family learning needs. Perhaps schools of nursing also need to review the manner in which the concept of community is presented to students. Patient education will not be improved and enhanced by hospital and community nurses who view themselves as unique, with separate responsibilities and who, as a result, may not communicate very effectively. Hospital and home are both a part of every patient's community. Community needs to be seen as a whole with complementary components not separate components. Nursing Administration Nurse managers in the hospital environment need to be aware of the philosophy of their institution related to patient education. Where a relatively low priority has been  78 assigned to patient education, the nurse manager who is committed to patient education must lobby for change. Nurse managers can provide the leadership necessary, by word and action, to help nurses see that education is a part of every interaction 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 of their expectations related to these topics. Perhaps the introduction of a nursing or interdisciplinary patient care model would assist nurses to view patient education as a part of comprehensive patient care and not as just another task or someone else's responsibility. Nurse managers also need to be aware of factors related to both the organizational structure and the patient population which block nurses in their attempts to provide individualized educational experiences and investigate ways of dealing with those factors. Given the tendency to decreasing length of hospital stay postpartum, nurse managers of both hospital and community perinatal programs must work collaboratively to ensure that resources and supports necessary to continue the learning process for postpartum mothers will be available in the community. Perhaps hospital and/or community nurse representatives, through prenatal classes, could begin to prepare expectant parents for the short hospital stay experience.  79 Parents need to be advised that it will not be possible to learn everything they need to know in hospital but that the learning process will continue once they are home. They could also be encouraged to begin thinking about the kinds of resources they may need after discharge and ensure that these resources are available to them. Study results may also be useful to prenatal educators. In collaboration with hospital and community nurse representatives, postpartum topics included in prenatal classes could be reviewed and adapted to reflect more of the informational infant topics mothers are interested in having addressed in hospital. Information on physical care/skill kinds of infant topics, such as cord care, will mean more to mothers when they are actually learning the skill. Since these are the kinds of topics most mothers appear to want addressed in hospital anyway, it may be more efficient to address such topics as infant growth and development in the prenatal period. What mothers have already learned can then be reinforced or enhanced either in hospital or at home. At the same time, learning about their infants may only have meaning for mothers when the infants become a visual and tactile presence. Given this perspective, it is possible that mothers' motivation to learn about infant care and behavior would not be very strong.  80 Nursing Research  Several questions arise as a result of the study which require investigation. 1. Is the perception of postpartum learning needs relative to home or hospital environment different for nurses who had family theory as a part of their basic nursing education? 2. How do nurses perceive postpartum educational activities in relation to their other job related duties? 3. Why do nurses appear to emphasize physical care/skill kinds of topics related to the postpartum period as opposed to informational topics during mothers' hospital stay? 4. Which topics do nurses perceive as their responsibility in the area of postpartum education? 