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Early postpartum discharge : factors affecting a woman’s decision not to participate Mahy, Jill 1994

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EARLY POSTPARTUM DISCHARGE:FACTORS AFFECTING A WOMAN’S DECISION NOT TO PARTICIPATEbyJILL MAHYBSN, The University of British Columbia, 1987A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FORTHE DEGREEE OF MASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIES(School of Nursing)We accept this thesis as conforming to the required standardTHE UMVERSITY OF BRITISH COLUMBIAAugust, 1994© Nancy Jill Mahy, 1994Signature(s) removed to protect privacySignature(s) removed to protect privacyIn presenting this thesis in partial fulfillment of therequirements for an advanced degree at the University of BritishColumbia, I agree that the Library shall make it freely availablefor reference and study. I further agree that permission forextensive copying of this thesis for scholarly purposes may begranted by the head of my department or by his or herrepresentatives. It is understood that copying or publication ofthis thesis for financial gain shall not be allowed without mywritten permission.(Signature)_____________________________Department of______________________The University of British ColumbiaVancouver, CanadaDate / / 97(ISignature(s) removed to protect privacy11ABSTRACTThis study was designed to investigate factors influencing a woman’s decision notto participate in an early postpartum discharge program. A factor-searching exploratorysurvey study was chosen for this study. The conceptual framework directing the studywas Pender’s (1987) Health Promotion Model. The sample was composed of 55postpartum women who gave birth at a tertiary care maternity hospital during a twomonth period. The study participants and their newborns had met the hospital’s earlydischarge program criteria but the women had made the decision not to participate. Allthe women in the study were interviewed by the investigator on their second or thirdpostpartum day prior to hospital discharge.The reasons expressed by the women for not participating in the hospital’s earlydischarge program were grouped into two major categories: need for physical andemotional restoration, and need for care. External and internal influences on theirdecision were also identified.The need for physical and emotional restoration included the following: need forsleep, rest and relaxation, need for comfort, and need for time alone. The need for careincluded: need for help, need for support, and need for protection. External and internalinfluences and barriers affecting a woman’s decision to stay in the hospital included:children at home, no help at home, lack of awareness of the program and influences ofphysician and family.111Recommendations from this study include the need for further research to examinethe perceptions and benefits of early discharge in regards to consumers, varying culturalgroups, and health-care professionals. Education with respect to the concept of earlydischarge is also needed. Postpartum preparation and planning for women and theirfamilies in the prenatal period through strong collaboration and networking betweenhospitals and community health units, and the establishment of family, community supportsystems, and resources is crucial. Development of a regional wide perinatal home careprogram, standardized perinatal healthcare and follow-up for childbearing women and theirfamilies is also strongly recommended.ivTABLE OF CONTENTSAbstractTable of ContentsList of TablesList of FiguresAcknowledgements11ivviviiviiiCHAPTER ONE: INTRODUCTIONBackground to the ProblemProblem StatementPurposeConceptual FrameworkSignificance of the StudyDefinition of TermsAssumptions of the StudyLimitations of the StudySummaryCHAPTER TWO: REVIEW OF SELECTED LITERATUREIntroductionEarly Postpartum DischargeMaternal TasksCHAPTER THREE: METHODIntroductionResearch DesignSampleData Collection ProceduresData AnalysisEthical and Human RightsSummaryCHAPTER FOUR: PRESENTATION OF FINDINGS AND DISCUSSIONIntroductionCharacteristics of the Sample123466889101019272727282930303131VCategory Concepts.34Need for Physical and Emotional Restoration 35Need for rest and sleep 35Need for comfort 39Need for time alone 42Need for Care 44Need for Help 44Need for Support 49Need for Protection 50External and Internal Influences and Barriers 52Ancillary Findings 56Summary 58CHAPTER FiVE: SUMMARY, CONCLUSIONS, IMPLICATIONS ANDRECOMMENDATIONSIntroduction 59Summary 59Conclusions 61Implications for Nursing Practice 61Implications for Nursing Education 65Recommendations for Nursing Research 66REFERENCES 68APPENDICESAppendix A: Program Criteria 73Appendix B: Information Letter 75Appendix C: Informed Consent Form 77Appendix D: Physician’s Letter 79Appendix E: Demographic Information Sheet 81LIST OF TABLESTable 1: Age Distribution of the Sample 32Table 2: Educational Level of the Sample 32Table 3: Employment Status of the Sample 32Table 4: Ethnic Origin of the Sample 33Table 5: Need for Physical and Emotional Restoration 35Table 6: Need for Care 44Table 7: External and Internal Influences and Barriers 52viLIST OF FIGURESFigure1. Health Promotion Model (Pender, 1987) 52. Interview Questions (Pender, 1987) 7viivii’AcknowledgmentsI would like to thank the chairperson of my thesis, Professor Elaine Carty andcommittee members Chris Bradley and Wendy Hall who generously shared with me theirtime, knowledge and expertise of the research topic and research process. Appreciation isalso extended to the nurses working in the British Columbia’s Women’s Hospital/TheVancouver Community Health Maternity Care at Home Program, for their diligentrecruitment of the women for this study.I would also like to thank the women in the study who gave their time and whoopenly expressed their individual thoughts and experiences thus contributing to nursingresearch.My thanks also extends to my husband, Robert, my dear friend Sue, and lovingfamily and friends for their support and encouragement.This thesis is dedicated to my mother, Joyce Mahy and my beautiful son Patrick,an early discharge baby.1CHAPTER ONEIntroductionBackground Information to the ProblemThe changing needs of the childbearing family and the economics of our healthcare system have resulted in new practices in perinatal care. On the one hand, a desire byfamilies for increased participation around birth and on the other, the necessity forhospitals to cut costs have led to the development of early postpartum discharge programs.Early postpartum discharge has been defined as the discharge from hospital of lowrisk postpartum mothers and their infants within 6 to 48 hours following birth and withfollow-up home care (Bradley, Carty & Hall, 1989; Hellman, Kohl, & Palmer, 1962). Anearly postpartum discharge program (EPDP) is designed to function as an organizedsystem of support, education and follow up for mothers and infants as they leave hospitalafter birth.In Canada there has been limited research conducted in the area of postpartumearly discharge. Studies that have been done, primarily in the U.S., have shown that thebenefits of early discharge are numerous for both the family and the health-care system.Early discharge appears healthy and safe for normal low-risk mothers and newborns(Lemmer, 1987; Norr & Nacion, 1987). Going home soon after birth can also result inincreased involvement of fathers with their newborns, less separation of the family afterbirth, and maternity care that is wellness-oriented and less fragmented (Bradley et al.,1989; Patterson, 1987; Stem, 1991; Yanover, Jones, & Miller, 1976). Although economichealth benefits have been hard to measure, it has been documented that early postpartum2discharge is an efficient use of hospital and community health services (Bradley et a!.,1989; Drummond, 1984; Patterson, 1987).At the time of the study, British Columbia’s Women’s Hospital, (formerly GraceHospital) the largest maternity hospital in Canada, and the Vancouver Health Departmentwere piloting an early discharge program called the “Maternity Care at Home Program”.This program, although evaluated positively by the families participating in it, wasproviding service at only one half of its capability. Half of the mothers eligible to gohome at 6-48 hours did not wish to do so. Data from other early discharge programs andresearch studies have also demonstrated that when early discharge is optional,participation is lower than anticipated (Bradley, et al., 1989; Stern, 1991; Waldenstrom,1989). It appears that some women believe it is better to be at home shortly after birthwhile others are either unaware of the benefits of the program or choose to recover in thehospital. The belief system underlying refusal to consider early discharge needs to beunderstood as fewer hospitals offer the option of a traditional stay and most expect allwomen who have had a normal birth to go home in the first 24-48 hours after birth.Problem StatementEarly postpartum discharge is rapidly becoming a common practice in NorthAmerican hospitals. Even though research has demonstrated that women who doparticipate in such programs are satisfied, many families, when given the option, choosenot to participate in this alternative health care service. Little is known about whatinfluences how women decide to participate in an early discharge program.3PurposeThe purpose of this study was to identify the factors influencing a woman’sdecision not to participate in an early postpartum discharge program. The study wasdesigned to answer the following research question: What factors influence a woman’sdecision not to participate in an early postpartum discharge program?Conceptual FrameworkThe decision to participate or not in the British Columbia’s Women’s Hospital’searly postpartum discharge program is a health care decision faced by 50 families a week.To assist in understanding a woman’s decision not to participate in an early dischargeprogram, a health promotion model based on decision-making around health behaviourswas used (Figure 1). Pender’s (1987) Health Promotion Model guided the design of thetopic questions for the study interviews and analysis of the data (Figure 2). This healthpromotion model was effective in examining the actual decision making process in alogical and systematic manner.According to Pender (1987), determinants of health-promoting behaviours inindividuals are categorized into cognitive-perceptual factors, modifying factors andvariables affecting the likelihood of action. Pender (1987) emphasized the cyclicalprocess by which individuals move back and forth between the decision-making andaction phases. The different factors can be more or less influential in a person’s decisionto act.Factors that facilitate health-promoting decisions and behaviours include: theimportance, and definition of health to the individual, the control and self-efficacy the4individual has in relation to her health and health decisions, the individual’s perception ofher health status and the perceived benefits and barriers to the health decisions she hasmade or will make (Pender,1987). Pender hypothesized that each of these individualperceptions or personal factors have motivational significance, that is; they influenceindividual readiness to engage in health-promoting decisions and behaviours (Pender,1987).Modifying factors that affect an individual’s disposition to engage inhealth-promoting behaviours are demographic, biologic, interpersonal, situational, andbehavioral. Demographic factors include characteristics such as age, sex, race, ethnicity,education, and income. Biologic characteristics encompass one’s physical abilities orphysical state that may enhance or disrupt abilities to initiate health actions. Interpersonalvariables encompass expectations of others, family health patterns and behaviours, andinteractions with health professionals. Situational factors include the health-promoting andcare options available and prior experiences with health-promoting actions. Behaviouralfactors involve having the cognitive and psychomotor skills to carry out behaviours andactions (Pender, 1987).The two salient variables affecting the likelihood of action are: perceived barriersto action, imagined or real, and internal or external cues that trigger activity. Barriersinclude individual perceptions regarding unavailability and/or inconvenience of a particularhealth promoting option.COGNITIVE-PERCEPTUALFACTORSMODIFYINGFACTORSPARTICIPATION IN HEALTHPROMOTING BEHAVIOURLikelihood of engaging inhealth-promoting behaviours1’Cues to actionFigure 1: Health Promotion ModelPender (1987, p. 58)IImportance of health Demographic characteristicsPerceived control of health Biologic characteristicsPerceived self-efficacy Interpersonal influencesDefinition of healthPerceived health statusSituational factorsBehavioural factorsPerceived benefits of[a1th-promoting behavioursPerceived barriers tohealth-promoting behaviours6The components of Pender’s (1987) model; cognitive-perceptual and modifyingfactors guided the development of the questions used in the study interviews (Figure 2).These factors in the model appeared relevant in assessing a woman’s health-care decisionwhether to participate or not in the early postpartum discharge program.Significance of the StudyThe findings from this study provide insight into the factors that influence awoman’s decision not to participate in an early postpartum discharge program.Knowledge of the relationships among factors influencing the health-care choices of awoman and her family provide information that can be utilized by health careprofessionals in both planning and implementing educational and supportive programs tomeet their needs. This knowledge is also important for the further development ofprenatal preparation for families and for early discharge programs. A greaterunderstanding of the effects of personal and interpersonal influences on women will assistfamilies to plan for a healthy and safe transition from hospital to home, Awareness of thedecision-making processes of women surrounding early discharge will enableidentification of nursing interventions that are appropriate to women and their familieswho are discharged early.Definition of TermsEarly postpartum discharge: hospital discharge within 6-48 hours of low-risk women andtheir newborns who meet the established early discharge program criteria (Appendix A).7I QUESTIONS FACTORSWhy did you decide not to participate in the earlypostpartum discharge program?Perceived benefits andbarriers to health-promotingbehaviour.Did you feel you had enough information to make Perceived control of healtha decision about participating? and self-efficacy.Did your ability! confidence to care Perceived health status andyourself and your newborn influence your decision self-efficacy.to stay in the hospital? Behavioural factors.Did you feel that the decision you made was the Perceived benefits andright one for you and your family? barriers. DemographiccharacteristicsWhat were the benefits for you staying in the Perceived benefits andhospital? barriers to health-promotingWhat were the barriers? behaviour.Who and what influenced you when you were Interpersonal influences.making your decision? Perceived control over health.What role did your home/hospital Situational factors.environment play in your decision? Perceived self-efficacy.When did you first hear about the Situational factors.early discharge program?Would you choose to stay in hospital the same Situational factors.length of time for another baby? Perceived health status andcontrol over health.Did you feel this was an important health Importance of health.decision?Figure 2: Interview questions and their relationship to categories of thePender’s (1987) Health Promotion Model.Pender, N.J. (1987). Health Promotion in Nursing Practice.