Applied Science, Faculty of
Nursing, School of
DSpace
UBCV
Hambley, Nancy Elaine
Master of Science in Nursing - MSN
University of British Columbia
CHNs were of the opinion that after the call women seemed more aware of self-care, seemed less anxious when caring for themselves or their infants, contacted their physician more appropriately, received more support, were more aware of community resources, used the available resources more, and got out more. It is recommended that the telephone call intervention be implemented for all women following birth, but that it occur earlier than six weeks postpartum, preferably at three to four weeks postpartum. Implications and recommendations for nursing practice, nursing education, nursing administration, and future nursing research are presented.
9409210 bytes
application/pdf
E V A L U A T I O N OF A T E L E P H O N E I N T E R V E N T I O N I N C O M M U N I T Y H E A L T H N U R S I N G P O S T P A R T U M C A R E by N A N C Y E L A I N E H A M B L E Y B . S c . N . , The University of Alberta, 1984 A THESIS S U B M I T T E D I N P A R T I A L F U L F I L M E N T OF T H E R E Q U I R E M E N T S F O R T H E D E G R E E OF M A S T E R OF S C I E N C E I N N U R S I N G in T H E F A C U L T Y OF G R A D U A T E S T U D I E S The School of Nursing We accept this thesis as conforming to the required^standard T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A July 1999 © Nancy Elaine Hambley, 1999 U B C Special Collections - Thesis Authorisatio... Page 1 of 1 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t ' o f the requirements for an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission for extensive copying of t h i s thesis for s c h o l a r l y purposes may be granted by the head of my department or by h i s or her representatives. It i s understood that copying or p u b l i c a t i o n of t h i s thesis for f i n a n c i a l gain s h a l l not be allowed without my written permission. Btjpax lurewt of The U n i v e r s i t y of B r i t i s h Col Vancouver, Canada A B S T R A C T The telephone is used frequently in community health nursing to provide care. Studies have not explored postpartum women's perceptions of telephone contact by community health nurses (CHNs) or described the C H N s ' views about using the telephone to provide postpartum care. Currently, C H N s implement a telephone intervention to women who are six weeks postpartum. The purpose of this study was to conduct a formative evaluation of this postpartum telephone intervention. The views of eleven women postpartum and seven C H N s toward the telephone intervention at six weeks postpartum were explored. Naturalistic Inquiry was used as the study's research methodology. Through purposeful sampling, data were collected from women postpartum through audiotaped telephone interviews and C H N s who participated in a focus group. Content analysis was undertaken concurrently with the data collection. The women and the C H N s concluded that the telephone call would be useful for all women postpartum following birth, especially primiparous women. The women confirmed that the call enabled C H N s to detect health concerns early, to offer information, to provide a chance to ask questions, and to give support and reassurance. The C H N s indicated that the call assisted them to assess women's postpartum adjustment and support needs, to give emotional support and anticipatory guidance, and to receive feedback about care given previously. The women valued the C H N s ' knowledge and approach. The length and timing of the call were satisfactory to some but not all women. Women stated they were more reassured, more knowledgeable, and more aware of community resources after the call. They inferred that they coped better, gained motivation, and took action to address unmet needs following receipt of the call . The C H N s were of the opinion that after the call women seemed more aware of self-care, seemed less anxious when caring for themselves or their infants, contacted their physician more appropriately, received more support, were more aware of community resources, used the available resources more, and got out more. It is recommended that the telephone call intervention be implemented for all women following birth, but that it occur earlier than six weeks postpartum, preferably at three to four weeks postpartum. Implications and recommendations for nursing practice, nursing education, nursing administration, and future nursing research are presented. iv T A B L E O F C O N T E N T S A B S T R A C T i i T A B L E O F C O N T E N T S iv L I S T O F T A B L E S v i i L I S T O F F I G U R E S v i i i A C K N O W L E D G E M E N T S ix C H A P T E R O N E 1 Introduction 1 The Research Problem 4 Purpose of the Study 5 Research Questions 6 Significance of the Study 6 Logic Mode l Framework 7 Definition of Terms 13 Organization of the Thesis 13 C H A P T E R T W O : L I T E R A T U R E R E V I E W 16 Women's Transition during Postpartum 16 Physical Needs of Women and their Infants 17 Psychological Needs of Women 20 Postpartum Nursing Care 26 United States 26 Canada 32 Telephone Use for Health Care Intervention 42 Helplines 43 Telephone Follow-up 43 Telephone Use in Postpartum Care 47 Helplines 47 Telephone Follow-up 49 Summary 55 C H A P T E R T H R E E : R E S E A R C H M E T H O D S 57 Research Design 57 Study Setting 59 Participant Sampling and Description 59 Data Collection 64 Telephone Interview-Postpartum Women 64 Focus Group-Community Health Nurses 66 Data Analysis 67 Ethical Considerations 71 V Rigor in Qualitative Research 73 Assumptions 77 Limitations of the Study 78 Summary 79 C H A P T E R F O U R : P R E S E N T A T I O N O F F I N D I N G S 80 Postpartum Women's Perceptions of the Telephone Intervention 81 Care Received and Resources Women Used during the First Six Weeks 81 Challenges or Concerns Women Experienced 82 Women's Impressions of the Telephone Ca l l 88 Perceived Changes Attributed to the Telephone Ca l l 98 Recommendations for the Telephone Ca l l intervention 105 Community Health Nurses' Perceptions of the Telephone Intervention 108 The Perceived Purpose of the Telephone Ca l l 108 Changes for Women and their Families from the Telephone Cal l 112 Advantages and Disadvantages of Telephone Use to Provide Intervention 116 Impact of the Telephone Ca l l on C H N s and their Practice 119 Recommendations for the Telephone Intervention 122 Summary of Findings 125 C H A P T E R F I V E : D I S C U S S I O N O F FUNDINGS 128 The Content of the Ca l l 129 The Process of the Telephone Ca l l 136 The Outcomes of the Ca l l 152 Use of the Logic Model 159 Summary 163 C H A P T E R SIX: S U M M A R Y , L I M I T A T I O N S , C O N C L U S I O N S , A N D I M P L I C A T I O N S 167 Summary of the Study 167 Limitations of the Study 173 Conclusions 176 Implications for Nursing 178 Nursing Practice 178 Nursing Education 182 Nursing Administration 184 Nursing Research 185 R E F E R E N C E S 189 Appendix A : C H N Telephone Intervention at Six Weeks Postpartum 198 Appendix B : Participant Information Sheet 199 Appendix C : Consent Letter (Postpartum Women) 200 Appendix D : Consent Letter (Community Health Nurses) 202 Appendix E : Interview Guide (Postpartum Women) 204 Appendix F : Focus Group Guide (CHN) 206 Appendix G : Community Health Nurses'Information Sheet Appendix H : Telephone Ca l l Documentation Sheet L I S T O F T A B L E S Table 1. Description of Participants V l l l L I S T O F F I G U R E S Figure 1. The Researcher's Logic Model for Six-Week Telephone Intervention p. 15 Figure 2. The Researcher's Refined Logic Model for Six-Week Telephone Intervention p. 166 ix A C K N O W L E D G E M E N T S I express my sincere appreciation to the eleven women who so wil l ingly shared their feelings and thoughts, enabling me to evaluate the provision of the six-week telephone intervention. I thank the community health nurses at the North Health Unit in Vancouver who offered valued perspectives; especially Sue Johnson C H N , whose enthusiasm and support is gratefully acknowledged. Words of gratitude are extended to my thesis cornmittee members: Dr. A n n Hilton (chair), Carol Mitchel l , and Linda Leonard for their collective wisdom, guidance, and support. I extend my thanks to the U B C School of Nursing for the assistance I received from the Sheena Davidson Nursing Research Fund. Lastly, I thank my dear friend Bob for his tremendous support during the many hours I spent to create this thesis. 1 CHAPTER ONE Introduction The three-month period following birth (fourth trimester) is a significant passage in the life of a family. Parents may be surprised by the continuing physiologic and psychosocial adaptation required after birth ( N A A C O G , 1986). Shorter postpartum hospital stays result in the maternal and infant adaptation emphasis shifting from hospital to home with families doing more self-care (Hampson, 1989). Currently, most mothers and their infants leave the hospital soon after birth; thus the nursing care to support womens' adaptation is primarily given at home. Donaldson (1988) notes that contemporary society is focusing as well on reducing perinatal mortality and morbidity. Field and Houston (1991) note that they and many others believe that postpartum nursing care is critical in helping mothers adjust, thereby promoting their ability to nurture and care for their infant ( N A A C O G , 1986; Simpson & Creehan, 1996). Yet, rarely do current postpartum services offer families more than one to two contacts during the postpartum period (Simpson & Creehan). Beck (1991) supports this statement adding that the contacts usually occur during the first two weeks postpartum. The health related needs of most women continue well after two weeks postpartum: many women request more support to adjust to their lifestyle and role changes (Erickson, 1992). Women at six weeks postpartum desire more rest (Erickson; Harrison & Hicks, 1983), greater support in meeting the conflicting demands of their partner, children, and household needs (Harrison & Hicks; Logsdon, Birkimer, & Barbee, 1997), and they seek help in sorting through feelings of emotional tension (Harrison & 2 Hicks), loneliness, and frustration (Logsdon et al.). Donaldson (1991) suggests increasing