5. Do beliefs about the hospital environment and the nurses in that environment have an impact on postpartum mothers' perception of postpartum learning needs? 6. Do nurses use principles of adult learning when conducting educational activities? 7. Why do both mothers and nurses perceive the need to have such a large proportion of postpartum learning needs addressed during a 48 hour hospital stay postpartum?  81 8. How would both mothers and nurses have answered if they had been asked to prioritize the ten topics each group identified as more suitably addressed in hospital and the ten topics each group identified as more suitably addressed at home? Summary The results of the study suggested that postpartum mothers wanted learning needs related to their infants addressed first, followed by those related to self, and those related to family last. Mothers perceived most of the infant topics as more appropriate to hospital and most of the family topics as more appropriate to home. The findings indicated that, while mothers' and nurses' perceptions of topics suitable for hospital were similar, their perceptions of topics suitable for home differed. Most of the mothers perceived infant topics as more appropriate to hospital and family topics as more appropriate to home. Most of the nurses perceived only physical care/skill kinds of infant topics as appropriate to hospital and informational topics related to the infant as more appropriate to home. The study also indicated that both groups expected a large portion of postpartum learning to occur within a 48 hour hospital stay postpartum. These findings have implications for each domain of nursing; practice, education, administration, and research. Given that length of hospital stay postpartum is becoming increasingly shorter, it is the  82 responsibility of education, administration, and research to provide direction for practice nurses in adapting to meet the learning needs of early discharge mothers.  83 REFERENCES Arndt, M.J. & Underwood, B. (1990). Learning style theory and patient education. Journal of Continuing Education in Nursing. 21(1), 28-31. Avery, M.D., Fournier, L.C., Jones, P.L., & Sipovic, C.P. (1982). An early postpartum hospital discharge program. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 11(4), 233-235. Bille, D.A. (1981). Practical approaches to patient teaching. Boston: Little, Brown, and Company. Bradley, C.F., Carty, E.M., & Hall, W.A. (1989). An evaluation of early postpartum discharge from a tertiary care maternity hospital. Unpublished manuscript, University of British Columbia School of Nursing and the Salvation Army Grace Hospital, Vancouver. Bull, M.J. (1981). Change in concerns of first time mothers after one week at home. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 10, 391-394. Cottrell, D.G., Pittala, L.J., & Hey, D.J. (1983). One-day maternity care: a pediatric viewpoint. Journal of the American Osteopathic Association. 83(3), 216-221. Cupoli, A., Gorvine, B., Horwitz, M., Kudzma, E., Midura, Sister M.J., Mott, S., Ramos, K.S., & Watson, J. (1971). Postpartum teaching regarding infant care, behaviour, and characteristics: a study. Bulletin Nurse - Midwives. 16(4), 112-121. Davis, J.H., Brucker, M.C., & Macmullen, N.J. (1988). A study of mothers' postpartum teaching priorities. Maternal Child Nursing Journal. 17(1), 41-50. Diers, D. (1979). Research in nursing practice. Philadelphia: J.B. Lippincott. Draves, B. (1984). How to teach adults. Manhatten: Learning Resources Network. Elbeik, M.A. (1986). Perceptions of hospital care. Health Management Forum. 7(1), 71-77. Glover, J.F., Houston, M.J., Hardy, L.K., & Clyne, N.A. (1985). A survey of postnatal education programs in British Columbia, Alberta, and Saskatchewan hospitals. Canadian Nurse. 81(11), 54. Gruis, M. (1977). Beyond maternity: postpartum concerns of mothers. Maternal Child Nursing. 2, 182-188. Hall, L.J. (1980). Effect of teaching on primiparas' perceptions of their newborn. Nursing Research. 