(2nd ed.). Norwalk, Connecticut: Appleton & Lange.8Maternity Care at Home: an established early postpartum discharge program of theBritish Columbia’s Women’s Hospital in collaboration with the Vancouver CommunityHealth Department, offering postnatal care and follow up at home for mothers andnewborns for the first ten days postpartum.Standard hospital stay: The hospital stay of 3-4 days for postpartum women whoexperience a vaginal birth and 5-6 days for those who experience a caesarean birth.Multipara: A woman who has given birth to two or more viable infants.Primipara: A woman who has given birth to one viable infant.Assumptions of the Study1. During the postpartum period, women are the most legitimate source ofinformation regarding their decision not to participate in an early dischargeprogram.2. The birth of a child is a significant event in the life of a woman and her family.Limitations of the StudyInterviews took place during the participants’ hospitalization on the postpartumunits of B.C. Women’s Hospital. The participants may have been hesitant to verbalizeopenly due to fear of jeopardizing their care, or feeling like they had to justify theirdecision to reject early discharge. It was felt that the advantage of interviewing womenwhen the experience was close at hand outweighed the disadvantages.Limitations also existed regarding the ability to generalize the study findings. Theparticipants were selected from one hospital during a specific period of time. The datathat emerged from the experiences of these women were relevant as they represented a9slice of life from the real world (Sandelowski, 1986).SummaryThis chapter has presented the background for understanding the research problem.The study’s purpose was discussed, the conceptual framework used to guide the study wasoutlined, the significance, relevance and key terms used to delineate the research problemwere defined. Finally, the underlying assumptions of the study were clarified.10CHAPTER TWOReview of Selected LiteratureIntroductionThe purpose of this section is to present an analysis of selected research in theearly postpartum discharge and maternal postpartum adjustments. There has been limitedliterature on the perceptions of postpartum women who choose not to participate in a earlydischarge program and no research has been done on the factors which influence a womanto stay in the hospital the traditional length of stay. Therefore the literature review thatfollows will focus on the concept of early postpartum discharge and related maternal-tasktheory. Literature on maternal tasks of the postpartum period might shed some light onwhy women feel they need to spend the early days after birth in hospital. This literaturereview will attempt to integrate these two areas.Early Postpartum DischargeStudies from Britain, Europe and North America relating to various aspects ofearly postpartum discharge have been cited in the literature since the late 1940’s. Theconcept of early postpartum discharge was first discussed in the medical literature in 1943when the standard postpartum hospitalization for mothers and newborns was ten days inNorth America (Guerriero, 1943). Early postpartum discharge was implemented inhospitals across the U.S. to assist with overcrowded maternity units (Callander et al.,1966). It was thought that early discharge would jeopardize the health of the mother andnewborn but reports from investigators conducting the first studies indicated it was safewhen follow-up home-care was provided. In Canada, early postpartum discharge11programs were not in existence until the late 1980’s at which time pilot research projectsbegan to be implemented in areas across Canada.Most of the research literature either describes the evaluation of established earlypostpartum discharge programs or, retrospectively, examines patient satisfaction. Theresearch that has been done has been limited by both the size of the samples and the areasof study. For example, only three of the published studies reviewed used experimentaldesign with random assignment utilizing a control group (Carty & Bradley, 1990;Waldenstrom, 1989; Yanover et al., 1976).Specific criteria for participation in an early postpartum discharge program weredeveloped by Yanover et al., (1976). Their study was the first in which the sample groupof 88 participants was randomly assigned into two groups, traditional hospital stay orearly discharge. The researchers concluded that early discharge was safe as well assatisfying for the patients and their families (Yanover et al., 1976). Patient satisfactionwas due to fewer disturbances in rest and sleep at home and the increased possibilities forfather involvement found at home. The participants in the study also felt that the mainbenefit of being in the hospital after the first postpartum day was to learn to care for theinfant and therefore they questioned the need for the traditional hospitalization stay tolearn those tasks (Yanover et al., 1976).Drummond et al., (1984) continued to evaluate discharge criteria relating to patientsafety outcomes of mothers and newborns in a community-based early discharge program.One of their conclusions was that admission into an early discharge program should be anoptional decision made by the physician and patient. The criteria examined in the above12study have remained standard for many subsequent programs, including the programwhich is the focus of this study (Bradley et al., 1992; Waldenstrom, 1989).The effects of early hospital discharge on maternal and infant outcomes werestudied by Lemmer (1987) who interviewed 21 primiparas choosing early discharge and21 primiparas with hospital stays longer than 24 hours. The early discharge sample waschosen from women who chose to go home early and met the study criteria. Acomparison group was chosen from women who delivered in the same time period butchose to stay in the hospital longer than 24 hours. Study questionnaires consisted of ademographic form, a maternal concerns questionnaire and an infant and maternal physicalassessment completed during a home visit after the women were home one week.Lemmer (1987), concluded that maternal and infant complications were not linkedto time of discharge. No significant differences occurred in intensity of concerns at oneweek postpartum between the two groups. The most intense concerns of primiparasregardless of length of stay focused on body image, infant care, behaviour and recognitionof signs of illness in the new baby. According to Lemmer (1987) primiparous womenrequire nursing care regardless of when they are discharged from the hospital. Womenchoosing early discharge had more social support at home following discharge (Lemmer,1987). The limitation of this study was that the sample size was small.Norr, Nacion, and Abramson (1989) examined the health impact of three differentdischarge conditions with a sample of low-income mothers and infants. The threedischarge conditions were as follows: 1) early discharge of mother at 24 to 48 hours andinfant after 48 hours 2) early discharge of both mother and infant together and,133) conventional discharge of both mother and infant. There were no significantdifferences among the three discharged groups in the frequency of maternal or infantphysical health problems. Significant group differences were found for maternal concernsand maternal attachment. Mothers and infants discharged together early had highermaternal attachment scores and lower maternal concerns than the conventional dischargegroup (Norr et al., 1989). This study was of particular importance because it was the firstto study high-risk women.Thurston and Dundas (1985) evaluated patient satisfaction and safety of an earlydischarge program implemented by two general hospitals and the community healthdepartment in Calgary, Alberta. The study enroled two hundred and sixty-seven womenand their infants. Participation in the study was voluntary for families who met the earlydischarge program criteria. Eligible mothers and infants were discharged from hospitalwithin 48 hours postdelivery and received three consecutive daily home nursing visits.Retrospective chart reviews were used to gather data on all participants and questionnaireswere sent out to the women in the study. It was noted by the investigators that there wasno increase in postpartum complications or readmission rates that could be attributed toearly discharge (Thurston & Dundas, 1985).Through the use of patient questionnaires it was found that patients were verysatisfied with the length of hospital stay and with the home visits. The patients foundthey were more relaxed, bonding was improved, and a home support system was availableto them. Over 90% said they would participate again and recommend the program tofriends (Thurston & Dundas, 1985). Five percent of the women in the pilot program said14they would not participate again as they required more rest, help at home, and had notwanted to be discharged home early. The program evaluation concluded that the programwas satisfactory and acceptable (Thurston & Dundas, 1985). One limitation noted in thisstudy was that study participants in the study were self-selected. Another area ofweakness was the measures used in this study were not well outlined or described.A Canadian nursing research study examining aspects of early postpartumdischarge was conducted at a large westcoast maternity hospital (Bradley, Carty & Hall,1989). This study examined the effect of the time of discharge on maternal and infantsafety, psychological function of the mother, patient satisfaction, and program cost. Usingan experimental design, with a sample group of 176 participants, both primiparas andmultiparas, the authors found that maternal and infant morbidity was low regardless ofdischarge time, and women in the early discharge group were less anxious and depressedand more confident than the longer hospital-stay women (Carty & Bradley, 1990).The quantitative findings of this study were also triangulated with a qualitativestudy of the early discharge group women. This qualitative study focused on theexperience of eight women who were discharged between 12-24 hours postpartum. Theinvestigators revealed the early discharge experience as representing a process of thewomen taking control of their own and their infant’s care (Hall & Carty, 1993). This isthe only grounded theory study found in the literature and is useful because it describeshow women prepared for successful early discharge and identifies features of thepostpartum nursing care which enhanced women’s feelings of confidence.Bradley et al. (1989) noted that the nurses in the study providing care at home to15the women believed in early postpartum care as a safe and satisfying option for manywomen and believed in reinforcement and positive feedback as a way of helping developmaternal self confidence and self esteem. It was concluded by these investigators thatearly postpartum discharge with follow-up should be made available to women in BritishColumbia (Bradley, et al., 1989).One of the major limitations of this study was a smaller than anticipated samplesize due to recruitment that took a year longer than expected. Only 10% of the 300physicians who initially agreed to participate referred patients into the study. This was anexperimental design and therefore, it depended on women to volunteer to be randomlyassigned to any of the three groups. According to the investigators, this made it difficultfor women who wanted to go home early and for those who wanted to stay in hospitallonger to participate because in a randomized study the women might be assigned a groupin which they did not feel comfortable (Bradley, et al., 1989).A more recent study was completed by Bradley, Carty and Winslow (1992)examining further the effects and outcomes of early discharge on the postpartum family.This study used a comparative, non-experimental design involving a convenience sampleof 117 women. It examined the difference between women who chose a standard hospitalstay of four days and those who chose to be discharged within 48 hours of birth.The significant findings from this study indicated that women who went homeearly were of lower socio-economic status, preferred to go home early so the father couldbe more involved with the newborn, and were less anxious at one month postpartum withregards to their baby (Bradley, et al., 1992). The women who stayed in the hospital for16four days required more support, advice, and reassurance than women discharged earlyand appeared to believe that the hospital was a safer place to spend the immediatepostpartum period (Bradley, et al., 1992).One limitation of this study identified by the investigators was that the sample wassmaller than anticipated due to slow recruitment of participants into the early dischargegroup. This limited recruitment was due to hesitation and ambivalence about earlypostpartum discharge on the part of women in the community and their health-careproviders.Patient satisfaction, a reflection of consumer attitudes and a key element indetermining the acceptability of early postpartum discharge, was investigated by Avery,Foumier, Jones, and Sipovic (1982). Satisfaction and safety in going home early wasassessed in women participating in an early postpartum discharge program. Aretrospective review was done on all the early discharge patients over a two year period.The review found few newborn and maternal complications (Avery et al., 1982). Aquestionnaire which asked women about their experience with early postpartum discharge,was sent out to all 154 women for completion. Responses revealed that 80 out of 86women felt comfortable going home early from the hospital. No control group was used(Avery et al., 1982).Patterson (1987) conducted one of the first studies which compared the attitudesand beliefs of women who were suitable and wished to be discharged home