the length of time postpartum care is required to be available to women, preferably to eight weeks postpartum. However, it is crucial that the time frame for the postpartum period be chosen acknowledging that postpartum care must be individualized and available to facilitate women's adjustment at their own pace. As Donaldson (1988) expresses, society currently is required to understand the importance of the adaptation to motherhood, as it may ultimately determine or greatly influence the health care outcomes for mother and child. Contemporary health care needs to systematically provide support to families during the fourth trimester (Siegel, 1992; Simpson & Creehan, 1996). The importance of family health care after the birth of an infant needs to be recognized and acknowledged (Field & Houston, 1991). The Healthy Beginnings (HB) postpartum program, which began July 1995, provides community based maternity care to all childbearing women and their families in Vancouver, B . C . (Vancouver Health Department, B . C . Women's Hospital & St. Paul's Hospital, 1995). Families receive contact by a community health nurse ( C H N ) within 24 hours of their hospital discharge and subsequent contact by telephone or home visits during the next six weeks is given based on family needs (B. Selwood, personal communication, September, 1997). Families identified as "at risk" according to the health unit guidelines, receive ongoing follow-up care (Vancouver Health Department et al., 1995). The H B program has been successful in reaching most families needing community based maternity care. A n evaluation of a five-month period of postpartum care (October 1995 to February 1996) indicates that 90% of families were reached within 3 the 24 hour period postdischarge and many received home visit contacts (Buhler & Carty, 1997; E . Carty, personal communication, November 3, 1997). Despite the program's success to date, parents and C H N s have expressed concerns. Some C H N s think that offering the H B program results in loss of the prevention focus of the community health program (S. Johnson, personal communication, November 19, 1997). C H N s find that the focus of the initial H B visits to families is on the physical care of mother and infant and on infant feeding and that parents are often not ready to hear about preventive resources such as support groups (S. Johnson, personal communication, March 23, 1998). C H N s are also concerned that women postpartum may be isolated and that women may stop breastfeeding at six weeks postpartum ( M . Davidson, personal communication, September, 1997). A s well , parents attending the parent and community advisory committee meetings for the H B program indicated that they felt overwhelmed with the information given by the C H N during the initial visits. These parents requested the C H N contact them again at six weeks postpartum (S. Johnson, personal communication, November 19, 1997). A six-week postpartum telephone intervention was commenced in July 1996 by one health unit in Vancouver, B . C . to address these concerns. The telephone intervention utilizes community health nursing skills and knowledge to determine, at six weeks postpartum, whether concerns exist with respect to infant feeding, immunization, family support, emotional adjustment, and awareness of community resources. Questions asked by C H N s during the telephone call are outlined in Appendix A . The telephone intervention is given only to women deemed not "at risk" by the C H N s . The C H N provides appropriate assessment, support, information, and referral during the telephone contact and women requesting further contact are referred to a C H N . Approximately seven C H N s provide the telephone intervention and it may not be the same C H N who offers the H B program. Spanish and Cantonese speaking C H N s reach families who speak these languages. Although the C H N s call all women at six weeks postpartum, they do not reach all of the women due to their workload. They attempt only twice to reach a family by telephone because the H B program takes precedence (S. Johnson, personal communication, November 19, 1997). Community health nurses at the health unit that offers the telephone intervention received approximately 1,000 birth referrals in 1997. During 1997 several C H N s gave the telephone intervention to approximately 600 English-speaking families and 200 non-English speaking families (S. Johnson, personal communication, January 7, 1998) for a contact rate of approximately 80%. During the initial three months of the intervention (July to September 1996), one C H N primarily provided the telephone contacts and she succeeded in reaching 101 postpartum families. The Research Problem Community health nurses have implemented the telephone intervention with women who are six weeks postpartum since July 1996. Although C H N s believe the telephone contacts are helpful for women and their families, no evaluation of these contacts has been undertaken. To date, only three studies were found that evaluated postpartum nurse initiated telephone intervention (Donaldson, 1988; Edwards & Sims-Jones, 1997; Rhode & Groenjes-Finke, 1980). Two of these studies found little difference in outcomes between those women who received a telephone call and those women who did not (Donaldson; Rhode & Groenjes-Finke). A third study (Edwards & Sims-Jones) found that those women receiving a telephone contact from a nurse, and who were more 5 socio-economically disadvantaged, were more likely to attend a parent-infant support group. The studies done to date demonstrate some weaknesses, small sample size and confounding variables. No studies have been found that use qualitative methods to explore postpartum women's perceptions of the use of the telephone as an intervention by community health nurses. Furthermore no studies have been found that describe C H N ' s views about the benefits and challenges of using the telephone as a postpartum intervention. Purpose of the Study The purpose of this study was to conduct a formative evaluation of the six-week postpartum telephone intervention by C H N s in order to identify the strengths and needed modifications of the contact and its implementation and to explore the views of women postpartum and C H N s about this intervention. Specifically the study explored womens' impressions of the contact, for example, the changes that occurred following receipt of the call, the perceived value of the call and the C H N contact, and women's suggestions for improving the telephone call. C H N ' s perceptions of the telephone call were pursued, for example, the benefits they believe women postpartum and families received from the call, the benefits of having the call as a part of the C H N role, and C H N ' s suggestions to improve the intervention. Information from the evaluation wi l l assist the C H N s to improve the intervention's process, content, and outcomes; therefore, a formative evaluation was chosen. Ultimately the goal of the evaluation was to increase the effectiveness of the telephone intervention in order to improve postpartum care and the health of women and their families. 6 Research Questions From the perspective of women postpartum who received a telephone intervention at six weeks postpartum, the research questions were: 1) What do they remember about the process and content of the telephone call? 2) In what ways was the telephone call helpful or not helpful to them? 3) What changes did they and their families make following receipt of the telephone call? 4) What changes might they suggest to improve the telephone intervention? From the perspective of community health nurses who provided the telephone intervention, the research questions were: 5) What do they perceive as the benefits for women and their families of the telephone call? 6) What do they perceive as the benefits of including the telephone call as a component of the C H N role? 7) What do they find are the challenges of offering the telephone intervention? 8) What changes might they suggest to improve the telephone intervention? Significance of the Study The study offers much needed research on nurse-initiated telephone support during the postpartum period; important because the telephone has the potential to access postpartum parents easily, giving support that ultimately enhances mother and child health (Hampson, 1989). The choice of telephone follow-up as an intervention mode acknowledges the strong support in the literature for use of telephone technology. Also , the study enhances understanding of postpartum care given to women in the community 7 setting by seeking women's ideas about their care and how telephone support can assist them. The study heeds the literature's suggestion that more emphasis be given to shift the care focus to the late postpartum using an individual approach. The telephone contact occurs during the late postpartum period and it offers individual care to women postpartum by addressing their concerns at the time of the call. Therefore, the study wi l l obtain valuable information about the challenges faced by women postpartum during the late postpartum period. The provision of the telephone call itself may stimulate maternal coping and problem solving (Donaldson, 1991). Since the study uses qualitative methodology it may identify outcomes undiscovered by previous quantitative research. Specifically, nurses may use the study results to maintain the intervention or alter the timing, frequency, or content of the call. If the evaluation results show that the telephone intervention is valued and perceived to be effective by C H N s and the women, the information wi l l give support for the C H N s to include it as an integral part of the postpartum care given to women. Log ic M o d e l Framework The framework for this study or evaluation is the researcher's conceptualization of a logic model that delineates the components of the telephone intervention. A logic model is a diagrammatic representation of a program that illustrates the relationships between various program components such as objectives, activities, outcomes and their indicators, and resources (Dwyer & Makin , 1997). More specifically, a logic model may illustrate to planners and stakeholders how a program fits