29(5), 317-322. Havighurst, R.J. (1952). Developmental tasks and education. New York: McKay.  84  Hiser, P.L. (1987). Concerns of multiparas during the second postpartum week. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 16(3), 195-203. Honan, S., Krsnak, G., Petersen, D., & Torkelson, R. (1988). The nurse as patient educator: perceived responsibilities and factors enhancing role development. Journal of Continuing Education in Nursing. 19(1), 23-37. Jansson, P. (1985). Early postpartum discharge. The American Journal of Nursing. 85(5), 547-550. Knowles, M.S. (1970). The modern practice of adult education. New York: Association Press. Knowles, M.S. (1972). Innovations in teaching styles and approaches based on adult learning. Education for Social Work. 8, 32-39. Kolb, D.A. (1984). Experiential learning. New Jersey: Prentice-Hall. Lemmer, C.M. (1987). Early discharge: outcomes of primiparas and their infants. Journal of Obstetric. Gynecologic, and Neonatal Nursing. 16(4), 130-136. Lesser, M. & Keene, V. (1956). The nurse-patient relationship in a hospital maternity setting. St. Louis: Mosby. Martell, L.K., Imle, M., Horwitz, S., & Wheeler, L. (1989). Information priorities of new mothers in a short stay program. Western Journal of Nursing Research. 11(3), 320-327. McCarty, E. (1980). Early postpartum care of mother and infant in the home care setting. Nursing Clinics of North America. 15(2), 361-372. Mooney, M.A. (1987). Use of adult education principles in medication instruction. Journal of Continuing Education in Nursing. 18(3), 89-92. Moss, J. (1981). Concerns of multiparas on the third postpartum day. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 10(6), 421-424. Murdaugh, C.L. (1980). Effects of nurses' knowledge of teaching/learning principles on knowledge of coronary care unit patients. Heart & Lung. 9(6), 1073-1078. Redman, B.K. (1984). The process of patient education. 5th ed. St. Louis: C.V. Mosby.  85 Rollins, A.J., Kaplan, J.A., Ratkay, M.E., Goodlin, R.C., Shaw, J.S., & Wernberg, R.P. (1979). A homestyle delivery program in a university hospital. Journal of Family Practice. 9(3), 407-414. Rush, J., Chalmers, I., & Enkin, M. (1989). Care of the new mother and baby. In Chalmers, I., Enkin, M., & Keirse, M.J. (Eds). Effective care in pregnancy and childbirth. Volume 2. pp. 1333-1346. Oxford: Oxford University Press. Sullivan, D.A. & Beeman, R. (1982). Satisfaction with maternity care: a matter of communication and choice. Medical Care. 20(3), 321-330. Sumner, G. & Fritsch, J. (1977). Postnatal parental concerns: the first six weeks of life. Journal of Obstetric. Gynecologic, and Neonatal Nursing. 6, 27-32. Tarnow, K.G. (1979). Working with adult learners. Nurse Educator. 4(5), 34-40. Thurston, N. E. & Dundas, J.B. (1985). Evaluation of an early discharge program. Can J Pub Health. 76, 384-387. Tough, A. (1971). The adult's learning projects. Toronto: Ontario Institute for Studies in Education. Tribotti, S.J., & Lyons, N.B. (1987, January). Nurses' and patients' perception of nursing diagnosis during the immediate postpartum period. Paper presented at the 3rd annual Perinatal Research Conference, Seattle. Waldenstrom, U. (1989). Early discharge as voluntary and involuntary alternatives to a longer postpartum stay in hospital--effects on mothers' experiences and breastfeeding. Journal of Midwifery. 5(4), 189-196. Waskerwitz, S., Fournier, L., Jones, P., & Meier, W. (1985). A comparitive analysis of newborn 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 and infants: early discharge with home care. The New England Journal of Medicine. 294(13), 702-705.  ===  APPENDIX A  ••■••■■••■= ■■••^■••^•■• i■^im•■^ NM, OM^■••• AM' WIN AM! •1■1.