earlyfollowing birth with those who wished to remain in the hospital for the standard stay. Shestudied 226 low-risk women whose post delivery hospital stay was 40 hours or less or17whose traditional hospital stay was two to three days. A ninety-one item questionnairewhich had been pre-tested in a pilot study with 52 subjects quantified their dischargechoice, early discharge program awareness, subject characteristics, criteria for postpartumcare choice, postpartum care beliefs, and satisfaction with postpartum care. Patterson(1987) had a response rate of 84%. She found that the late discharge group of womenincluded more primiparas than multiparas. The mothers in the early group believed thathome was the best place to be for recovery and the hospital group thought the nurses weremore helpful than family members (Patterson, 1987).Mothers in the late-stay group indicated that their decision to stay in the hospitalwas more often influenced by others compared to the early discharge group who checkedoff “self’ as the one making the decision to go home early. Nearly all the women knewabout the program prior to delivery. When asked their postpartum care choices andbeliefs, the late group stated they valued rest and sleep, quiet atmosphere, attention fromothers, a knowledgable person nearby and rated the hospital the best place to be followingbirth. The women in the late group believed the hospital was the best place to rest andthat nurses were more helpful than were family for giving confidence and support to newmothers (Patterson, 1987). The early group felt going home early would result in a morecomfortable surrounding and a partner that was more involved with the newborn. Theyalso stated their home was the best place to be following birth (Patterson, 1987). This isthe only study which looked at attitudes and beliefs as factors influencing a woman’sdecision.Attempts to capture women’s perceptions of early postpartum discharge were the18goals of Rush and Valaitis (1992). Two surveys were conducted in the Hamilton area toascertain which hospital services were valued by women in postpartum recovery, whysome women did not choose the early discharge program, and what services they wouldneed if they were to go home within 48 hours (Rush & Valaitis, 1992).The first survey involved 65 women. They were given a questionnaire on thesecond postpartum day asking what hospital services they would miss if they weredischarged on the second postpartum day. The second questionnaire, sent to aconvenience sample of 200 postpartum women at 6 months, asked them to rate theimportance of hospital services and whether they would agree to participate in arandomized study in which they would have been discharged within 48 hours or haveremained in hospital for the traditional length of stay. The response rate for the firstsurvey was 89% and, the second survey was 70%. According to these surveys, womenranked the 24 hour access to nursing care and advice as being the most important service.If they were to be discharged home on the second postpartum day they would require a 24hour telephone line, nursing visits, and homeworker help (Rush & Valaitis, 1992). Only17% of women stated that they would have agreed to participate in the randomized studyas they feared they would be discharged early and they stated they did not have support athome.The reasons for the development of early postpartum discharge programs havebeen consistent among the studies. These reasons included: effective utilization ofresources and services, increased involvement of fathers and families, the recognition ofpregnancy as a health state rather than an ifi state, an alternative to home delivery and the19mother’s desire to go home earlier (Britton & Britton, 1984; Jansson, 1985; Waldenstrom,1989). In-depth research is still required to further investigate the above variables andparticular outcomes such as safety, cost-effectiveness and patient satisfaction as they relateto early postpartum discharge.The few studies that have examined why women do not want to be dischargedearly from hospital suggest that women worry about getting enough rest at home and areconcerned that they would miss the information the nurses can provide. No studies havespecifically asked the question asked in this study or examined the factors that influence awoman’s decision not to participate in an early discharge program. As more hospitalsmandate early discharge the answer to this question is critical.Maternal TasksTo examine early postpartum discharge and the health care decision-makingprocess of postpartum women an understanding of the context of the physical andpsychosocial changes that take place following birth is required. The literature onmaternal tasks of the postpartum period, including concerns and educational needsexpressed by both primiparous and multiparous women will facilitate this understanding.Reviewing the research and literature on the overwhelming adjustments that postpartumwomen experience will assist in understanding their decision not to participate in an earlydischarge program.Many studies have indicated that women encounter a series of maternal tasks inthe early postnatal period. These tasks have been defined by studying the expressedconcerns of women in the postnatal period (Gruis, 1977; Hiser, 1987; Bull, 1981; Harrison20& Hicks, 1983; Moss, 1981). Postpartum maternal adaptation can be summarized inrelationship to six major maternal tasks: 1) physical restoration, 2) learning to meet theneeds of the dependent infant, 3) establishment of a relationship with the newborn, 4)altering lifestyle and relationships to accomodate a new family member (Bull, 1981;Gruis, 1977; Mercer, 1986; Rubin, 1984) and, 5) replenishing psychic energy (Ziegal &Cranley, 1984), 6) reviewing the events of childbirth experience and integrating the actualexperience with the expected experience (Mercer, 1981). The following section willreview the research that examines and supports maternal task theory.Rubin (1961) described two phases of maternal tasks in the postpartum period,“taking-in and taking-hold”. The “taking-in” phase is a time of passive and dependentmaternal behaviour taking place on the second to third postpartum day while the “takinghold” phase is a time of independent and autonomous maternal behaviour occurring on thethird to tenth postpartum day. The “taking-in” phase allows the mother time for rest,food, care and to adjust to her new role. The “taking-on” phase finds the motherbecoming more involved with her baby (Rubin, 1961). The development of the maternalrole as described by Rubin (1984), is affected in a progressive series of cognitiveoperations and the accomplishment of maternal tasks.Physical restoration is one of the primary maternal tasks of the postpartum period,along with replenishing psychic energy (Ziegal & Cranley, 1984). Rubin (1984) observedthat when the new mother’s need for sleep has been satisfied she awakens with “a wellspring of trust and faith”. The mother’s attempts to recover from the birth process and theemotional tension created by the immediate postpartum adjustments are hampered by21unanticipated fatigue and, if recovering in the hospital, the unfamiliar hospitalenvironment (Grossman, Eichler, & Winickoff, 1980; Shereshefsky & Yarrow, 1973). Aprimary complaint among childbearing women is fatigue and lack of energy (Harrison &Hicks, 1983).Self-reports by postpartum women confirm that sleep disturbance is a source ofdistress (Campbell, 1986; Harrison & Hicks, 1983; Mercer, 1986). When asked toidentify physical complaints in the postpartum period women consistently have notedfatigue among their foremost concerns (Moss, 1981; Tulman, Fawcett, Groblewski, &Silverman, 1990). Women report their physical discomforts contribute to the emotionaldistress of the postpartum period by decreasing their stamina to cope with the demands ofmotherhood (Tulman et al., 1990). Sleep deprivation and insufficient rest are likely toremain a problem’ once women get home and throughout the postpartum period (Carty,Bradley & Winslow, 1994; Lentz & Killien, 1991; Niven, 1992).It has been suggested that new mothers, even if they didn’t have to care for theirinfants, are likely to have sleep problems due to excitement, mood variation and thestrange environment in the hospital (Niven, 1992). Karacan et al (1969) found thenumber of night time awakenings were associated with the need to urinate and episiotomypain. Schweiger (1972) found causes of disturbed sleep to be due to physical discomforts,urinary frequency, and the presence of babies. In Campbell’s (1986) study of sleeppatterns of mother infant dyads, frequent interruptions in maternal sleep were related tothe unpredicted sleep-wake patterns of the newborn. Other influences included thewoman’s emotional state, endocrine changes, prenatal sleeping patterns, over tiredness,22and medication usage (Campbell, 1986).An exploratory study, conducted with 34 women during the first 48 hourspostpartum, revealed that women had no opportunity for uninterrupted sleep, due mainlyto the newborn feeding and presence of hospital personnel (Lentz & Killien, 1991). Thisstudy did find that the disruptive nature of the hospital environment interfered with a newmother’s “restorative sleep” (Lentz & Killien, 1991). Keefe (1988) also found that newmothers reported averaging less than six hours of sleep per night. The mothers whoseinfants were placed in the hospital nursery reported a shorter duration and decreasedquality of sleep, than those mothers that kept their infants in their rooms with them(Keefe,1988). In a descriptive study of 42 early discharged women and 64 traditionalhospital stay mothers very little difference was noted between early discharge mothers andthe hospital stay group in their self-reported feelings of tiredness (Carty, Bradley &Winslow, 1994).Although it is often assumed that the period of hospitalization following delivery is atime of recovery and rest for the new mother, research findings would suggest otherwise(Carty et al., 1994; Lentz & Killien, 1991; Moss, Bolland, Foxman & Owen, 1987). Fromthe results of these studies it can be suggested that new mothers experience interruptedsleep in the early days postpartum which interferes with physical restoration.Studies have found that multiparous women find meeting the needs of everyone athome a frequent and overwhelming postpartum task (Hiser, 1987; Grubb, 1980; Moss,1981). Allocation of time to meet the needs of the new infant and of other familymembers and manage a household has been found to be an overwhelming task for23multiparous women (Grubb, 1980). Multiparous women in a study by Moss (1981)voiced concerns and about the pressures that a new child places on the rest of the familyand the new complex structure of the family system.Moss (1981) examined 56 multiparous women on the third postpartum day andfound mothers were more frequently concerned with family relationships, especially otherchildren’s reactions to the baby than with themselves or their baby. This study alsoconcluded that both priniiparous and multiparous women were concerned with bodyalterations and physical restoration in the postpartum period (Moss, 1981). This was alsosupported by a later study by Strang and Sullivan (1985).Waltz and Rich (1983) examined maternal postpartum tasks related to the birth ofa second child. Data were collected by interview and observation of 14 mothers duringthe two to three days of hospitalization after childbirth. Written recordings ofobservations and interviews were made within 24 hours after the observations orinterviews occurred. Six behavioural codes were used to analyze the recordings:promoting acceptance of the second child by the first child, planning for the new familylife; reformulating the relationship with the first, child, identifying the second child, andassessing self as capable of mothering two children. Findings from this study revealedthat mothers focused intensively on their relationship with their other children (Waltz &Rich, 1983).Postpartum concerns and educational needs of new mothers are described inseveral studies. The studies following address several of the maternal tasks. Gruis (1977)studied concerns of postpartum women in a study using a questionnaire given to 1724primiparas and 23 multiparas at one month postpartum. It was found that both groupswere concerned about regulating family demand, and emotional tension. Primiparas weremore concerned about infant behaviour and feeding and multiparas were more concernedabout fatigue and time for self.Pridham, Hansen, Bradley, & Heighway (1982) studied the concerns of newmothers at one week postpartum. The study comprised 38 primiparas and 24 multiparas.The three most frequent daily issues for these postpartum women were infant care, infantdevelopment, and signs and symptoms of infant illness. The two groups had similarconcerns but multiparas had more parenting concerns than primiparas.In another study by Pridham (1987) 48 primiparas and 35 multiparas weresurveyed using observations and questionnaires at seven days, one month, and threemonths postpartum. The leading concerns at each time period were changes in presentlife style and infant care tasks (Pridham, 1987).Harrison and Hicks (1983) sent 158 multipara and primipara women aquestionnaire asking them to identify their concerns and their sources of help at fourweeks postpartum. The investigators found the primiparas expressed more minor concernsand multiparas had the same number of concerns but they labelled the concerns as major.These concerns included: regulating demands of husband, fatigue, emotional tension, dietand finding time for personal interests. This study also revealed that the husbands werethe most frequent source of help used for support with changing roles and responsibilitiesfor the women in the study (Harrison & Hicks, 1983).Hiser (1987) examined 20 low risk multiparas and their postpartum concerns at 1025to 14 days postpartum. It was found that mothers were concerned whether they weremeeting the needs of everyone at home, finding time for themselves, being a good motherand their physical weight. These woman in the study had more family concerns thanmother or baby concerns (Hiser, 1987).Educational requests of women in the postpartum period emphasize the desire andneed to know how to care for their infants and themselves as outlined in the followingstudies. There is evidence that priniiparous women benefit from structured teaching andsupportive counselling interventions that address their concerns, attitudes, perceptions, androle-related knowledge (Hall, 1980).Bull and Lawrence (1985) studied seventy-eight women of mixed parity and theiruse of knowledge during the first week at home with a new baby. Seventy percent ofwomen reported information on self-care and infant physical care and feeding was helpfuland