within a broader program and how it assists in developing a common understanding of the program for all involved (Rush & Ogborne, 1991). Logic models are useful because they outline the flow of a 8 program, with all its components, and they help to make the theory underlying the program more explicit (Dwyer & Makin ; Moyer, Verhousek, & Wilson, 1997). Logic models may (a) help identify the stakeholders and the outcomes associated with a program, (b) offer a framework for a process evaluation, (c) identify hypotheses for the activities pertaining to the outcomes, (d) allow for comparison of the program design with the program implemented, (e) offer an overview of the issues a program wishes to address, (f) illustrate both the short term outcomes and the long term impacts desired by a program, and (g) outline the data to collect and whether the data relate to process information or outcomes (Julian, Jones, & Deyo, 1995; Rush & Ogborne). Logic models have been successfully used to accomplish a variety of purposes (Moyer et al., 1997; Rush & Ogborne, 1991). For example, planners evaluating a Perinatal Addictions Program found a logic model helped them to outline in detail the expected outcomes and the success criteria for the program, to assign appropriate responsibilities to staff, and to communicate program activities and outcomes clearly to stakeholders (Julian et al., 1995). A logic model is a program planning tool that ensures that evaluation is considered and included when designing a program (Dwyer & Mak in , 1997; Moyer et al., 1997). Such a model integrates evaluation into program planning by showing program objectives and indicators, so one may determine i f the objectives are met and i f the program activities are carried out as planned (Dwyer & Makin). Because logic models offer planners a visual overview of a program's components, they highlight unintended consequences of the program and the pertinent issues as well as questions needing consideration in the program's evaluation (Rush & Ogborne, 1991). 9 Logic models help community health practitioners conceptualize health promotion more clearly, which in turn helps them design programs that are relevant. Logic models are useful for community health practice because they show the indicators that capture both the program's process and its outcomes. Both of these are important to know when assessing whether or not community health programs are achieving the results desired (Moyer et al., 1997). A s an evaluation tool, the logic model assists staff to create and maintain programs that respond to the initial concerns and better meet the goals and objectives set (Julian et al., 1995). However, the user of a logic model is cautioned to realize that while the intervention may succeed in alleviating the concern it was designed to address, it may not do so with clear cause and effect linkage (Julian et al.). This tendency for indirect change is particularly pertinent to community health practice; indeed a multitude of factors may impact on the outcomes resulting from a program intervention. None the less, logic models are useful tools for planning community health programs because they illustrate overtly the links between program activities and the outcomes anticipated: Logic models make tracking progress towards the achievement of outcomes easier for program evaluators. Use of a logic model provided the researcher with a visual overview of the telephone intervention, and this assisted the researcher to interpret the formative evaluation results. The focus of a 'formative evaluation' is to assess the conduct of programs and their interventions in their early stages of implementation so that information obtained from the evaluation may be used to improve the program further. The evaluation is used to improve program implementation, solve unanticipated problems, test a program intervention with a small sample, either to gather estimates of 10 the magnitude of impact expected or to ensure that participants are moving toward desired outcomes (Patton, 1987, 1997; Rossi & Freeman, 1993). Guba and Lincoln 's (1989) definition of formative evaluation was used in this study: "a formative worth evaluation focuses on assessing the extrinsic value of the evaluand with the intent of improving it, by applying it and assessing the extent that desired outcomes are produced" (p. 190). A formative rather than summative evaluation of the telephone intervention is most suitable for this evaluation because the C H N ' s in this study are prepared to alter the telephone intervention to improve their postpartum services. A summative evaluation by contrast would benefit a program or intervention already well established. B y analyzing the 'indicators' or signs that the objectives are being achieved in the formative stages of the telephone intervention, the researcher realizes whether progress is being made towards achieving either the short or long-term outcomes desired. The logic model developed for this evaluation assists the researcher to see how the components of the telephone intervention link together to achieve the goal of ultimately enhancing the health of women postpartum. For example, adequate support greatly aids the healthy adjustment of women postpartum. To assess whether the long-term outcome objective of women obtain support or feel adequately supported during postpartum is met, the researcher first looks to the short-term outcome objective and indicator. To meet the short-term outcome objective, the telephone intervention must result in women express awareness of sources of support and the means to obtain support. If women indeed expressed this awareness, then the intervention has met the short-term objective. In meeting this objective, the telephone intervention creates the possibility that 11 the long term objective wi l l also be met, women w i l l adjust better during postpartum, and their health is enhanced. Hence, using a logic model for the formative evaluation of the telephone intervention ultimately assists the C H N s to adjust the intervention as needed (Moyereta l . , 1997). The H B program goal and objectives are presented prior to discussing the logic model chosen for the formative evaluation. The goal of the H B program is to provide community based maternity care to all childbearing women and their families in Vancouver that is effective, integrated and accessible and that w i l l improve the health care system's utilization of resources. Specifically the program w i l l (a) promote, maintain, and restore the health and wellbeing of childbearing women and their families at home and in their community; (b) involve women and their families in planning, implementing, and evaluating service delivery; (c) provide culturally sensitive care; (d) promote more effective use of hospital and community resources; (e) develop interagency, community, and regional collaboration in planning, implementing, and evaluating health care services to childbearing families; (f) promote a "seamless" and effective continuum of maternal health care that promotes continuity and consistency while minimizing fragmentation and duplication; and (g) examine and address levels of acceptability and satisfaction to families and health care providers (Vancouver Health Department et al., 1995). The telephone intervention was implemented by C H N s to address some of the needs both they and parents noted from the contacts made to families in the initial H B program period. C H N s wanted to increase or emphasize the prevention focus of their role during their contacts with families. C H N s view the telephone intervention as an 12 opportunity to review community resources with families, discuss family support systems, assess maternal and family feelings and adjustment, and offer guidance regarding infant care and feeding. C H N s have found that these areas of focus can not always be included in their contacts made to families in the early postpartum period. The six-week telephone intervention augments the H B program by giving preventive services to families during the later postpartum period. Dwyer and Makin ' s framework for a logic model was chosen in this study for a formative evaluation of the telephone intervention used by C H N s with postpartum families (1997). Their framework was chosen because of this researcher's wish to evaluate both the process and outcome components of the telephone intervention. Not only does this framework include both, unlike others, but also it is easy for the researcher to follow. Figure 1 shows the logic model created for the telephone intervention by the researcher from this framework, including the C H N ' s goal, the intervention component, the long and short-term outcome objectives and indicators, the process objectives and indicators, and the resources required for the telephone intervention. Using the model as a visual tool, one can see the flow between each element of the intervention. The process component (or implementation of the intervention by the C H N s and comments related to the process received from the women, postpartum), and the outcome component (or those changes occurring for women, postpartum as a result of receiving the telephone call) come together as the focus of this study's formative evaluation. 