^INE^IN=MI • IW MMI^■•■  86  The Greater Victoria Hospital Society Mother/Babe Unit Parent Teaching Sheet  GREATER VICTORIA HOSPITAL SOCIETY  MATERNITY PARENT TEACHING SHEET SUBJECT A. BREAST FEEDING  D/M/Y  REMARKS  •  - --  •  •••• ••••• ••■■•••••  11111 WM.  1. Nipple care 2. Demand feeding 3. Positioning & burping 4. Timing 5 .Expressing milk 6. Engorgement 7. Storage of EBM B. FORMULA FEEDS 1. Amount first few days 2. Demand feeding 3. Formula prep. 4. Positioning 6 .Burping C. BABY CARE^• 1. Bath procedure 2. Cord care 3. Care of genitalia 4. Axilla temp 5. Clothing 6. Safety Measures  •  D. HYGIENE 1. Pen care 2. Sitz bath 3. Normal changes in flow E. PATIENT INFO. 1. Nutritional educ.  •  2. Family planning 3. Physiotherapy 4. Community resources 5. Guide to parenting booklet 01 - 01 - 0969 - 0  -..')  L1.11LJALI-A.  87  The Greater Victoria Hospital Society Maternity Department Criteria for Early Postpartum Discharge QUALITY UTILIZATION MANAGEMENT  GVHS/CRD POST-PARTUM HOME FOLLOW-UP PROGRAM  PT. TELEPHONE NI:  ADMISSION DATE: ^ DISCHARGE DATE: ^  DISCHARGED WITH HOME FOLLOW-UP PROGRAM:  DISCHARGE TIME:  YES ^^NO ^  ANTENATAL HISTORY RECORD: Program Inclusion Note Documented:  ^  Program Exclusion Note Documented:  YES^^^NO ^  ^  YES^^  ^  NO ^  DELIVERY: DELIVERY DATE: ^  Vaginal  ^  Caesarian Section  DELIVERY TIME:  (24 hr. clock)  PHYSICIAN(S):  DISCHARGE CRITERIA:^Please CIRCLE the number/s) of the criteria that were NOT MET: MOTHER  ::  .:BABY  :  1.  37 + Weeks pregnancy  1.  Birthweight more than 2500 grams  2.  Uncomplicated delivery  2.  3.  Healing incision or episiotomy  Normal temperature control, respiratory rate, heart rate and colour  4.  Stable hemodynamic system  3.  Feeding well, voiding normally  5.  Rhogam given, if indicated  4.  6.  Single birth  Circumcision 6 hours or more prior to discharge  7.  No 4th degree tear (or tubal ligation)  5.  No congenital defects requiring medical management  8.  No Identified Social Problems  6.  9.  No voiding problems  Absence of increased Hyperbilirubinemia  10. Can communicate in English  BARRIERS TO DISCHARGE WITH PROGRAM: ^  Late Discharge  ^  Other:  ^  Reside outside Program catchment area  ^  Other:  Please return to MEDICAL STAFF AFFAIRS on completion.  MSA# 1 diMDP-HFUP.Frm  88 Appendix C Postpartum Learning Needs Questionnaire and Background Information Sheets Postpartum Learning Needs Questionnaire The questionnaire reflects concerns and interests that have been identified by postpartum mothers as important learning needs. They are divided into three areas; self, infant, and family. Please indicate, by checking the appropriate box, where you believe each concern or interest would be more suitably addressed; during a 48 hour hospital stay or at home with visiting nurses.  Example: Concern/Interest^During Hospital Stay^With Visiting Nurse Strategies for dealing with fatigue^0^  0  Concern/Interest^During Hospital Stay^With Visiting Nurse SELF 1.  2.  Information on nutrition/diet: - for regaining figure^0^  0  - while breastfeeding infant^0^  0  Information about an exercise regime 0^  0  89  Concern/Interest^During Hospital Stay ^With Visiting Nurse  3. Understanding the labour and delivery experience^0^ 4. Strategies for dealing with fatigue^0  ^  5. What to expect regarding blood flow 0^  0  0 0  6. What to expect with changes to breasts^  0^  0  - episiotomy/stitches^0^  0  - hemorrhoids^  0^  0  - constipation^  0^  0  - irritability^  0^  0  - tension^  0^  0  - the baby "blues"^0^  0  7. How to deal with postpartum discomforts:  8. How to deal with emotional swings:  9. How to deal with feelings associated with becoming a new mother: - feeling isolated^ 0^  0  90  Concern/Interest^During Hospital Stay^With Visiting Nurse  - feeling tied down^0^  0  - questioning ability to be a "good mother"^0^  0  - needing time for self^0^  0  - finding other mothers with whom to share experiences^0^  0  10. How to prepare for returning to work: - child care arrangements ^0^  0  - home management^0^  0  - feelings (e.g. guilt, ambivalence) ^0^  0  11. When to call the doctor or public health nurse about health problems (mother's health problems not infant's)^  0^  0  0^  0  12. Other topics or areas of concern: (please specify)^  91 Concern/Interest^During Hospital Stay^With Visiting Nurse  INFANT 1. Information about infant's appearance (e.g. shape of head, skin color)^ 2.  