information on infant behaviour would have been useful.Davis, Brucker, and MacMullen (1988) examined the teaching priorities of newmothers. One hundred and seventeen low risk mothers of various parity and age groupswere given a questionnaire on postpartum day 13 to assess their learning needs. Motherswanted to know how to care for themselves especially with regards to episiotomy care andhow to care for and feed their infant.Women experience several developmental tasks following the birth process,requiring understanding and support from family and health care professionals for them tomaster them effectively (Gruis, 1977; Rubin, 1984; Mercer, 1985; Ziegal & Cranley,1984). This knowledge is based on a variety of research studies and theoretical writing on26the emotional and physical concerns and adaptations of women in the postpartum periodusing interviewing, observing and self-reports of womens’ experiences prenatally,intrapartum and postnatally.Although much research has been completed on maternal tasks, and concerns thatare linked sometimes to these tasks, no studies have specifically focused on potential earlydischarge populations and determined what factors prevent them from pursuing earlydischarge. It is possible that necessary structures and supports for dealing with concernsand maternal tasks have been intrinsically identified with hospital nursing care. However,the needs and concerns of women during the postnatal period must be met whether thenew mother and newborn are recovering in hospital or at home.27CHAPTER THREEMethodIntroductionThis section describes the research design of this study, sample selection, datacollection procedure, instruments for data collection, data analysis procedures andprocedures for the protection of human rights.Research DesignAn exploratory, factor-searching design was used in this study. A factor-searchingsurvey is used to describe or name a given situation. The type of theory produced in afactor-searching study “names theory” either in the form of narrative description, formalconcepts or categories (Diers, 1979). This design enabled the investigator to studywomen’s perceptions of the factors that influenced their decision not to participate in anearly postpartum discharge program.SampleThe sample consisted of 55 postpartum women. All women who met the selectioncriteria and were still in hospital (n=67) were approached to participate in the study.Eight women declined participation due to their discomfort with the English language andfour women stated they did not have time to do the interview.Women selected for inclusion in the study met the following criteria:1) The Maternity Care at Home Program (M.C.A.H.) criteria were met (Appendix A);2) The services of the early discharge program had been offered;3) They had decided not to participate.28Data Collection ProceduresParticipants for this study were recruited from the postpartum units of BritishColumbia’s Women’s Hospital. The M.C.A.H. nursing staff identified women who hadmet the early discharge criteria (Appendix A) but who decided not to go home early. Anintroductory information letter describing the study (Appendix B) was given to thewomen. If the woman indicated that she was willing to participate by checking theappropriate box on the introductory letter and returned it to the nursing station, theinvestigator met with the woman and explained the study in more detail. Participantssigned a consent form (Appendix C) prior to the interview. The patient’s physician wasinformed of her participation in this study by a letter (Appendix D).Interviews took place in each participant’s hospital room. Interview times wereflexible and averaged 30 minutes in length. The interviews were audiotaped and fieldnotes were kept by the investigator. Five women declined audiotaping due to difficultieswith the English language so these interviews were recorded by hand.Although each question on the interview guide was asked, each woman wanted totalk about her own personal situation and how it affected her decision not to participate inthe early discharge program. Consequently, questions with respect to some aspects ofPender’s model, for example, importance and definition of health, were not clearlyaddressed by most participants.Instruments for Data CollectionTwo instruments for data collection were utilized in this study. A demographicand health-related information sheet was used to collect background information on each29participant (Appendix E). An interview guide, with questions developed from theconcepts of Pender’s (1987) health promotion model was used as the basis of a semi-structured interview (Fiqure 2). The questions to be used were reviewed by theinvestigator’s advisory committee.Data AnalysisEach audio tape was reviewed and data were recorded by hand. Because thewomen did not directly answer all the questions on the interview guide, it was notpossible to establish categories based on Pender’s model for analysis purposes. Thereforea decision was made to analyze the data using an inductive approach, “deriving thecategories from the data themselves” (Waltz, Strickland, & Lentz, 199 l,p.3O4). The majorcategories that emerged from the data were the need for physical and emotionalrestoration, and the need for care. These needs were identified as the main reasons whywomen chose not to go home early. The women in the study also identified external andinternal influences and barriers, such as the views of their family and their physician,which had an impact on their decision. Wherever possible the categories and factorswithin the categories were related to the concepts of Pender’ s (1987) health promotionmodel.To ensure reliability of the category descriptions, five experienced postpartumnurses were given the data from ten study interviews and the list of major categories andwere asked to identify the categories into which the data would fit. There was a 90%agreement between the nurses and the researcher with respect to the categories in whichthe factors were placed.30Ethical and Human RightsProcedures for the protection of human rights were followed. Prior to conductingthe study, permission was obtained from the University of British Columbia BehavioralSciences Screening Committee for Research and Other Studies Involving Human Subjects.Permission was also obtained from British Columbia’s Women’s Hospital ResearchCoordinating Committee, for the utilization of hospital resources for research purposes andfor the solicitation of subjects for the study.The purpose of the study was explained to the participants verbally and in writing(Appendix B). Use of an informed consent and protection of confidentiality addressed therights of the subjects (Appendix C).Confidentiality of results was maintained by coding the participant’s names so theiridentity was known only to the researcher. Access to the data was limited to theresearcher and her advisory committee. Participants were not identified by either theirresponses to the study, or on the demographic health-related sheet, consent forms orinterview tapes.SummaryA factor-searching survey research design was used to collect data for this study.Fifty-five participants were interviewed about their decision not to participate in an earlypostpartum discharge. The taped interviews were reviewed, summarized and analyzedthrough the process of inductive content analysis. The categories that emerged from thecontent analysis are presented in Chapter 4 with a discussion of the findings.31CHAPTER FOURPresentation and Discussion of FindingsIntroductionThis chapter presents the findings and incorporates a discussion of those findings.Initially, characteristics of the sample are summarized and discussed. Then, the selectedcategories are presented and discussed in relation to the literature and the study’sconceptual framework. Finally, ancillary findings of the study are presented anddiscussed.Characteristics of the SampleThe demographic characteristics of the study sample included; the participantsages, educational background, employment status, ethnic origin, parity, method of birthand postpartum support person. Many of these characteristics represent the demographicmodifying factors found in Pender’s (1987) model.Age of the participants ranged from 19 to 42 years of age (Table 1). Seventy-sixpercent of the women in the study were married; twelve percent were living in a common-law relationship; seven percent were single and three percent of the women wereseparated. The women were well educated (Table 2), with approximately sixty percentworking outside the home on a full or part-time basis (Table 3). Ethnic origin of thesample is described in Table 4.32Table IAge Distribution of the SampleAge Frequency Percent<20 1 220-29 20 3630-39 29 5240> 5 9Total 55 100.0Table 2Educational Level of the SampleEducation Level Frequency PercentUp to Grade 12 3 5.4Completed High School 20 36.3Completed College 15 27.2Completed University 17 30.9Total 55 100.0Table 3Employment Status of the SampleEmployment Status Frequency PercentFull-time 23 41.8Part-time 13 23.6Homemaker 12 21.8Unemployed 7 12.7Total 55 100.033Table 4Ethnic Origin of the SampleEthnic Origin Frequency PercentEuropean-Canadian 26 47.2Asian-Canadian 14 25.5Indo-Canadian 6 11Hispanic-Canadian 5 9Filipino-Canadian 4 7.3Total 55 100.0Forty-nine percent (n=27) of the study participants had experienced the birth oftheir first child and fifty-one percent (n=28) were mothers who had their second to fifthchild. Sixty-six percent of women, (n=36) had experienced vaginal births, over half of thestudy participants and, 34% (n=19) of the women had experienced caesarean births.Sixty percent (n=33) of women in this study reported that their husbands orpartners were the main support person for them in the postpartum period; twelve women(21.8%) reported that their mothers were the main support. Six (11%) reported their sisteror aunt were their main support, and four women (7.2%) reported their friends to be theirmajor support. The main support person for these women were their husbands/partners,which has been found in other studies (Bradley, et al., 1989; Lemmer, 1986; Patterson,1987).The majority of the women in this study were well educated, with the mean age of27.7 years with a standard deviation of 4.60. The youngest participant was 19 years andthe oldest 42 years of age. In comparing the primiparas and multiparas ages, theprimiparas were slightly younger than the multiparas. Most of the women were employed34either in full-time and/or part-time work outside the home. There was almost equaldistribution and representation of women in the study who were primiparas and multiparasas well as of women who had experienced vaginal and caesarean births. There was avariety of ethnic representation in the study.Researchers have noted that demographic characteristics such as multiparity, lowincome, and young age have a negative impact on maternal adjustment, suggesting thatthese women may be particularly vulnerable in an early postpartum discharge program(Lederman, 1986; Mercer, 1986; Patterson, 1987). The sample in this study did notappear to have demographic characteristics that would jeopardize maternal adjustments,although many of the women expressed having other children at home as a factor for notparticipating in the early discharge program.Category ConceptsContent analysis of the interview data resulted in the development of two majorcategories: the need for physical and emotional restoration and the need for care. Severalexternal and internal influences and barriers were also found to be influential in awoman’s decision to stay in the hospital. The two major categories, and the external andinternal influences and barriers matched the major concepts of Pender’s (1987) healthpromotion model.The need for physical and emotional restoration included the following factors:need for sleep and rest, comfort, and time alone. This category was reflective of thewomens’ perceived health status, one of the cognitive-perceptual factors found in Pender’s(1987) model. The need for care included the following factors; need for help, support,35and protection. This category reflected a woman’s perception of her self-efficacy, anotherof the cognitive-perceptual factors found in Pender’s (1987) model. The women alsoidentified several internal and external influences and barriers which influenced theirdecision to stay in the hospital longer and, according to Pender (1987) are classified asmodifying factors. The postpartum tasks and concerns of women during the postpartumperiod enhanced one’s understanding of the categories (Bull, 1981; Mercer, 1981; Gruis,1977; Rubin, 1984).Need for Physical and Emotional RestorationThe women described several physical and emotional needs which influenced theirdecision not to participate in an early postpartum discharge program. The womenidentified their needs, then indicated that these needs could not be met through the earlydischarge program. They believed that the home environment was not conducive tohaving their needs met. Women presented a variety of reasons that ranged from the needfor sleep to needing time alone. The relevant factors are summarized in Table 5. Thefactors are then described with quotations from selected interview responses.Table 5Need for Physical and Emotional RestorationDescription Frequency Percent38 6915 27.312 22Need for rest and sleepNeed for comfortNeed to have time aloneNeed for rest and sleep. Women expressed the need for extra rest, time forrelaxation and the desire to have more sleep. This response was articulated by a large36majority of the women as an influential factor in their decision to stay in the hospital.The need for more rest was described by the women in the study as a response to feelingsof being tired, fatigued, energy-drained, exhausted, and weak. One woman described it asher “battery was totally drained”. Another felt as if she had been “hit by a truck”, and athird stated that she could “sleep for days”.Women identified biologic characteristics and situational factors such as fatiguefrom the physical strain of pregnancy, birth process, disrupted sleep patterns and thephysical and emotional changes of the immediate postpartum period as the reasons whythey were so tired. Situational factors identified by these women included the work theyhad done prenatally at home, and on the job, and the work that was waiting for them oncethey got home. Women were tired from working during the prenatal period andanticipated more of the same ahead when they got home.Women stated that if they stayed in the hospital they could get the rest and sleepthey needed by “napping” anytime of the day or night, sleeping in between feedings,having the baby looked after in the nursery, and relaxing anytime to “recharge thebattery”. Multiparous women commented that it was great having the nursery open soyou could have