13 Definition of Terms The following terms were utilized in the evaluation: Primiparous- a woman who has had one birth at more than 20 weeks gestation, regardless of whether the infant is born liveborn or stillborn. Gestation-the number of weeks since the first day of the last menstrual period [ L M P ] . Multiparous-a woman who has had two or more births at more than 20 weeks gestation (Olds, London, & Ladewig, 1996). Postpartum transition- a period of time which is similar to illness in that women postpartum encounter new challenges in their own physical recovery, but differs from illness in that women postpartum still continue to deal with routine life situations, relationship and task maintenance activities, while adding the physical and emotional care of an infant to these duties (Logsdon et al., 1997) Organization of the Thesis Chapter one includes the background information that prompted this study, the purpose of the study, and the significance of it for community health nursing practice. A s well , the framework that guides the study is presented and discussed. In chapter two literature related to; women's transition during postpartum, postpartum nursing care, telephone use in health care, and use of the telephone to provide health care during the postpartum period is reviewed. Chapter three presents the methods used in the study including the research design; Naturalistic Inquiry, the sample and setting, a description of the participants, the data collection and analysis procedures, ethical considerations, rigor for qualitative research, and limitations of the study. The findings of this study are presented in chapter four and in chapter five a discussion of these findings with respect to both the C H N ' s and the women's perspectives and the literature reviewed is presented, Finally, in chapter six the implications of the findings for community health nursing practice, nursing education, nursing administration, and future research are presented. The researcher's conclusions, limitations of the study, and a summary of the study are offered. 15 Goal To enhance the health of women, postpartum and their families Target Group Women who are six weeks postpartum and who reside in the North Health Unit area Components Nurse initiated community based postpartum telephone support Long-term outcome Objectives -Increase the duration of breastfeeding -Increase postpartum women's capacity to create health for themselves and their families -Increase the support given to women during postpartum Long-term outcome Indicators -Women express decision to increase duration of breastfeeding -Women obtain support or feel adequately supported during postpartum -Women express decisions/changes made that enhance the health of the infant, themselves, or their family Short-term outcome Objectives -Increase awareness of the breastfeeding and parent-infant drop-ins -Increase awareness of CHN as a resource for family health -Increase awareness of the benefits of increasing the duration of breastfeeding -Increase knowledge of community resources, maternal and family adjustment, infant care/feeding practices -Women perceive support if available or express desire to seek support Short-term outcome Indicators -Women express interest in attending breastfeeding or parent-infant drop-in -Women express awareness of or use of CHN as a resource -Women express awareness of the benefits of increased breastfeeding duration -Women express awareness of or receipt of information re: community resources, maternal adjustment, infant care/feeding practices -Women express awareness of sources of support and the means to obtain support Process Objectives -Offer preventive focused assessment, information, referral, and support to women during the later postpartum period -Provide appropriate care to women by telephone during the late postpartum period. Process Indicators -Type of information sent to women -Number and focus of referrals made -Number of questions discussed during each six week call -Number of women requesting or needing further support -Themes or constructs expressed by the women about the CHN role and their impressions of the telephone contact -Themes or constructs expressed by CHNs about their role and the telephone call Resources -Community Health Nurses -Questions for six week telephone call -Health unit written information -Health unit recording document for six-week call -Health unit breastfeeding and parent-infant drop-ins -Community resources Figure 1. The Researcher's Logic Model for Six-Week Telephone Intervention, Based on Dwyer & Makin (1997) 16 C H A P T E R T W O L I T E R A T U R E R E V I E W The literature review addresses four areas: (a) women's transition during postpartum, (b) postpartum nursing care, (c) telephone use for health care intervention, and (d) telephone use in postpartum care. Women's Transition during Postpartum In 1994, Ba l l notes that motherhood might be defined as a physiological and psychological process that leads to and underpins the experience of both giving birth and nurturing a child and that almost invariably provokes strong emotions. The definition directs one to look at both the physical and emotional aspects of not only birth but also the period following or postpartum. The postpartum period is defined as the time from birth until the woman's body returns to an prepregnant condition or approximately six weeks (Olds et al., 1996). The period is divided into three phases: immediate or the first 24 hours postbirth; early or the first week postpartum; and late or the second to sixth week postbirth (May & Mahlmeister, 1990). The period of six weeks is often used to assess physical and emotional symptoms related to adjustment because it coincides with the physical check-up for women at six weeks (Ball , 1994). A n example is the study of the postpartum experiences of women in North and West Vancouver in 1992. The period of six to eight weeks was set as the postpartum period under study because this period is generally considered by the medical profession as a transition period for mothers and infants (Erickson, 1992). However, some authors challenge the notion that postpartum should be viewed as a period of six 17 weeks duration. B a l l argues it might be unreasonable to consider any specific period of time as the one in which women are adjusting. She notes we can not assume there is one period or specific time that is the "right" time for assessing women's adjustment. Recognizing that the postpartum time frame of six weeks is being currently challenged in the literature, this study's literature review focuses on the concerns expressed by women during their postpartum transition. These concerns include the physical needs of women and their infants, and the psychological needs of women. Physical Needs of W o m e n and their Infants Most nursing texts indicate that for the majority of women the following physical changes are expected by six weeks postpartum: involution of the placental site occurs, vaginal tissues return to former dimensions and menses resume for nonlactating women, i ureter and renal pelvis dilation ceases, weight loss is achieved, breasts become softer, prepregnancy bowel patterns resume (Olds et al., 1996), voluntary muscles and support of the pelvic floor regain tone, thyroid function returns to prepregnant levels (Simpson & Creehan, 1996), lochia ceases, and the uterus returns to prepregnancy size and location (Olds et al.; Simpson & Creehan). In addition, the literature reviewed for this study offers a glimpse of the physical concerns expressed by women postpartum with respect to themselves or their infants. For example, Tobert (1986) studied the frequency and intensity of concerns of women postpartum at two days postdischarge and at one month postpartum. She found primiparous women had concerns at two days postdischarge related to pain from perineal sutures and recognizing infant illness; as well , both primiparous and multiparous women were concerned about safety, feeding, and growth and development of the infant at this time. A t two weeks postpartum, women worried 18 about discomfort from sutures, breast care, infant feeding, and recognition of infant illness, (Fishbein & Burggraf, 1998), weight loss, episiotomy or incision pain, and hemorrhoids (Ruchala & Halstead, 1994). A t four weeks postpartum Tobert found women were concerned about birth control while Harrison and Hicks (1983) noted that women at five weeks postpartum were concerned about diet and exercise. Most impressively, women noted fatigue as a prominent concern at two days post discharge (Tobert, 1986), at two weeks postpartum (Fishbein & Burggraf, 1998; Ruchala & Halstead, 1994; Woollett & Parr, 1997), at three weeks postpartum (Cadman, 1995), at one month postpartum (Tobert), at six weeks postpartum (Erickson, 1992; Harrison & Hicks, 1983), up to four months postpartum (Chapman, Macey, Keegan, Borum, & Bennett, 1985), and at six months postpartum (Woollett & Parr). Gardner (1991) surveyed 35 women, postpartum, on their fatigue (level and type) at two days, two weeks, and six weeks postpartum: Their fatigue was found to peak at two weeks postpartum and to decrease to near normal levels by six weeks. Older women, women with more education, and those with more household help experienced less fatigue. Fatigue increased with childcare problems. The author suggests that another postpartum visit should be scheduled between two to six weeks postpartum to identify those women who are not fatigued but who are actually experiencing mood disorders since the symptoms present similarly. Research on telephone helplines offers a valuable picture of parents' physical concerns during the six-week postpartum period and beyond. Calls received by help lines operating in the 1980s and 1990s indicate that parents' main worries were infant care and feeding (Buhler & Carty, 1997; Elmer & Maloni , 1988; Jones, Maestri, & M c C o y , 1993; 19 Rush & Kitch, 1991; Valaitis, Tuff, & Swanson, 1996). For example, the majority of calls to the Bright Beginnings Warmline of Pittsburgh, Pennsylvania were from mothers concerned with breastfeeding, i.e., the effect of diet or medication on breastfeeding, the frequency of feeding, and the amount to give (Elmer & Maloni , 1988). A n evaluation of the Newborn Hotline in Vancouver, B C revealed that parents requested information about infant illness (26%), breastfeeding (24%), and feeding (21%) (Buhler & Carty, 1997). Childcare issues, breastfeeding, and nutrition were the primary focus of parents contacting the Hamilton-Wentworth, Ontario InfoLine, and physical changes were the main maternal issues noted (Valaitis et al., 1996). Gilhooly and Hellings (1992) documented during a six-month period the types of problems families in Oregon had during breastfeeding and their requests for help. Mothers were the most frequent callers (64%) with 17.9% of the calls concerning infants less than one week old, 37.7% concerning infants one to four weeks old, and 17.9% concerning infants five to eight weeks old. Overall, 80% of the calls concerned infants less than 12 weeks of age. Sore nipples, poor infant feeding, and general breastfeeding information were the topics most frequently discussed. In a Canadian study of the factors influencing the duration of