0^  0  0^  0  - sleep/wake states^0^  0  - facial expressions^0^  0  Information about infant's behaviour: - crying^  - use of senses (e.g. sight, hearing)^  0^  0  - attaching and removing infant ^0^  0  - positioning infant^0^  0  - breast and nipple care^0^  0  - managing breast engorgement^0^  0  3. Instruction regarding breast feeding: (to be completed by breast feeding mothers and nursing staff)  92 Concem/Interest^During Hospital Stay^With Visiting Nurse  - medications and breast feeding^0^  0  - storing and freezing breast milk ^0^  0  - instruction regarding bottle feeding for mothers who plan to give the odd bottle feed (water, expressed breast milk, or formula) ^0^  0  - weaning infant^ 0^  0  4. Instruction regarding bottle feeding: (to be completed by bottle feeding mothers 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^  0  ^  93 Concem/Interest^During Hospital Stay^With Visiting Nurse  5.  Information on infant nutrition: - knowing when infant is satisfied with feeds^  6.  0^  0  normal voiding and stool pattern 0^  0  vitamin and fluoride supplements 0 ^  0  - when to introduce solids^0^  0  - kinds of solids to begin feeding^0^  0  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  weather and comfort^0^  0  - dressing the infant for the  - providing a safe environment for the infant^  0^  0  94  Concem/Interest^During Hospital Stay ^With Visiting Nurse  7.  Information on infant health/ illness: - how to take an infant's temperature^  ()^  0  0^  0  health problems^0^  0  - immunizing an infant^0^  0  - recognizing when an infant is unwell^ - when to call the doctor or public health nurse about an infant's  8.  Information on how infants grow and develop^  0^  0  0^  0  9. Other topics or areas of concern: (please specify)^  95  Concern/Interest^During Hospital Stay^With Visiting Nurse  FAMILY 1. Information about changing relationships between partners: - helping a partner who may ()^  0  sharing household responsibilities 0^  0  sharing child care responsibilities 0 ^  0  - finding time to be together^0^  0  feel "left out"^  2.  Regulating the demands of partner, housework, and job^0^  0  3. Adapting to changes in lifestyle^0^  0  4.  Dealing with "advice" from friends and family^  0^  0  - when to resume sexual relations^0^  0  - methods of contraception^0^  0  - family planning^ ()^  0  5. Information in the area of sexuality:  96 Concern/Interest  ^  During Hospital Stay^With Visiting Nurse  6. Other topics or areas of concern: (please specify)  ^  0^ 0  97 Background Information Early Discharge Eligible Postpartum Mothers  1. Age: 19 or below^0^20 - 24^0 25 - 29^0^30 - 34^0 35 - 39^0^40 or over 0 2.  Education: Some high school^ 0 Completed high school^0 Some college/university^0 Completed college/university^0 Completed post graduate studies ^0  3.  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^0  4.  I am planning to: (check one) breast feed^0 bottle feed^0  98 5. I expect that the help available to me after discharge will meet my needs for assistance at home. Yes^0 No^0  99 Background Information MatemaVNewbom Nurses  1. Age: 24 or below^0^ 25 - 29^0 30 - 34^0^ 35 - 39^0 40 - 44^0^ 45 - 49^0 50 or over^0 2. Years in nursing: 2 or below^0^ 3- 4^0 5 - 9^0^ 10 - 14^0 15 - 19^0^ 20 - 24^0 25 - 29^0^ 30 or more^0 3. Educational preparation: (check one only) RN diploma^  0  Post basic baccalaureate in nursing^0 Generic baccalaureate in nursing^  0  Baccalaureate in other than nursing ^0 Master's in nursing^  0  Master's in other than nursing^  0  100 4. Other post basic preparation related to maternal/child nursing e.g. midwifery: (please specify)  101  Appendix D Cover letters Dear Staff Member, Maternal/newborn nurses are increasingly concerned that shortened length of stay provides little time for teaching. The Maternity department has introduced a pilot early discharge program in which a small group of physicians and their patients