the nurses care for the baby during the night or when visitors and theother children came in. The participants stated clearly that they felt they would be unableto get the needed rest and sleep at home due to other children and householdresponsibilities. These were seen as perceived barriers to going home early. It wasperceived that there would be no one to help with the baby through the night and it wouldbe difficult to relax and rest at home. The women believed the nurses were available to37relieve them of caregiving activities so they could get the rest and sleep they needed.The multiparous women in this study rated the need for rest and sleep more highlythan primiparous women. Eighty-eight percent of multiparous women (n=24) compared tofifty-one percent of primiparous women (n=14), expressed the feeling that the need forrest and sleep was a factor for not participating in an early postpartum discharge program.The multiparous women expressed concerns about the needs of their other children if theywent home early to recover. They would find it hard to rest or sleep when the new babywas napping as they would feel obligated to meet the demands of the other children aswell as the household tasks. One woman stated, Hthey expect you to do it all, look afterthe children and the house as well as a new baby. It is much easier to just stay in thehospital away from all the mess and confusion.” There was a sense from the women inthe study that family demands were not negotiable.Fatigue has been documented in the literature as an area of concern affecting thedevelopmental tasks of the postpartum period for both primiparas and multiparas(Campbell, 1986; Gruis, 1977; Moss, 1987; Tulman et al., 1990). Perceived competencein feeding was related to the amount of rest for breastfeeding women (Pridham, 1987).Rubin (1984) believed that a deep refreshing sleep that lasted for several hours afterdelivery was necessary for the maternal task of physical restoration to be completed.Studies assessing differences between multiparous and primiparous women andtheir need for rest and sleep have not presented any conclusive findings. Tobert (1986)and Smith (1989) indicated multiparas score fatigue higher as a postpartum concern thanprimiparas. This might be due to multiparous women anticipating extra demands of other38children, workload at home, less time for themselves, and less paternal involvement(Lederman, 1984; Patterson, 1987). The integration of a newborn into the existing familystructure is one of the major maternal tasks of all postpartum women (Gruis, 1977).Primiparas might find it difficult to sleep due to the new changes in their body,surroundings, and in being awake at night with an infant. Women in this study wereinterviewed either on their second or third postpartum day, a time when fatigue is great(Bradley et al., 1986; Tobert, 1986)The findings from Patterson’s (1987) study parallels the results of this study. Theneed for rest and sleep and a quiet atmosphere were highly rated by women dischargedlate and as the reason the hospital was chosen as the best place to rest. Early dischargewomen, on the other hand,preferred the comfortable surroundings of their home as thebest place to rest after childbirth (Patterson, 1987). It was also found by otherinvestigators that women who participated in early discharge liked being in their ownhome as they felt more relaxed and they found their home environment comforting(Bradley, et al., 1989; Lemmer, 1987).Both groups of women, those who chose to stay in the hospital and those whoparticipated in early discharge, regarded rest and sleep as crucial to their recovery. Bothchoices of environment, home and hospital, should be able to provide the rest postpartumwomen need. However, even though some women feel that the hospital is moreconducive to rest, some studies have found that women report that they are not getting therest and sleep they need while in the hospital due to noise and repeated interruptions fromhospital staff and routines (Lentz & Killien, 1991; Moss,1987).39In summary, the women in the study believed the hospital was the best place forthem to rest and sleep following birth. The flexibility of the hospital environment to restanytime and the ability to be away from the family and the daily household demandsinfluenced the women’s decision. It seemed these women did not believe they couldcontrol these areas of their life and therefore they could not improve their health status ontheir own.Need for comfort. Need for comfort was the second highest factor which wasfound to influence the women’s decision to stay in the hospital. By staying in thehospital the study participants felt they would receive interventions that would help relievetheir pain and discomfort. The women stated they were feeling pain and discomfort fromthe birth process as well as pain from perineal stitches and bruising, and caesarean birthincisions. These physical discomforts are biologic characteristics as identified under themodifying factors of the model (Pender,1987). The study participants also felt their homeenvironment could not offer the same “comfort measures” they felt they needed for theirpostpartum recovery.There were a greater number of women who expressed the need for comfort after acaesarean birth (n=6) and/or forcep assisted birth (n=5) than women who gave birthspontaneously (n=4). Other forms of discomfort described by women in the study wereuterine cramping, breast and nipple discomfort, and headaches. These biologiccharacteristics influenced the womens’ perception of their health status. They felt theyrequired a longer hospitalization to restore themselves to a healthy state.The women also described the health care professionals understanding as being40“emotionally comforting”. Measures of comfort offered by the nurses were described as:access to help 24 hours a day, access to analgesics, hot packs and sitz baths, and theabffity to rest and sleep anytime. One woman stated that it was “nice to have your mealsprepared, your room cleaned and someone around to care for you when you are feelinguncomfortable”.More primiparas (n=7) in this study expressed breast soreness than multiparas(n=4). This was also noted by Smith (1989) in her study of women’s postpartumconcerns. Breast pain and discomfort has been noted as a major concern of postpartumwomen who are breastfeeding (Smith, 1989; Ellis & Hewat, 1984). Other researchershave implied that coping with breast discomfort is part of the physical restoration, that isrequired to adapt to motherhood and care for an infant (Gruis, 1977).Both situational influences and interpersonal factors were instrumental in thewomen’s decision to stay in the hospital. Two women commented that they felt depressedabout going home and therefore staying in the hospital was best for them. Other womenstated they felt fearful and anxious about going home, particularly primiparous women.These feelings resulted from the equating home with “facing reality” and, in the case offirst-time mothers, the fear of the unknown. The women felt that they would be “isolatedand lonely” at home and would have no one to talk “things” over with, as there would beno one available to them. The women perceived the need to have someone to talk to whounderstood their health status. Women described being in the hospital as helping them“feel better”. The women seemed to enjoy being in aienvironment that provided themwith services, such as a clean room and meal services as well as people who were there to41care for them. Several women stated that the peop1e in the hospital know and understandwhat you have been through”.The literature supports the fact that coping with physical discomfort, compoundedby fatigue in the postpartum period is part of the maternal task of physical restoration(Gruis, 1977; Rubin, 1984). Physical restoration includes healing and recovery of thephysical trauma of birth (Gruis, 1977; Mercer, 1986; Rubin, 1984). However, littleresearch has been done on postpartum pain and effective comfort measures.Bradley, Carty and Winslow (1992) found women who remained in the hospitalthe traditional length of stay rated their physical condition as an important concern andrated it significantly higher than women in the early discharge group. Patterson’s (1987)late discharge mothers reported that attention from others was a significant factor forstaying in the hospital. By staying in the hospital the women were able to receivecomfort measures they felt they could only receive in the hospital.The participants in this study emphasized their need for comfort. The womenequated their need for postpartum comfort measures with what the hospital environmentcould offer. These perceptions are supported by research studies that have examinedaspects of early discharge (Bradley et al., 1993; Patterson,1987).Need for time alone. Needing time alone was another factor that influenced thewomen’s decision to stay in the hospital, as they knew some solitude would improve theirhealth status. Some of the women in the study felt they needed to be away from theirfamilies so that the time spend by themselves and with the new baby could be maximized.The women believed that the presence of the other children at home was an interpersonal42influence that interfered with their ability to know their newborn. One woman stated, “Itis the only time you have with this baby so you need to make the most of it.” “You needtime alone with this baby so you can get to know this baby as an individual, as you willnever have this chance once you get home,” expressed one multiparous woman. Similarcomments were made by others. Many women commented that you can never go back onthis time or make up for it once it is gone. Another woman stated the she needed to “regroup” and another described this time in the hospital as the chance to “bridge thetransition from one stage to another, from the birth to now”.The need to be alone was found to be more relevant for multiparas (n=8) thanprimiparas (n=4). Multiparous women described many responsibilities involving otherfamily members and no time left over for themselves and the new baby to be alonetogether. The two primiparous women that expressed this need were from large extendedfamilies and feared for alone with their babies. They did not want to have to share themwith anyone else.Women also stated that they needed personal time and the ability to pamperthemselves in the hospital. One woman expressed herself by stating, “If you don’t get thistime now you can crash very easily from the emotional strain of it all.” Two women inthe study commented that it was a luxury to stay in the hospital. A few women expressedfeeling selfish and somewhat guilty staying in the hospital. One woman made thefollowing comment, “I enjoy having the freedom to read, sleep and just do anything,anytime of the day and night.” Similar comments were expressed by several other womenin the study. Some women did not believe they were capable of going home and taking43control of their lives and recovery, an indication of decreased feelings of self-efficacy.The women in the study felt they needed an artificial environment to set time aside tomeet their own needs because they felt they had no control over their health.The literature supports the need for women to be alone with the new infant.Integration of the infant into the family and adjusting one’s lifestyle is an importantpostpartum maternal task (Gruis, 1977; Rubin, 1984). Rubin (1961) theorized that the“taking-in” phase of maternal adjustment requires rest, food, care, and time occurringwithin the first two to three days postpartum prior to “taking-hold” of the woman’s newrole. Replenishing psychic energy is part of the postpartum recovery period and womenin this study felt that the time in the hospital, away from family and other distractions is atime for regrouping and gathering psychic energy (Ziegal & Cranley, 1984).Early discharge research has found that many women enjoy being home andsharing time with their families and state that this is one of the main benefits of goinghome early (Bradley et al., 1989; Patterson, 1987; Lemmer, 1987). Drummond’s (1984)findings also indicated that women were motivated to go home early to avoid any delay inintegrating a new infant into the family unit.Many of the factors in this category are similar to study findings involving womenwho stay in the traditional hospital postpartum stay and those who participate in earlydischarge (Bradley et al., 1992; Patterson, 1987). Both groups of women appear to bestriving to fulfil the same maternal tasks of postpartum. Some women find it is better toachieve these tasks in the hospital. For others, it is easier at home. The question thatneeds to be addressed is whether or not they could have time alone at home rather than44having to use hospital resources.The need for physical and emotional restoration reflects the women’s need for restand sieep as expressed by the study participants for their reason for staying in thehospital. Women also felt the hospital provided them with comfort measures, bothphysical and emotional in nature, that they felt their home environment could not provide.The women in the study needed the services that the hospital provided them in order tochange their health status to be more congruent with their definition of health, which wasto be more rested, relaxed, comfortable and recharged.Need for CareThe women identified a need for care and this care included: help in caring for selfand baby, support on a 24 hour basis, and physical and emotional protection from the“outside world”. These factors are summarized in Table 6.Table 6Need for CareDescription Frequency PercentNeed for help 26 47Need for support 19 34.5Need for protection 8 14.5Need for help. Women stated that they needed to be in hospital to receive the helpservices that only hospital could provide. This included help to care for themselves andthe baby, assistance with breastfeeding, meal and accommodation services, educationalinformation, and advice from health professionals. These situational and behaviouralfactors assisted women to increase their perceptions of self-efficacy and to change their45perceived health status to fit more closely with their definition of health.The women, mainly first-time mothers, expressed that they particularly needed helpin caring for and understanding the needs of a newborn. One woman stated, “I don’tknow anything about babies; the nurses know everything and are so confident in handlingthem.” This lack of confidence or perceived low self-efficacy made them fearful andscared to go home early. The women believed they had little control over their healthand that they could not independently access information that they required outside of thehospital setting.The primiparous women defined nurses as providers of information and advice, asteachers