breastfeeding, Bourgoin et al. (1997) found women (n=350) still had breastfeeding problems at one month postpartum with the majority of these occurring in the first three weeks. Women weaned their infants due to fatigue and insufficient milk production at one and three months postpartum, respectively. Lack of milk supply, pain when feeding, and leaking breast milk were reported in Cadman's (1995) study of greatest concerns of primiparous women during the first month postpartum. She states that although the women knew that 20 a commitment was needed for breastfeeding success, many did not sense the potential for negative physical effects. In Buhler and Carty's study (1997) 26% of the postpartum women (n=139) described their general health as "poor" or "fair" at one month postpartum. Woollett and Parr (1997) report that 25% of women who were considered low risk during pregnancy and who received minimal labor intervention described their physical health as "not very good" at six months postpartum. The authors suggest that physical recovery may be slow and is a source of concern for women well after the traditional six-week postpartum period. Psychological Needs of W o m e n Birth may be perceived by parents as a stressful life event (Leung, 1985). During the postpartum period, a heightened state of confusion and negative emotions with anxiety and mood disorders may be noted (Leung). Maternal role development may be impaired due to emotional distress, inadequate information, support, and guidance (Driscoll, 1990). Conversely, the postpartum period may be viewed as an opportunity for both a restoration of a former equilibrium and positive growth (Leung). Tobert (1986) found that at two days postdischarge (five to seven days postbirth) primiparous women were most worried about being good mothers, and multiparous women were anxious about return of their figure. A t two weeks postpartum, other studies have revealed that women "felt down", tense, irritable, tearful, a loss of social support (Ruchala & Halstead, 1994), tied down or that they had "baby blues" (Fishbein & Burggraf, 1998); they expressed concerns about body image, managing the household, being a good mother, inability to concentrate, and lacking personal time (Fishbein & 21 Burggraf). During the second to sixth postpartum week, women expressed confusion about their roles while trying to adapt; they expressed needs for more personal time and support (Erickson, 1992). Cadman's (1995) identification of the concerns of primiparous women, noted when interviewed on average at 21 days postpartum, provides a detailed picture of the psychosocial issues women have during this time. Women, as their former world changed, were concerned about "becoming a mother" and worried about increasing levels of anxiety. The sense of total responsibility they felt lead to feelings of joy, anxiety, and tension. Yet, some women reported enhanced feelings of mastery and self-esteem. These women recognized a need for "emotional and physical restoration", as their bodies felt very different following birth. The resulting fatigue led to sleep deprivation that interfered with all aspects of their life. In Cadman's study (1995) "breastfeeding" resulted in mixed emotional experiences for the women. Some women felt pressured to breastfeed, which resulted in feelings of guilt when they gave formula because their nipples were sore. Also , some women felt disappointment when their breastfeeding experience was different from their expectations. They were not prepared for the time commitment and the "messiness of the feeding." Women were concerned with "balancing roles." They felt a loss of roles and a need to balance roles with respect to work, partner, family, and as individuals. Women had not predicted the major losses to their relationships with their partners. Yet, women felt positive towards creating a new family and the changed role of their partners as fathers. Women felt a loss of self-expression when they put personal goals on hold. Women talked about feeling anxious when caring for their infants. They hoped to 22 "develop a relationship with their infant", to learn about their infants' behaviors and needs and to provide adequate care for them. A last concern of the women was the "unsupportive attitudes or actions of others" for example, receiving conflicting or negative information which was often given with a lack of consideration for the mother's needs, or given in direct disagreement with their own parenting style. Women at one month postpartum describe themselves as sitting during most of the day (83%), spending most of the day in their nightgown (38%), and feeling that they were not accomplishing as much as usual (65%) (Fishbein & Burggraf, 1998). A t one month postpartum, Tobert (1986) found no significant difference in frequency and intensity of concerns between primiparous and multiparous women: Generally, the women all worried about being a good mother, about having personal time, and about the return of their figures. However, the focus of their concerns differed. For 70% of the multiparous women, return of their figure, reaction of siblings, and household demands were the foremost concerns. In contrast, for 80% of the primiparous women, the infant's physical needs were the prime focus: recognizing infant illness, their normal growth and development, and their sleeping and feeding patterns. A t six weeks postpartum, studies reveal that women identified psychosocial needs related to rest, mood changes, and family adjustment (Rhode & Groenjes-Finke, 1980) as well as to regulating the demands of husband, housework, and children; to the return of their normal figure, and their personal time; and to their own feelings about coping with visitors and friends (Harrison & Hicks, 1983; Logsdon et al., 1997; Rhode & Groenjes-Finke). Buhler and Carty (1997) report that 92.5% and 96.3% of the women, when asked about their feelings about being a mother, replied that they felt "good" or "excellent" 23 respectively at one and three months postpartum. These same authors found, at one month postpartum, that women felt most confident about knowing when immunizations were needed and how to use a car seat properly but felt least confident about knowing when their infant was i l l , knowing what to do i f their infant gagged or choked, or knowing i f their infant was getting enough milk. Depression is an issue of significant psychological interest in the postpartum period. Postpartum depression is a mood disturbance that affects approximately 10% to 26% of all childbearing women (Beck, 1995). It may appear from a few days to several weeks or months after delivery and, left untreated, can continue for up to a year following birth (Misr i , 1995). Symptoms often include frequent crying, insomnia, appetite changes, difficulty concentrating and making decisions, feelings of worthlessness and sadness, lack of interest in usual activities and personal appearance (Olds et al., 1996). Physiological factors seem to influence the onset of depression. In a study looking at thyroid and Cortisol levels during late pregnancy and the postpartum, the precise timing of the return of these hormone levels to normal ranges was unknown, though these levels were expected to return to normal by six weeks. Women with lower thyroid hormone levels at 38 weeks gestation were also those displaying postpartum depressive symptoms. These women also had slower declines of serum Cortisol levels, and at six weeks postpartum their levels were significantly higher than those women without depressive symptoms (Pedersen et al., 1993). Several authors have looked at other factors that precipitate development of postpartum depression. Evidence exists that social support may greatly influence women's well-being during postpartum (Gjerdingen & Chaloner, 1994). A n Australian 24 study found that 58% of women at three months postpartum were depressed. The women stated they needed more support during the four to six week postpartum period (Griepsma et al., 1994). Leung (1995) found primiparous women, seen at two to four weeks postpartum, were either anxious or depressed depending on their expectations and social support. The women who were anxious desired more support for the day to day family and household tasks and the group of women who were depressed desired more emotional support. The onset of postpartum adjustment difficulties appears to vary. Anderson, Fleming, and Steiner (1994) studied associations between mood and other salient issues during transition to motherhood and found that negative moods and depression during pregnancy were significantly associated with depression during postpartum. M i s r i (1995) also confirms this relationship. Women with postpartum blues during the hospital stay or at two days postpartum were found to be significantly more depressed at six to eight weeks than those women who did not have the blues in the hospital (Morsback & Gordon, 1984; Rhode & Groenjes-Finke, 1980). Morsback and Gordon found that the onset of depression may occur in late pregnancy or early postpartum for some women. Other women, who were deemed low risk when they were assessed for the presence of "blues" while in the hospital, were found to be depressed when assessed using Pitt's Atypical Depression Questionnaire six weeks later. In a recent evaluation of postpartum care, 45.3% of the women responded affirmatively when asked at one month postpartum i f they had felt sad or depressed since the birth of their infant (Buhler & Carty, 1997). B a l l (1994) takes a broader perspective on the underlying factors for depression. She found that 19.4% of her sample of 279 mothers were emotionally distressed, with the 25 women who were anxious showing greater depressive symptoms at six weeks postpartum. She believes as does M i s r i (1995) and Woollett and Parr (1997) that a woman's personality, physical factors, and her social and family support influence how well she adjusts. The exact etiology for a woman's depressive illness is not usually clear. M i s r i notes that research studies indicate that 8 to 28 percent of women with a previous depression w i l l l ikely have symptoms of depression during a subsequent pregnancy or postpartum period. Also , women developing mood disorders later in pregnancy