are participating. Low risk, vaginally delivered mothers and infants are discharged at 48 hours with nursing follow up in the home the next day. My question is, given early discharge with follow up in the home, are there some postpartum learning needs that are more suitably addressed in hospital and others that would be more suitably addressed in the home environment? For my Master's thesis, I would like to compare the views of staff and a selected group of vaginally delivered primiparas eligible for the early discharge program on the subject. Over the next two months, I will be asking all the nurses on the Mother/Babe Unit to assist me by participating in this study. Your participation would involve a questionnaire which will take approximately 15 minutes to complete. Postpartum mothers who agree to participate will be completing the same questionnaire. All information is confidential and will be used for the purposes of this study only. If you choose to participate, place a completed questionnaire in the envelope provided and  102 drop it into the labelled container in the C.C. Conference Room on either the A or B side. Questionnaires are to be returned unsigned and there will be no identifying marks on either questionnaire or envelope. You may withdraw your participation any time 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 a completed questionnaire. Your assistance is important to me. The delivery of maternal/newborn care has changed dramatically in recent years. As the professionals charged with meeting the education needs of new mothers, your assistance will be invaluable in helping to develop postpartum education programs that will continue to meet mothers' needs through change and over time. Once the study has been completed, I will share the results at a staff meeting and attach a summary of the results to the minutes. Please feel free to contact me if you have any questions. Thank you for your consideration. Yours truly,  Sue Dean^  Elaine Carty, Associate Professor  MSN Student, U.B.C. School of Nursing ^UBC School of Nursing 727-4212, L 5211^  Thesis Supervisor, 228-7444  103 Dear New Mother, Today's trend toward shortened length of hospital stay postpartum has an impact on the teaching that maternal/newborn nurses can provide. The Maternity department has recently commenced a trial early discharge program involving a small group of physicians and their patients. The program involves discharging vaginally delivered, healthy mothers and babies at 48 hours postpartum and providing nursing follow up in the home the next day. You may or may not be participating in this program at present. However, the advent of shortened length of stay postpartum signifies a need to adapt current methods of providing postpartum education. To accomplish this requires the assistance of those most involved with postpartum education; new mothers and their nurses. For my Master's thesis, I would like to compare the views of maternal/newborn nurses and first time mothers on which postpartum learning needs would be more suitably addressed in hospital and which postpartum learning needs would be more suitably addressed at home with the visiting nurse of the early discharge program. Over the next two months, I will be asking all vaginally delivered first time mothers like yourself if they wish to participate in the study. Your participation would involve a questionnaire which will take approximately 15 minutes to complete. Maternal/newborn nurses who agree to participate will be completing the same questionnaire. All information is confidential and will be used for the purposes of this study only. If you choose to participate, place a completed questionnaire in the envelope provided. Questionnaires are to be returned unsigned and there will be no identifying marks on either questionnaire or envelope. You may withdraw your participation any time you wish. If you do not wish to give information in a particular  104 category or area, feel free to leave it