and experts. Sixty-eight percent (n=19) of primiparous women stated theyneeded the educational information they could access in the hospital. One first-timemother stated, “They tell you in prenatal classes about these things but nothing sinks in.”Many of the women expressed they would not know what to do if they did not have thenurses to ask or help them. “You are supposed to know all this stuff but you forgeteverything you read,” commented one women. These women believed resources did notexist outside the hospital for them.Teaching from the nurses decreased the women’s anxieties and increased their selfefficacy in caring for their baby once they go home. “It is nice to be around the nurseswhen a problem comes up as it helps for the next time,” stated one study participant. Onefirst-time mother said, “If I went home I don’t know who would help me with the babyand answer my questions.” Another comment was made by one of the women that “thenurses guide and teach you as you are going through things”.46Past postpartum experiences were stated by some women to have influenced theirdecision to stay in the hospital. Two women had experiences with their last babiesbecoming jaundiced and requiring re-hospitalization for phototherapy. Both of thesewomen stated they did not want to go through the same experience again. Anotherwoman had her last baby prematurely and had not planned to go home early because shewas afraid that might happen again. Because of these negatives experiences these womenfelt it was best to stay in the hospital for the health of themselves and their babies.Another factor identified by the women which influenced their decision not toparticipate in the early discharge program was the need to have breast-feeding establishedbefore going home. The women in the study did not perceive they would receive thesame help with breastfeeding at home. This lack of knowledge about community was abarrier for the women, therefore they decided not to participate in the early dischargeprogram.Two women who had breastfed previous children stated that they wanted theirmilk supply established and breastfeeding “off to a good start” before leaving the hospital.Two other women who had failed to breastfeed with their other children equated supportand information on breastfeeding before leaving the hospital with ensuring success atbreastfeeding. First-time mothers were anxious for the help they were receiving from thenurses on breastfeeding. One woman stated, “I know absolutely nothing about this wholething so I need all the help I can get.” Another woman stated “it was a lot harder than Ihad expected and wanted to feel good about breastfeeding before I went home.”The physical strain and difficulty experienced with breastfeeding were expressed47by some women as factors affecting their decision. Sore nipples, difficulty with the babylatching on to the breast, and scheduling feedings were some of the specific problemsidentified that needed nursing support. The women stated that being in the hospitalallowed them to spend time breastfeeding in a supportive and helpful atmosphere. Onewoman stated, “If you get the feeding off to a good start it will help once you are home.First-time mothers expressed much more apprehension than multiparas andappeared nervous regarding newborn feeding. They stated that they lacked the knowledgeto breastfeed successfully. By staying in the hospital they felt they would gain the skillsand information required to be successful. One woman commented that she found it was“great to have the nurse around the first few times that you fed the baby; it helps boostyour confidence”. The help they received from the nurses was equated with increasedfeelings of self-efficacy about breastfeeding.A few of the multiparous women in the study had negative past experiences withbreastfeeding which led them to want more help from the nurses. “Milk coming in” wasseen as an indicator of success. One woman stated that “once the milk is in, all will gowell”. Several of the women thought it was best to stay in the hospital until thebreastmilk was in.Establishment of breastfeeding was an important consideration for many of thewomen in this study as eighty-eight percent (n=48) of the women were breastfeeding atthe time of the study interviews. It is well documented that infant feeding is a paramountconcern and priority for women in the early postpartum period (Smith, 1989; Tobert,1986). The women in this study supported the theory that successful breastfeeding was48intrinsic to healthy maternal adaptation. The nurses working in the M.C.A.H. programcited one of the major concerns of women in the immediate postpartum as breastfeeding.This was also demonstrated in the study by Bradley et al. (1989). Chapman (1985)studied women’s postpartum concerns with breastfeeding and they included in the order ofpriority: milk supply, sore nipples, frequency of feeds, and breast milk storage. Thisstudy also found that breastfeeding was a priority for women and they felt that staying inthe hospital would lead to success in this process. Ironically, a qualitative study by Ellis& Hewat (1984) found that women who stay in the hospital longer are less successfulwith breastfeeding than women who go home early.In Patterson’s (1987) study the main concern and the reason for staying in the hospitallonger for primiparous women was their need to improve their ability to care for theirbaby correctly and having knowledgable people to help. Lemmer (1987) found thatprimary concerns for first-time mothers who stayed longer in the hospital were learningabout their infants and becoming acquainted with them. Women in the traditional hospitalstay group in the Bradley et al., (1992) study rated learning about baby care significantlyhigher as a factor of importance in their decision-making, than women in the earlydischarge group.It is apparent from the study’s findings that establishing breastfeeding is a majorcomponent of the need for help for both primiparous and multiparous women. Thewomen’s lack of self-efficacy around feeding was a factor which influenced their decisionto stay in the hospital. Women approached breastfeeding as a learning process andbelieved that by staying in the hospital longer they would learn the knowledge and skills49to establish a milk supply required for successful breastfeeding before being dischargedhome.The repeated findings in a number of research studies suggest there is a group ofwomen who are not confident in their ability to care for themselves and a new baby. Itwould seem these women feel that they do not have the control over their health to thedegree that they can independently address their health care needs. The women in thisstudy chose to stay in the hospital to reduce their concerns and to increase their self-efficacy.Need for support. The women included being supported as part of their definitionof health. They felt supported in hospital but they did not believe they would beadequately supported at home. The women defined support broadly. They believedhealth-care professionals understood what they were going through and consequently theirpresence was an interpersonal influence that would assist them to feel supported. Supportalso included helping with the baby at night, providing support for breastfeeding, helpingmeet their physical needs, and providing interventions in the event of an unexpected crisisfor themselves or their infants. The women believed the support would decrease theiranxiety and increase their self-efficacy. To address their need for support they wantedaccess to nursing and medical care and support 24 hours a day. Women described supportas having access to nurses and doctors who could check them and the baby anytime.Nursing and medical support helped build their confidence in caring for their babyand in caring for themselves. One woman commented that she would not trust what herhusband said if she asked a question about the baby, but she trusts the nurses’ expert50advice. Another woman said that she wanted to take the night nurse home with her. Onewoman stated that she was “scared to death” to go home with her baby on the firstpostpartum day. “I don’t know anything about babies. I would probably have killed him,”stated the woman.This need for support, in part, was related to interpersonal influences. Thesewomen believed that family members lacked the skills or would not be available toanswer questions or help them with baby care at home. Many of these women stated theyhad no support available to them if they went home early from the hospital.The literature also describes a woman’s need to feel supported and understood inthe postpartum period (Mercer, 1981). Patterson (1987) found that the women in the latedischarge group highly rated attention from others as a reason for staying in hospital; theyalso wanted to be in the hospital to ensure nurses would be close by. This same group inPatterson’s (1987) study found the nurses more helpful than family members in helpingthem gain confidence.Need for protection. Women stated that because of their current health status, theyneeded protection. Protection from the outside world was articulated by responses suchas, “I want to stay in a cocoon with just myself and my baby; I don’t want anyone tobother us”. One woman stated, “The nurses protect you from the external world”. Othercomments regarding protection were: “You don’t have to worry about anything while youare in the hospital; everyone is here to help you. It is so easy in here. I feel depressedwhen I go home after having a baby. The hospital feels so safe and everyone is so nice.When you go home reality sinks in and there is no one to fuss over you.”51When some women talked about being protected from the reality they weredescribing being away from the work and tasks at home. The hospital acted as “a barrieragainst the outside world”. Many of the women expressing this need wanted to beprotected against outside influences such as visitors, other children and loneliness orisolation. The women saw the care they received from the health-care professionals andhospital environment with offering an artificial, protective environment. These situationalfactors would be absent at home.The need for protection was one of the most unexpected factors found in thiscategory. More primiparas than multiparas indicated a need for protection, which wasdefined as both emotional as well as physical. The primiparous women may have beenparticularly worried about incorporating the new infant into their lives, and taking on thecare-taking role that they wanted as little interference as possible.The women in this study perceived the hospital as a supportive environment incontrast to Lemmer’s (1987) study and Hall & Carty’s (1993) study. Both studies notedthat women who chose early discharge felt that it was just as safe at home as in thehospital. They felt a sense of comfort in the home environment and they received supportfrom their husbands and family (Hall & Carty, 1993; Lemmer, 1987).Other research on postpartum women’s hospital experience contrasts with theresults of this study. Moss (1987) found that many women discontinued breastfeedingbecause of dissatisfaction with the help and assistance from the hospital staff. In anearlier study, Moss (1981) also found that women hospitalized with their first baby foundthe nursing staff demanding and they would have preferred more help than they received.52Studies have found that women find the advice in hospital which is given by manydifferent people inconsistent, confusing, and anxiety provoking (Moss, 1987).This category indicates these postpartum women had a need for care, and definedthat care as only available in the hospital. The situational factors in hospital as opposedto interpersonal influences at home defined their needs for education, modelling, advice,support and protection. First-time mothers emphasized their need for information and theimportance of access to advice, support, and protection from the hospital resources.Questions arise as to whether these needs could be met in the home environment.External and Internal Influences and BarriersThis section describes modifying factors evolving from the content analysisthat influenced a woman’s decision to stay in the hospital. These included situational andbehavioral factors, and interpersonal influences such as home environment, influentialpeople and lack of awareness of the early discharge program. These factors affected thefeelings of control over their health and consequently their decision about earlypostpartum discharge. The specific factors are outlined in Table 7.Table 7External and Internal Influences and BarriersDescription Frequency PercentChildren at home 25 45.5No help at home 24 43.5Physician influences 13 23.5Partner, family and friends influences 11 20Did not know about the program 11 2053Having other children at home was major factor influencing women’s decision tostay in the hospital. The women with children at home felt that they needed to stay in thehospital so they could rest and recover without the other children around and so theycould spend time alone with the new baby. Three women distinctively stated, “No oneelse can take your place at home so it is better not to be around at all.” One womanadded that “you will just get caught up in doing it all”. The children, according to thewomen in the study, expected the mothers to play with them or do things for them thatonly the mother could do. Many of the women who expressed this concern missed theirchildren but felt it was better to stay in the hospital for them and their families. Concernfor the other children at home was one of the highest rated concerns for multiparouswomen in many studies (Gruis, 1977; Harrison & Hicks, 1983; Patterson, 1987; Smith,1989). Research reflects the concerns of multiparous women for their children in thepostpartum period and for the integration of the new member into the family.Another factor cited frequently which influenced many women to stay in thehospital longer was lack of help at home. Women described needing help with thechildren and the household tasks such as cleaning and cooking. Nearly half (44%, n=24)of the women in the study, both primiparas and multiparas, stated they had little or nohelp at home. The women felt that they would receive better help in the hospital thanwhat they would receive at home from their family. This finding is similar to that ofPatterson’s (1987), that women who refuse early discharge prefer to stay in the hospitalfor the help they can receive.The women stated that their husbands and family members wanted them to rest54and get healthy and stronger before coming home. One woman stated, “My husbandwants me to stay in so I can learn as much as I can about taking care of the baby.” Manywomen stated that their husbands and family were scared to take them home so