w i l l l ikely have these same disruptive moods in the postpartum period. The risk of psychotic illness in the first three months postpartum is 15 times the risk in non-postpartum women (Misri). Women, therefore, are at greater risk of severe psychiatric morbidity during postpartum than at any other time in their lives (Pedersen et al., 1993) due to either emotional or physical factors or a combination of these. Thus, authors suggest these factors need to be remembered when considering the complexity of women's feelings during the postpartum period (Ball ; M i s r i ; Woollett & Parr). In summary, women's initial focus on their physical needs and their infant's needs during the immediate and early postpartum period tends to shift towards the broader psychosocial needs in the late postpartum. The physical changes expected in postpartum, as noted in nursing texts, and the concerns expressed by women as documented by research, differ. Also , research done to date indicates that physical healing and concurrent achievement of emotional stability can be expected by six weeks postpartum; however, it also suggests that women postpartum continue to have varied concerns, related to their physical and emotional recovery from birth, well past the traditional six-week postpartum period. Postpartum Nursing Care Gjerdingen and Fontaine (1991) ask, is it " the life changes per se that cause health problems or has society failed to help growing families adjust to their changes?" (p. 192). To understand why women continue to express concerns during the postpartum period and to answer this question, the literature on postpartum nursing care was reviewed. Although many health care providers assist women during the postpartum period, this literature review includes only that which focuses on care given by nurses. Programs based from acute care centers or community agencies in the United States and Canada and studies from the United States or Canada on postpartum nursing care were examined to reveal both the temporal and thematic patterns of care received by women postpartum during the period of 1980 to present. Also , comments from various authors on the state of postpartum nursing care are included. United States A trend to shorten the period of postpartum follow up arose during the 1980s concomitantly with the introduction of early postpartum discharge. There has been a trend to engage community health providers to focus on women postpartum and their infants because of a concern for their health. In a review of early discharge programs in the United States, Beck (1991) notes that the number of follow-up visits and care provider-initiated telephone calls varies from one visit or call within 24 hours of discharge to several visits or calls over the first two weeks postpartum. Brooten (1995) notes that in the United States, a variety of home follow-up care programs have been developed to meet family needs after early discharge. What is needed, Brooten proposes, is coordinated discharge planning, coordinated post discharge 27 services, provision of in-home services, and continued health care follow-up. Presently, the various types of health care coverage available to clients results in differential application of a program based on a client's reimbursement plan. The result is concern for certain mothers and infants due to early discharge. The following examples from the United States, of postpartum nursing care or postpartum studies illustrate the trend to shorten the provision of postpartum nursing care to women. The four programs following emphasize nursing care during the early postpartum period and the physical recovery and care needs of mother and infant. In 1987, perinatal hospital nurses in California implemented a program consisting of a follow-up telephone call to families 48 hours postdischarge (Siegel, 1992). During the follow-up telephone call the nurse assessed the family's adaptation, offered support, teaching, and referral. The author states that families benefited physically and emotionally from receiving a systematic assessment by telephone and the telephone call fosters the overall goal of promoting family functioning. Soon after the implementation of the follow-up call, the number of calls from parents to the nursing unit doubled. Parents sought information before and after receiving their follow-up call at 48 hours postdischarge. This demand resulted in the initiation of a 24-hour telephone warm line. The warm line is available to parents for up to three months post birth. Following initiation of the follow-up call from the nurse, the number of calls from parents to the hospital unit doubled and calls to the warm line were three times the number of deliveries. Clearly, a telephone contact to families at 48 hours post discharge was not sufficient to meet parents needs evidenced by parents continuing to seek this contact well after the initial follow-up call. 28 The Ohio Maternity and Newborn Home visit program offered prenatal education and home visits to families. Mothers and infants were, on average, discharged on the first postpartum day after a vaginal birth and on the third postpartum day following a cesarean birth depending on the well being of the couplet. Each family received one home visit, which occurred within 72 hours of discharge with most occurring at 48 hours post discharge. A twenty-four hour helpline was also available. The authors reported that 99% of the families were satisfied with this service (Williams & Cooper, 1996). The Tender Beginnings Program in Connecticut offered families a return visit to the delivering hospital between 48 and 72 hours postdischarge (Weinberg, 1994). During the visit, mother and baby are physically assessed and infant feeding, support, and family coping measures are discussed. If the family declines the visit then a telephone interview is scheduled. Two weeks following, a nurse telephones the family to assess family coping. Over 50% of mothers made a return visit and 98% of the parents receiving a postpartum visit expressed satisfaction. The Maternity Nursing Home Follow-up Project in South Carolina provided a telephone assessment by a nurse at 24 hours after discharge (Brown & Johnson, 1998). Two nurses (one focused and trained in infant care and the other in postpartum care) visited families at home within 72 hours of discharge. During this visit, the nurses assessed the mother, the infant, and the home environment, and they referred families to community resources as needed. A nurse made a follow-up telephone call a week after the first home visit. Previously identified concerns were addressed and a second home visit for the third postpartum week was then scheduled. The program terminated after this visit. Most (97%) of the project group mothers were extremely pleased with the project: 29 they felt the visits had been very helpful to them because they received information and reassurance from the nurses. The authors found that most of the family's problems were identified and interventions initiated during the first visit. They discovered that 97% of the families visited within 72 hours of discharge had knowledge deficits related to self-care; 80% of the families needed help to obtain resources, and 21% of the mothers experienced fatigue or ineffective coping. Also , 75%, 44%, and 41% of the families had knowledge deficits related to infant care, infant feeding, and newborn jaundice, respectively. The authors state these findings are "alarming." Because most of the problems were resolved by the time of the second visit, and the infant was "incorporated" into the family, Brown and Johnson decided to eliminate the second home visit, as they believed it to be unnecessary. Yet, it seems doubtful that the knowledge deficits and the other concerns described would be completely alleviated so soon. Considering the positive response of the mothers to the visit, it seems likely that these women would benefit from further nursing contact. Two studies were found that extended postpartum care to the traditional six-week period and beyond. Norr, Nacion, and Abramson (1989) studied early discharge follow-up of low-income, low-risk women who were visited by a nurse one to two days postdischarge, during the second postpartum week, and at four to six weeks postpartum. The nurse assessed maternal and infant physical well being and taught safety, health, and infant growth and development. Those mothers discharged early with their infants achieved higher attachment scores and had fewer concerns and greater satisfaction with the postpartum care received. The authors recommend monitoring of maternal and infant health during the first postpartum month because both the mothers and infants had 30 physical health needs throughout the first month. Brooten et al. (1986) followed perinatal nurse specialists making home visits during the first week and at 1,9, 12, and 18 months postdischarge, to families with low birth weight infants discharged earlier than was usual practice. These specialists contacted families by phone during the first two weeks postdischarge and weekly for eight weeks. Families were given instruction, counseling, and daily on-call telephone availability of the nurse specialist for 18 months. Families phoned the specialists as needed and used this service frequently to address questions and concerns. Comparison of the two groups of infants showed no differences in outcomes measured; however, the families made frequent and appropriate use of the nurse specialist to gain support and information. Both of these studies suggest strongly that concerns extending well beyond the boundaries of the physical care of mother and infant continue to arise for women and families in the late postpartum period and beyond. In a review of the current means of providing postpartum care to families in the United States, Bake well-Sachs and Persily (1995) suggest that early hospital discharge has exposed gaps in health policy as care has shifted from the health care system to the community and to the family. Thus, postpartum care following hospital discharge has gained increasing importance due to the need to monitor mothers and babies for complications. Edmonson, Stoddard, and Owens (1997) and L i u , Clemens, Shay, Davis, and Novack (1997) studied whether