blank. Refusal to participate will in no way compromise your care while a patient on the Mother/Babe Unit. Consent to participate will be assumed by the return of a completed questionnaire. Please return your completed questionnaire to the main nursing station (Communication Centre) or give it to your nurse. If you have any questions, please contact me. More flexible methods of providing postpartum education must be developed in order to meet the needs of today's new mothers. Your input will be valuable in helping nursing plan toward meeting those needs. Thank you for your assistance. Yours truly,  Sue Dean^  Elaine Carty, Associate Professor  MSN Student, UBC School of Nursing^UBC School of Nursing 727-4212, L 5211^  Thesis Supervisor 228-7444  105 Appendix E Early Discharge Eligible Postpartum Mothers' and Matemal/Newbom Nurses' Responses to Questionnaire Mothers' Responses to Questionnaire n = 89  Concem/Interest  ^  Hospital^Home  A.^Self 1. Nutrition/diet  a.  regain figure  b. while breastfeeding  2. Exercise regime  3. Labour and delivery experience  4. Fatigue  5. Blood flow  6. Changes in breasts  8*  92  (7) **  (82)  70  30  (63)  (27)  8  92  ( 7)  (82)  76  24  (68)  (21)  35  65  (32)  (60)  97  3  (86)  (3)  83  17  (75)  (15)  106 Concern/Interest  Hospital  Home  97  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)  7. Postpartum discomforts a. episiotomy/stitches  b. hemorrhoids  c. constipation  8. Emotional swings a.  irritability  b. tension  c. baby "blues"  9. Feelings as a new mother a.  isolation  b. tied down  c. ability to be a "good mother"  d. time for self  107 Concern/Interest e.  10.  share experiences with other mothers  b. home management  c. feelings of guilt/ambivalence  13.  10  90  (9)  (81)  1  99  (1)  (86)  3  97  ( 3)  (84)  2  98  (2)  (85)  75  25  (68)  (23)  30  70  (27)  (63)  When to call doctor/P.H. nurse (mother's health)  12.  Home  Returning to work a. child care  11.  Hospital  Community support systems  Other topics/concerns: location of nearest emergency services (1) concerns/questions re physical  (1)  conditions  B. Infant 1. Infant appearance  96  4  (87)  (4)  108 Concern/Interest  Hospital  Home  87  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)  2. Infant behaviour a. crying  b. sleep/wake states  c. facial expressions  d. use of senses  3. Breast feeding a. attaching/removing infant  b. positioning infant  c. frequency of feeds  d. breast/nipple care  e.  f.  breast engorgement  medication and breast feeding  109 Hospital  Home  41  59  ( 38 )  (54)  53  47  (48)  (42)  16  84  (14)  (74)  a. feeding technique  (3)  (0)  b. amount to feed  (3)  (0)  c. frequency of feeds  (3)  (0)  d. kind of formula  (3)  (0)  Concern/Interest  g. storing/freezing breast milk  . bottle feeding instruction  i. weaning infant  4. Bottle feeding  e.  kind of bottles/nipples  (3)  (0)  f.  formula preparation  (3)  (0)  g. care of bottles/nipples  (3)  (0)  87  13  (78)  (12)  91  9  (82)  (8)  19  81  (17)  (72)  5. Infant nutrition a.  satisfaction with feeds  b. voiding/stool pattern  c. vitamin/fluoride supplements  110 Concern/Interest  d. introducing solids  e.  kinds of solids to introduce  Hospital  Home  2  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)  6. Infant care a.  handling/holding  b. bathing  c.  dressing  d. cord care  e. skin care  f.  dressing for weather/comfort  g. providing safe environment  7. Infant illness a. taking infant's temperature  111 Concern/Interest  b. recognizing an unwell infant  Hospital  Home  70  30  (62)  (27)  66  34  (59)  (30)  18  82  (16)  (73)  34  66  (31)  (59)  10  90  ( 9)  (79)  3  97  ( 3)  (85)  8  92  (7 )  (81)  3  97  ( 3)  (85)  c. when to call doctor/P.H. nurse (infant health)  d. immunization  8. Growth and development  9. Other topics/concerns:  C. Family 1. Changing relationships a. the partner who is feeling "left out"  b. sharing household responsibilities  c. sharing child care responsibilities  d. finding time to be together  112 Concem/Interest 2. Regulating demands  3. Changes in lifestyle  4. Dealing with "advice"  Hospital  Home  1  99  (1)  (88)  2  98  (2)  (88)  10  90  (9)  (80)  7  93  (6)  (82)  8  92  ( 7)  (80)  3  97  ( 3)  (83)  5. Sexuality a.