soon andit was up to the doctor to make the decision. Some women commented that theirhusbands were too busy to have them home and it was better for them to stay in thehospital so they could be looked after by the nurses.The study participants commented that friends and family influenced their decisionby telling them to rest while they could. This was especially true for mothers with otherchildren. One woman said that her friends with children were very adamant that “if yougo home early you will never catch up on this time and you will wear yourself out”.The people that women said influenced their decision the greatest were theirphysicians, although partners and/or husbands, family and friends were also influential inthese women’s decision to stay in the hospital. Many women expressed that it was up tothe doctor to discharge them and their babies. One woman stated, “My doctor said it wasbetter for me to stay in the hospital.” Another said that her doctor told her there was norush for her to go home. Of the thirteen women that stated it was up to their physician tomake the decision, all were Asian-Canadian. These women felt it was best to stay in thehospital and wait for the doctor to discharge them. They also expressed that if theirdoctor felt it was better to stay in then they would do what he or she said was right to do.Over half of these women did not know about the early discharge program and did notknow they could ask their doctors about going home. The physicians attending thesewomen were not active users of the hospital’s early discharge program.55Women in Patterson’s (1987) study, when asked who was influential in theirdecision to choose early discharge, said that it was their own decision and for latedischarge women it was partners, family, friends, physicians and hospital nurses.A large percentage of women were unfamiliar with the early discharge programand therefore did not plan to participate. Some women heard about the programprenatally but were unclear on how it worked and operated. Half the women stated that ifthey had known about the program they might have gone home early. They felt becausethey didn’t know about the program they were not organized to go home. Other womenwere adamantly against the concept of going home early. A small group of women whenasked whether they would go home early with their next baby said they would have towait and see how things worked out. Gruis’(1977) findings suggest that women requireantenatal preparation to help cope in the postpartum period.The factors such as other children and no help at home were prominent andoverwhelming issues affecting the study participants’ decision to stay in the hospitallonger. There was a sense from the women in this study that the hospital was notnecessarily providing them with medical care but a replacement for services and resourcesthat they were lacking in their own homes and community. It could be surmised that itwas just easier for the women and their families to stay in the hospital. The womenseemed to enjoy being in an environment that provided them with services such as a cleanroom and meal services as well as people who were there to care for them. The womenalso appeared to appreciate having things done for them.The other two areas that were extremely revealing in this section were the56influence others had on the women in this study and the lack of information they hadabout the early discharge program. It appeared that the women influenced by theirphysicians and family felt vulnerable and helpless in making the decision to either gohome early or stay in longer due to lack of experience and knowledge in making informedhealth-care choices. Cultural-health practices could play a large role in how influentialcertain people are and how health-related information is relayed and processed. Lack offamily preparation and involvement also appear to be influential in these women’sdecision to stay in the hospital longer. The majority of factors listed in this section couldbe addressed by better education of physicians and families, and increased communityservices.These findings contrast with the research that has been done on women whoparticipate in early discharge as they define themselves as risk takers who rely heavily ontheir own decision making (Hall & Carty, 1993). In Patterson’s (1987) study the majorityof women participating in early discharge knew about the program in advance througheither prenatal classes or information pamphlets. This assumption is reinforced by the factthat women who chose the traditional hospital stay feel that the hospital is the best placefor recovery following birth and have no knowledge of alternatives (Bradley, et al., 1989;Lemmer, 1986; Patterson, 1987).Ancillary FindingsThe investigator had some apprehensions that the women would be reluctant tospeak openly about their decision while they were still in the hospital. The studyparticipants on the contrary, were very responsive in discussing their experiences and57decision with the investigator. The majority of the women articulated their reasons fornot participating in early postpartum discharge in a well-framed and organized manner.In addition to the answering the interview questions, the majority of the women inthe study were very eager to discuss their labour and birth and immediate postpartumexperience. This finding reflects the need to review the events of the childbirthexperience and integrate the actual experience with the expected experience. This is oneof the tasks of the postpartum period as noted by Mercer (1981).In conclusion, the information gathered through the interviews was used to developthe categories. The categories were then examined in relation to the health promotionframework. The women in the study did not believe that they had control over theirhealth. They perceived themselves to be tired and uncomfortable. Demographiccharacteristics, interpersonal influences, situational factors, and behavioural factors actedto influence the women’s perceived health status so they ended up seeing the homeenvironment as a barrier to health-promoting behaviours. In particular, perceived healthstatus, perceived control of health, self-efficacy and perceived benefits and barriers wereaddressed through the women’s expressed views on their decision to stay in the hospital.The study participants chose to stay in the hospital because they believed it wasthe best for their health and for their babies. The women felt this was an important healthdecision and was important for their postpartum recovery. They based this decision ontheir health status at the time of the decision and past health experiences with thepostpartum period.58SummaryThe findings presented in this chapter consist of a summary of relevantdemographics of the participants, description of responses obtained from the studyinterviews, and discussion of the findings. The women who participated in the study wereable to describe the factors that influenced their decision to not participate in an earlypostpartum discharge program. Through a process of content analysis, the responses werecategorized according to their primary focus in order to relate them to influential factorsaffecting a woman’s decision. Two main categories were identified; the need for physicaland emotional restoration and the need for care. The individual perceptions that make upthe cognitive-perceptual factors of Pender’s (1987) Health Promotion Model werereflected in the findings of the study.59CHAPTER FIVESummary, Conclusions, Implications, RecommendationsIntroductionThis study was designed to identify the factors influencing a woman’s decision notto participate in an early postpartum discharge program. An overview of the study ispresented in this chapter followed by conclusions, implications for nursing practice,education, and recommendations for future research.SummaryThis study was exploratory in nature, and was carried out using a factor searchingdesign and, content analysis was used to examine the data of the interview questions,based on the Health Promotion Model by Pender (1987). Fifty-five study participantsconsisting of 28 primiparas and 29 multiparas, were interviewed on their second or thirdpostpartum day during their hospital stay. The sample was recruited from a large tertiarycare maternity hospital in Vancouver, British Columbia. All women interviewed had metthe criteria of the hospital’s early discharge program but had decided to stay in thehospital rather than go home early.The study identified the factors influencing the study participants’ decision to stayin the hospital. The two major categories factors emerged: 1) need for physical andemotional restoration and 2) need for care. External and internal influences and barriersaffecting the participants’ decision to stay in the hospital were also identified.When examining the findings in light of Pender’s (1987) health promotion model,two of the cognitive-perceptual factors stand out. The women felt they were not healthy60enough to go home (health status) and that they were not confident enough to go home(self-efficacy). The modifying factors found in Pender’s (1987) model were also relevantin looking at the factors. These included: biologic characteristics such as fatigue,situational factors such as having other children at home, and behavioural factors andinterpersonal influences such as the ability to carry out the required skills to carethemselves and their baby, and the influences of their physician and family.By staying in the hospital the women were able to increase their self-efficacy andenhance their perception of their health status prior to being discharged home. Thewomen perceived the hospital as the best place for them to access the health-care they feltthey needed for recovery and maternal adaptation. The women perceived many barriers togoing home and many benefits in staying in the hospital.Participants demographic profiles revealed no apparent relationship between ageand method of birth. Multiparous women reported that the primary reason for notparticipating in an early discharge program was because they had other children at homeand no help. Primiparous women expressed the need for the availability of education andsupport in caring for themselves and their new baby 24 hours a day. The need for restand sleep was expressed by more multiparous women than primiparous women as thefactor affecting their decision to stay in the hospital. A high percentage of the women inthe study did not feel prepared to go home because they did not know about the earlydischarge program prior to their hospitalization. The participant’s physicians were foundto be the most influential figures in the women’s decision to stay in the hospital longer.61ConclusionsWomen stay in hospital because they feel their needs for physical and emotionalrestoration and care can best be met in the hospital environment. Situational factors suchas other children at home, lack of support at home, and the views of significant othersinfluence the decision women make about participating in an early postpartum dischargeprogram.ImplicationsThis section presents the implications for nursing practice, theory, education andresearch. Changes that can be made within the present perinatal health-care system andthose that would be ideal for the future will be discussed.Nursing PracticeModifications in nursing practice and in the delivery of consumer education is oneof the first steps toward addressing the findings of this study. In the near future it will beexpected that all women without complications will go home within 24-48 hours of birth.The focus then needs to be on assisting women to re-frame their perceptions andexpectations of the postnatal period. This will increase their self-efficacy and put them ina more effective control of their health status and related health-care decisions.Nurses and others who care for women in the postnatal period must develop andimplement education programs and practice measures that are relevant to theoverwhelming needs and maternal definition of health, in the context of the birth of a newinfant. Supportive care and education that is able to assist women with unique concernsand maternal tasks of the postpartum period is critical, whether women are recovering in62hospital or at home.The need for rest and sleep was demonstrated in this study’s findings and has beendocumented in the literature on early postpartum discharge and maternal tasks as being anoverwhelming need for all postpartum women (Bradley, et aL, 1992; Mercer, 1986; Rubin,1984). The other area of great need for women was the aspect of education and help inthe postnatal period. Both of these areas require care and attention and must be addressedif the goal is to provide optimal postpartum recovery and adaptation for all childbearingfamilies within and outside the hospital environment.Helping families to plan for early discharge is critical so that women are able toobtain as much rest and sleep as possible. Family members can be involved in screeningvisitors, planning rest periods, cooking meals and taking on housekeeping tasks. If familymembers are not available community services need to be put in place.Expanding and improving postnatal education into existing prenatal classes, andincorporating infant care classes in community centres and on local cable networks wouldenhance the accessibility of postnatal preparation for women and families.The care and teaching that individual families receive when in the hospital mustbe carried through to the community. This can occur by implementing a comprehensiveand efficient method of communication between hospitals and community health units,which would allow information to be shared in a timely way. Early contact and homevisits following hospital discharge would result, ensuring effective teaching and supportextending from hospital to community. Prenatal and postpartum home visits from thecommunity health nurse, utilizing a detailed referral system from community to hospital,63and hospital to community would enhance the utilization of resources and services closerto home.Childbearing women, their families and health care professionals require accurateinformation on a variety of perinatal healthcare issues and options. Resources must beaccessible and available to assist in bridging the information gap. The belief that thehospital is the only place to obtain support, assistance, and recover postnatally, or thatearly discharge is also best for all women, needs to be explored and challenged by allparties involved in perinatal healthcare. With education and knowledge, women mightincrease their self-efficacy and may find health-promoting decisions easier to make.Familiarizing and educating women and their families as to the choices available tothem involves effective marketing of community health resources, services