infants discharged early are at increased risk for hospital readmission. The readmitted infants were more likely to be first born (Edmonson et al.; L i u et al.), breastfed (Edmonson et al.), preterm (Edmonson et al; L i u et al.), low birth weight (Liu et al.), born to women younger than 18 years old (Liu et al.), or the infants of 31 women on Medicaid insurance with <grade 12 education (Edmonson et al.). L i u et al. suggest that future studies evaluate the efficacy of follow-up care after early discharge and that close individualized care be given to families in the first days of life. Edmonson et al. suggest that, since most of the concerns occur in the first week, the timing of the hospital discharge may not be as crucial as the timing of the postpartum follow-up care and that future research should look at the impact of offering families timely postpartum care. In the United States, one to four percent of term infants are readmitted to hospital, many for jaundice. Despite these concerns, follow-up of infants discharged before 48 hours of age does not always occur (Lee & Perlman, 1996). In 1992, the American Academy of Pediatrics ( A A P ) recommended that all infants discharged less than 48 hours of age should receive follow-up care. Maisels and Kring (1995) found that as many as 67 percent of the infants discharged before 48 hours of age were first seen more than two weeks following discharge. In 1995, the A A P issued stricter policy statements recommending that infants discharged within 48 hours of age be assessed within 48 hours of discharge. Lee and Perlman conclude, upon review of recent early discharge programs, that use of less rigorous selection criteria for discharge and limited follow-up after make early discharge a risk for infant morbidity (Lee & Perlman, 1996). These authors are focused on the postpartum care given to families during the early postpartum period. While there are differences in the application of programs in the U S A , the vision professed by these authors seems incomplete and narrow; these programs do not attend to the needs of families in the later postpartum period or in the psychosocial realm. Fishbein and Burggraf (1998) write that the limited medical 32 definition of uterine involution is used to assess postpartum recovery and to develop policy, both of which have implications for family health. They note that Tulman, Fawcett, Groblewski, and Silverman (1990) suggest women based on their assessment of women's functional status in various role activities are not fully recovered from childbirth until three to six months after delivery. Fishbein and Burggraf maintain that postpartum recovery based on uterine involution and physiological adaptation is inadequate: they advocate that health care professionals recognize that a fourth trimester needs to be determined and the effectiveness of postpartum nursing in meeting the needs of women during this time be established. Hence, more research and dialogue with parents are essential to evaluate the effectiveness of existing and new interventions. A s Brooten (1995) notes, the challenge is to develop and implement the most effective service available to all perinatal families who need them. Canada With few exceptions, all families delivering an infant in Canada are eligible for and receive medical care under Medicare. The provision of postpartum home care in Canada is the responsibility of regions in each province. In British Columbia, Regional Health Boards, Community Health Councils, and Community Health Service Societies oversee and give direction for health care services throughout the province. Guidelines for perinatal care, developed by a provincial committee, are available for health care providers in hospitals and in the community. Thus, health care professionals strive for continuity of care from hospital to community. Each region in the province creates programs to meet its own needs. For example, the British Columbia Reproductive Care Program ( B C R C P ) developed criteria for mothers and infants discharged less than 48 33 hours post birth. The criteria may be individualized by hospitals to address particular needs of their populations, regions, and geography ( B C R C P , 1997). Given the trend for earlier discharge than ten years ago and considering that each region may have differing availability of community follow-up and resources, the B C R C P suggests that hospitals and communities develop their own standards of care for hospital length of stay, depending on the availability of these resources. The most common pattern of care today in Canada is publicly funded postpartum care provided by public health nurses (PHN). Health care reforms related to fiscal issues and indicators of utilization and health care have created changes in postpartum care. In some provinces, nurses other than PHNs give postpartum care, either exclusively or in combination with registered nurses. Victorian Order of Nurses ( V O N ) and privately paid nurses who have skills to care for women postpartum and their infants may go into the community. Consequently, in some areas of the country all postpartum families may receive visits and services from a P H N ; in others, only families deemed at greater risk would receive P H N services (Gupton & M c K a y , 1995). A review of the services provided in the past and ones currently operating indicate that services to postpartum families are still in the nascent stage of development and are influenced strongly by resources in the health regions. In the 1980's, the trend in postpartum care was to visit families in the late postpartum period with the visits addressing a wide range of concerns. Home visits were given to 71% of primiparous women and 58% of multiparous women in Alberta during the 1980's, with visits occurring between eight to twelve day's postpartum. Maternal nutrition, family adjustment, infant's behavior, breastfeeding, and fatigue were the topics 34 covered at the first visit; teaching and support on infant feeding and the physical care of the mother were also provided (Field & Houston, 1991). If a second follow-up visit was made, the focus was usually on problems with infant feeding or issues related to the infant. The authors' note that, since many C H N s did not provide a second visit, the opportunity to offer anticipatory guidance and reinforcement of teaching and information previously discussed, is very limited; therefore, the authors question the effectiveness of the C H N teaching. A 1990 Ontario survey of public health interventions to determine the nature, extent, and timing of postnatal follow-up services shows that home visits were the primary mode of postpartum care delivery, with most visits taking place approximately eight to 14 days postpartum. Telephone contact was made with equal frequency either before the seventh day postpartum or between eight to 14 days postpartum (Edwards, Mackay, & Schweitzer, 1992). The telephone visits might include assessment, counseling, or health education. The authors do not outline the topic of the calls, nor were the calls evaluated for effectiveness. A n exception to the previous indications of postpartum care in the 1980s is an early discharge program developed in 1981 in Hamilton, Ontario (Rush & Valaitis, 1992). In this program, low risk women and infants were discharged within 48 hours of an uncomplicated delivery. They were offered one prenatal assessment visit by a P H N , two home visits by a P H N within the first 24 hours after discharge and daily home visits by a P H N for five days. A s well , laboratory and homemaker services were available. Only 1.5% of eligible women took part in the program. While few women in the 1980s 35 appeared ready to take advantage of early discharge and the accompanying follow-up, this readiness increased by the early 1990s. The length of postpartum hospital stay in Canada has steadily decreased with many families being discharged within six to forty-eight hours after a vaginal birth and on the third or fourth day following a cesarean birth (Gupton & M c K a y , 1995). In B . C . most mothers and infants are discharged within 2.3 days of a vaginal delivery and within 3.3 days following a cesarean delivery ( B C R C P , 1996). Gupton and M c K a y comment that the safety of earlier discharge was a concern in the 1980s when these discharge programs commenced; this worry continues to be discussed as evidenced by the following data. The rate of neonatal length of stay (LOS) in Canada has decreased during the period of 1984 to 1994 (Wen, L i u , & Fowler, 1998). The average L O S in 1984 was 5 days compared to 2.9 days in 1994. The change in L O S is most evident in normal and large birth weight infants. The authors acknowledge potential benefits for infants discharged early (increased mother-infant bonding and breastfeeding) but caution that risks also arise, especially i f community follow-up care is not available. They suggest further research to examine potential risks to newborns. In the Vancouver region, in the early 1990s, health care professionals began to address the trend towards earlier hospital discharges. Guidelines developed for discharges less than 48 hours post birth suggest that home care (one home visit within 24-48 hours of discharge) by a community health nurse must be available. A program that ensures ongoing assessment of mother and infant must also be available ( B C R C P , 1997). The frequency and the number of subsequent visits by community health nurses (up to ten 36 days postdischarge or a defined period of time) is based on nursing assessment and care needs (White, 1992). Hospital nurses offer home visits or telephone contacts during the first five days postdischarge to women l iving in the areas of West and North Vancouver, B . C . (Erickson, 1992). The nurses provide information, assessment, and support regarding infant and maternal care and infant feeding. Those families needing further support are referred for community health nursing care. A 24-hour telephone line is available to families from the local hospital. Although the mothers reported that the services were supportive and valuable, many mothers noted inconsistencies in service from the nurses with some mothers receiving visits too late to meet their needs or some