^resuming sexual relations  b.^contraception  c.^family planning  6. Other topics/concerns:  Note.^* = percent; ** = actual  113 Matemal/Newbom Nurses' Responses to Questionnaire  Concern/Interest  ^  Hospital^Home  A. Self 1. Nutrition/diet a.  regain figure  b. while breastfeeding  2. Exercise regime  3. Labour and delivery experience  4. Fatigue  5. Blood flow  6. Changes in breasts  14 *  86  (7) **  (44)  76  24  (39)  (12)  20  80  (10)  (39)  74  26  (37)  (13)  30  70  (16)  (38)  96  4  (50)  (2)  92  8  (48)  (4)  114 Concern/Interest  Hospital  Home  98  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)  7. Postpartum discomforts a.  episiotomy/stitches  b. hemorrhoids  c. constipation  8. Emotional swings a.  irritability  b. tension  c. baby "blues"  9. Feelings as a new mother a.  isolation  b. tied down  c. ability to be a "good mother"  d. time for self  115 Concern/Interest e.^share experiences with other mothers  10. Returning to work b. home management  c. feelings of guilt/ambivalence  Hospital  Home  8  92  (4)  (47)  (0)  (50)  0  100  (0)  (50)  6  94  ( 3)  (45)  82  18  (41)  (9)  31  69  (16)  (36)  11. When to call doctor/P.H. nurse (mother's health)  12. Community support systems  13. Other topics/concerns: phone numbers of LaLeche League, lactation consultants, breast pump distributors  B.  (1)  Infant 1. Infant appearance  94  6  (48)  ( 3)  89  11  (49)  (6)  2. Infant behaviour a.^crying  116 Concern/Interest b. sleep/wake states  c.  facial expressions  d. use of senses  Hospital  Home  87  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)  3. Breast feeding a.  b.  attaching/removing infant  positioning infant  c. frequency of feeds  d.  e.  f.  breast/nipple care  breast engorgement  medication and breast feeding  g. storing/freezing breast milk  117 Hospital  Home  53  47  (27)  (24)  2  98  (1)  (49)  a. feeding technique  (50)  (0)  b. amount to feed  (49)  (0)  c. frequency of feeds  (49)  (0)  d. kind of formula  (47)  (2)  e.  kind of bottles/nipples  (44)  (4)  f.  formula preparation  (43)  (5)  (40)  (7)  87  13  (47)  (7)  94  6  (48)  (3)  4  96  (2)  (48)  0  100  (0)  (50)  Concern/Interest  h. bottle feeding instruction  i.  weaning infant  4. Bottle feeding  g. care of bottles/nipples  5. Infant nutrition a. satisfaction with feeds  b. voiding/stool pattern  c. vitamin/fluoride supplements  d. introducing solids  118 Concern/Interest  e. kinds of solids to introduce  Hospital  Home  0  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)  6. Infant care a.  handling/holding  b. bathing  c.  dressing  d. cord care  e. skin care  f.  dressing for weather/comfort  g. providing safe environment  7. Infant illness a. taking infant's temperature  b. recognizing an unwell infant  119  Concern/Interest  Hospital  Home  55  45  (29)  (24)  0  100  (0)  (48)  8  92  (4)  (48)  c. when to call doctor/P.H. nurse (infant health)  d. immunization  8. Growth and development  9. Other topics/concerns: -^growth spurts: ages dealing with feeding behaviour  (1)  C. Family 1. Changing relationships a.^the partner who is feeling "left out"  b.^sharing household responsibilities  c.^sharing child care responsibilities  14  86  ( 7)  (44)  8  92  (4)  (48)  10  90  (5)  (45)  120 Concern/Interest d.^finding time to be together  2. Regulating demands  3. Changes in lifestyle  4. Dealing with "advice"  Hospital  Home  2  98  (1)  (49)  0  100  (0)  (50)  0  100  (0)  (49)  19  81  (10)  (42)  29  71  (15)  (36)  25  75  (13)  (39)  17  83  (9)  (44)  5. Sexuality a.  resuming sexual relations  b. contraception  c.^family planning  6. Other topics/concerns:  Note. * = percent; ** = actual  

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0086404/manifest

Comment

Related Items