and networksystem. Communities and their health-care provider’s must be targeted as they mayrequire information and education programs to meet their different needs. Thesemarketing strategies must also be evaluated for their effectiveness in reaching thispopulation of women.Many of families, such as the Indo-Canadians and Asian Canadians, haveculturally-based rituals surrounding the birth of a new family member. For example, thesenew mothers often have large extended families. Recovery at home, with close familymembers for comfort and support and with health care professionals visiting in the homerather than the unfamiliar environment of the hospital, would seem to be an excellentchoice for these women. Culturally-sensitive programs that encourage interaction andinvolvement of the family would enhance learning and relieve anxieties for many64childbearing women and their families.Programs that incorporate support for physical and emotional restoration andprovide information to new parents are essential. A regional program would involve closecollaboration between the community and hospital, utilizing specialized perinatal nurses,homemakers, and a variety of support services that would follow families through theirpregnancy and postnatal period. The program would offer families planned home visitsby a nurse, and 24 hour phone contact immediately after hospital discharge for the firsttwo to six weeks postpartum. The visits would be based on need and/or request from thefamilies and would utilize specialized nurses in the area of maternal-family nursing.Homemaker and child care services would be provided on a sliding fee scale to familieswho need assistance with light housework and child care.All of the early discharge programs in the regional area would encompass a systemin which planning was done with each family. The programs would also include teachingsessions for expectant parents during the last trimester focusing on postpartum dischargeinstructions for mothers and babies. The program would incorporate and expand thescope of existing perinatal services in the community health units and hospitals, such asprenatal classes and postnatal drop-ins and speciality clinics designed for perinatalfamilies.Women would be registered into a perinatal program during their pregnancy orpostnatal period. Referrals would be made by community/hospital health professionals,primary care givers, and/or the women themselves. By registering the women during theirpregnancy, program planning and patient preparation would be facilitated creating less65anxiety for both the families and caregivers. Referrals between professionals could occurat anytime throughout the perinatal continuum. Evaluation would be a standardcomponent of the programs, ensuring ongoing quality and satisfaction for all users of theservice. With education and access to appropriate resources new families could viewearly postpartum discharge of mothers and newborns as a normal and healthy part of thelife cycle.Nursing EducationNurses are closely involved in the provision of care for postpartum women andtheir families and are often the primary health-care contact for many families within thecommunity and hospital. For this reason there is continued need for updated nursingcurriculum. The curriculum needs to incorporate the following: the critical needs andconcerns of postpartum women with respect to parity, cultural and socio-economicdifferences, influential factors affecting health-care decision-making, and the benefits andbarriers of associated with early postpartum discharge and traditional postnatal care.Postpartum maternal-task theory and Pender’s (1987) Health Promotion Model arevaluable tools and their use should be encouraged in the education of nurses caring forwomen in the postpartum period.Pender’s (1987) framework would be helpful for nurses in assessing, assisting, andeducating women in other related health-care decisions. Both the cognitive-perceptual andmodifying factors were helpful in understanding the decision the women made. Theframework can be a model for nurses to use when planning educational programs and inunderstanding women’s health-care decisions.66Recommendations for Nursing ResearchExamination of issues affecting women in the postpartum period such as rest andsleep, physical and emotional comfort needs, and need for care, requires furtherexploration and research. These issues need to be examined in relationship to the hospital versus home environment, and how women’s needs can best be met inthe early postnatal period. Research on breastfeeding success and the effects of earlydischarge must be explored further.Studying women’s expectations about rest and sleep, both prenatally andpostnatally, would be extremely useful for women, as well as health-care providers toknow and understand. Qualitative research would enhance and contribute to basicconstructs in this area. Demographic and comparative studies would be helpful to identifycommonalities between groups, and the factors and variables affecting rest and sleep inthe postnatal period.Many studies have been done on the general needs and concerns of women butvery few have examined the specific areas in detail and of different sample groups andcultures. By isolating specific groups and populations such as multiparous women andcultural groups, sampling would provide information surrounding the barriers andsituational influences affecting women’s postpartum recovery. These issues can then betargeted for appropriate nursing intervention and changes in the delivery and practice ofperinatal health-care, especially in relationship to early postpartum discharge.Examining how women frame their beliefs and expectations surrounding thechildbearing period would be enlightening. How do they identify such areas as lost67periods with newborns that can never be regained? Can health professionals be justifiedin trying to intervene and change these beliefs and expectations?Examining the perceptions of women’s partners and their experience with earlydischarge would be very relevant, as husbands and/or partners were found to be the mahisupport person for most women in this study. It would also be interesting to examine theperceptions of other family members in relationship to early postpartum discharge and theaffects on the family from a qualitative perspective. Experimental research needs to becontinued as well, to assist in unravelling the fears and misconceptions that plague a largegroup of childbearing women, their families, health-care providers and society in generalsurrounding the concept of early postpartum discharge.Investigating in more detail women’s attitudes and beliefs surrounding the perinatalperiod and how these influence their feelings of self-efficacy and control over their healthwould be enlightening.In conclusion, it is this investigators’s hope that research will continue to beconducted to expand the body of nursing knowledge in the general area of postnatal careof women and their families. An area of particular interest is the delivery of present dayperinatal healthcare and the everchanging and eclectic needs of today’s childbearingwomen.68ReferencesAvery, M.D., Fournier, L.C., Jones, P.L., & Sipovic, C.P. (1982 July/August). An earlypostpartum hospital discharge program. 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Maternal-Child Nursing Journal, 12, 185-216.Waltz, C.F., Strickland, O.L., & Lenz, E.R. (1991). Measurement in Nursing Research.Philadelphia: F.A. Davis Company.Yanover, M.J., Jones, D., & Miller, M.D. (1976). Perinatal care of low risk mothers andinfants: Early discharge with home care. The New England Journal of Medicine,294(13), 702- 705.Ziegal, E.E., & Cranley, M.S. (1984). Obstetric Nursing (8th ed.). Toronto: Collier MacmillanCanada, Inc.Appendix AM.C.A.H. Criteria7374STANDARDS AND CRITERIA FOR POSTPARTUM MATERNAL ANDNEWBORN DISCHARGE FROM GRACE HOSPITALStandard 1: Healthy mothers and newborns will be discharged and referred to the MaternityCare at Home Program earlier than norm.CRiTERIA1.1 A mother will be eligible for discharge from Grace Hospital if:• vaginal birth - discharged 6-48 hours postpartum;• Caesarean Section - discharged 3-4 days postpartum;Blood Pressure < 140/90;Temperature < 38° C p.o at discharge;No significant vaginal bleeding { excludes any client with transfusion };No uterine atony { exclude IV oxytocins> 12 hrs };Normal appearance of incision/episiotomy;No significant ongoing urinary difficulties;No clinical evidence of deep venous thrombosis;Blood loss < 1000 CC at delivery;HgB >95 intrapartumPostpartum HgB > = 90 - if not available at time of discharge, then the postpartumHgB must be obtained with a copy of the report to be sent to the attending physicianand to the MCAH Program;No surgical or medical problems for which a patient requires continued hospitalization.Breastfeeding Mothers:Mother demonstrates ability to put the baby to breast;Baby able to latch on to the breast and suckle effectively.1.2 Newborns will be eligible for discharge from Grace Hospital if:Completed Normal Newborn Discharge Examination;Birth weight> = 2500 grams and appropriate weight for gestational age;Gestational age between 37 and 42 weeks;No evidence of asphyxia at birth (Apgar 7 or greater at 5 minutes);Vital signs on discharge: Temperature 36.1° C - 37.2° CRespiration rate 30-60 per minuteHeart Rate 100-160 per minute;Normal cord blood results (no blood group incompatibility);No abnormal voiding or stool patterns;No abnormal feeding patterns;No evidence of significant clinical jaundice;Normal muscle tone, cry, infantile reflexes and behaviour;Newborn screening:- Hip check - [if not done at hospital, screening will be done by physician]- PKU and thyroxine screening test - [if not done at hospital, a form is given to bedone by physician or laboratory]Appointment to see attending physician within one week of discharge.Appendix BInformation Letter7576THE UNIVERSITY OF BRITISH COLUMBIA&-‘iool of NursingT. 206-2211 Wesbrook MallVancouver, B.C. Canada V6T 2B5Fax:(604) 822-7466DearMy name is Jill Mahy. I am a registered nurse and I am currently a student in the Masterof Science in Nursing Program at the University of British Columbia. As my thesis topic, I aminterested in studying the influences affecting a womans’ decision to not participate in an earlypostpartum discharge program.I believe that it is important to explore human experiences by asking the people who livethem to teach me about them. Gaining knowledge about a woman’s decision not to participatein an early postpartum discharge will assist in improving the quality of nursing care and servicesfor postpartum families.Please consider participating in this study by agreeing to be interviewed about yourdecision. The interview will be scheduled to take place in your hospital room prior to discharge.Your privacy will be protected at all times. Any information that you share will be held instrictest confidence and you will never be identified in any published or unpublished materials.You have the right to withhold or remove any information that you desire. You may withdrawfrom the project at any time without jeopardy or prejudice to your health care.Data collecttd from the interview will be audio tape recorded and handwritten notes willbe taken by the interviewer. No names will appear on the recordings, and the only other personsto read them will be two faculty members who are my thesis faculty members. All tapes andtranscripts will be destroyed upon completion of the study.-If you are interested in participating in this study, please place a tick in the appropriatespot (yes or no) below and return this letter to the nursing station or to your nurse.Yes,_____ I am wffling to participate in the study.No,_____I would prefer not to participate in the study.Thank you for considering this requesLYours sincerely,Jill Mahy, R.N., B.S.N.875-6956Elaine Carty,Associate Professor,Thesis Supervisor822-7444Appendix CInformed Consent Form77THE UNIVERSITY OF BRITISH COLUMBIA78School of NursingT206-2211 Wesbrook MallVancouver, B.C. Canada V6T 2B5ITel: (604) 822-7417Fax: (604) 822-7466I agree to participate in the nursing research study to be conducted by Jill Mahy, R.N.,B.S.N. who is a graduate student in the Masters program of the School of Nursing of theUniversity of British Columbia..The study and my role in it has been explained to me. I understand that my participationis voluntary and that I may withdraw at any time without consequence to my health care. Iunderstand that my participation includes a 45 minute interview with the researcher in my hospitalroom at Grace Hospital. I understand that all information will be held in the strictest confidenceand that I will never be personally identified in published or unpublished materials. I havereceived the names and telephone numbers of the thesis advisors at the University of BritishColumbia. I have had the opportunity to ask questions and concerns about the study.My signature on this form verify my intention to participate in this study. I have receiveda copy of this consent form for my records.SIGNATURE_____DATEParticipantSIGNATURE_____InvestigatorJill Mahy, R.N., B.S.N.875-2899Elaine Carty,Associate ProfessorThesis Supervisor822-7444Appendix DPhysician Letter7980THE UNIVERSITY OF BRITISH COLUMBIASchool of NursingT. 206-2211 Wesbrook MallVancouver, BC. Canada V6T 2B5Fa.: (604) 822-7466Jill Mahy,#103 - 3819 Cambie StreetVancouver, B.C.V5Z 2X6Telephone: 875-6956Dear Dr._________________My name is Jifi Mahy. I am a registered nurse and I am currently a student in the Master ofScience in Nursing Program at the University of British Columbia. I am doing a research studyon a woman’s decision not to participate in an early postpartum discharge program.This letter is to inform you that your patient, Mrs./Ms.______________________________has agreed to participate in this study by consenting to one interview during her hospital Stay.If you have any questions or concerns about the study, or your patient’s participation, please feelfree to contact me at 875-6956.Thank-you.Sincerely,Jill Mahy, RN, BSNAppendix EDemographic Information Sheet8182Demographic Information SheetAge of participant:__________yearsMarital Status of participant: single:__________common law:__________married:_________divorced:__________Ethnic background of participant_____ ___ __________ _________Highest level of education of participant____ ______ ___ ___Occupation of participant______ _Occupation of spouseTotal income level of household:_ _ __Number of persons currently living in participants household:___Number of children/agesof participant:_ ____Number of pregnancies:_Brief history of participants present and past birth and postpartum experiences:Brief description of the support and help that is available to the participant:

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