wanting more than one home visit. Less than ten percent of the mothers reported that the C H N s ' services were the most useful to them. The findings of the study suggest that there are discrepancies between what is needed by women and what is provided for them in the postpartum period. Dalby, Will iams, Hodnett, and Rush (1996) reported on the evaluation of an Ontario obstetrical discharge program. Three groups of women were compared on safety (number of visits to emergency or doctor and hospital readmission) and satisfaction (confidence in newborn care, postpartum care, and hospital environment). The preprogram control group consisted of women and infants deemed eligible for early discharge prior to commencement of the program, the early discharge group included women and infants who were discharged early, and the concurrent group consisted of women and infants choosing to opt for the traditional length of stay. Women in the early discharge group had access to a lactation consultant, to home visits by P H N s or by the 37 V O N , to a homemaker, to a 24-hour hospital telephone line, and to community resource information following discharge. Feedback was attained on the women's satisfaction with hospital care, breastfeeding, their needs during the first postpartum week, and the help they received. N o significant difference was seen among the groups on safety or satisfaction. However, the early discharge mothers used more resources than the other two groups. The authors conclude that the early discharge program with home follow-up appears to be a feasible option, offering safe and effective care. They state that early discharge home with follow-up as described is adequate, but unfortunately their evaluation only elicits the needs of the women in the first week postpartum. Once again, the care focus is likely on the physical needs of mother and infant, and such a focus precludes gaining valuable knowledge of how the mother, infant, and family adjust over the course of the postpartum period. The Healthy Beginnings (HB) program in Vancouver, B . C . offers contact to mothers from a community health nurse within 24 hours of discharge. The C H N assesses family needs during the initial telephone contact according to established protocols, and the family and the nurse mutually decide on ongoing contact. The C H N initiates a second telephone contact between the fourth and sixth day postpartum to families not receiving a home visit. Exceptions to this time frame are those women discharged within 24 hours of birth. They are visited within 24 hours postdischarge and a second visit is recommended within the next 72 hours along with daily contact by phone or in person until breastfeeding is well established. A telephone line is available for parents seven days per week for immediate support, and drop-in services for breastfeeding and parenting assistance are available during the week (Vancouver Health Department et al., 1995). 38 During a five-month evaluation period of the H B program, October 1995 to February 1996, it was determined that 98% of the families were contacted within 72 hours of discharge (Buhler & Carty, 1997). Maternal readmission decreased or remained constant, but there was an increase in infant re-admissions due to neonatal hyperbilirubinemia. The majority (88%) of families received at least one home visit, and more than one home visit was given to 48% of women. Women expressed much satisfaction with the care received both in the hospital and in the community. Positive responses about the community care were four times more frequent than negative comments about care received. Also , health care providers expressed positive support for the program and its continuum of services (Buhler & Carty; E . Carty, personal communication, November 3, 1997). A current focus in Canada is on continuity of care from hospital to community and cost-effectiveness of the care approaches used, for example, home visits or telephone contact. The responsibility for early postpartum care today is placed on the community resources. Since greater accessibility to nursing care and support is demanded by families discharged from hospital, P H N s have changed their services,to include 24hour telephone lines, weekend and off-hour availability, and enhanced referral linkages. Support groups in the community for parenting and breastfeeding have become increasingly important (Gupton & M c K a y , 1995). Earlier discharge from hospital has resulted in PHNs changing their skil l set and care focus. Management of acute care health concerns such as sore nipples and engorgement and physical assessment skills has become the norm in the P H N repertoire. The changes have brought benefits: the provision of care in the home allows for family 39 centered approaches that encompass many family members and the home offers privacy and a relaxed setting for families to discuss concerns and discover strengths. Yet, the Canadian health care system still needs to address weaknesses in the continuity of care from hospital to home, because each community has its own barriers to overcome and because the priority for postpartum care is on the physical wellbeing of the mother and infant (Gupton & M c K a y , 1995). Interestingly, the guidelines for discharge and length of stay for term birth by the Canadian Pediatric Society and the Society of Obstetricians and Gynaecologists of Canada (SOGC) (1996) state that care for mothers and infants should be individualized. The guidelines are that proper nursing follow-up in the home be available for discharges within 12 to 48 hours of birth. Although they suggest that more research on support for the mother and baby in the home environment be required in order to validate these guidelines, they do not acknowledge the potential needs of families for longer postpartum follow-up or psychosocial support. A s a consequence of more intense care given to women and infants, the P H N role has shifted to emphasize a prevention of illness focus, where previously health promotion was paramount. A shift back to health promotion would require P H N s to resume a wider scope of practice that includes the family and the community and that encompasses a longer temporal focus extending well beyond the immediate postpartum period (Gupton & M c K a y , 1995). The programs described in this section indicate that the Canadian health care system predominately focuses on the physical needs of mother and infant in the immediate and early postpartum periods. 40 B a l l (1994) writes that the focus of postnatal care has been traditionally on establishing infant feeding and the physical recovery of the mother, assuming that i f these two factors were satisfactory then the emotional and psychological needs of mothers would fall in to place. Ruchala and Halstead (1994) found that this assumption is not always accurate. They interviewed low risk women in their homes about their postpartum experience, and they note that the postdischarge experience of low risk women is an area for considerable improvement. Pridham and Chang (1992) state the transition toward mothering a new infant is a process of personal and interpersonal change that occurs as maternal tasks are taken on and as mothers appraise their mothering abilities. Although adjustment of mother and infant peaks in the first month, the transition continues until infant care and parenting issues are no longer unfamiliar. A s a woman copes with parenting issues, she evaluates her abilities and acquires satisfaction in parenting. The process of creating the identity of new mother may, say the authors, differ in the first month postpartum from the second and third postpartum months. Nurses would thus be wise to explore how mothers balance their own needs with parenting tasks during these first three months. Erickson's (1992) Canadian study of postpartum women's experiences indicates women request further supports for their lifestyle and role adjustment during later postpartum, and Tobert (1986) suggests that supportive-educative services should go beyond the initial postpartum period. To meet women's needs as they shift during the first three months, programs designed to address concerns in the early postpartum should differ in content from programs designed for the later postpartum period. 41 Again, studies, programs implemented, and the comments of health care professionals indicate that postpartum care still emphasizes a physical care focus with care occurring primarily in the early postpartum period or in the first one to two weeks postpartum. A s such, current health care does not appear to provide adequate support to families during the fourth trimester (first three postpartum months) ( N A A C O G , 1986). Several authors suggest that the components of a quality postpartum follow-up program and the necessary skills and knowledge required to meet the needs of postpartum families following discharge are not well known (Arnold & Bakewell-Sachs, 1991; Field & Houston, 1991; N A A C O G , 1986; Simpson & Creehan, 1996; Wil l iams & Cooper, 1996). C H N s must be able to articulate consequences of the service given to individuals or families when planning programs (Byrd, 1997). Consumer satisfaction is a determinant, not only of current service, but also of future services: A n y community health nursing service must account for consumer views (Foxman, Moss, Bolland & Owen, 1982; N A A C O G ) . Thus authors suggest that womens' impressions of postpartum interventions be explored so that interventions given are those desired (Foxman et al; Rhode & Groenjes-Finke, 1980; Rovers & Isenor, 1988). Research is needed to determine the critical interventions that lead to healthy postpartum outcomes for women and their families. Maternal adjustment is achieved gradually. Women seek more information and validation in making the transition to motherhood and each individual woman's adaptation varies. Women respond to various changes during the first eight weeks postpartum; nurses in providing care must adapt to women's coping skills and abilities. B y looking at mothers' concerns around six weeks postpartum and the types of services 42 available to date, it is noted that gaps exist. Therefore, one can appreciate and understand mothers' continuing requests for care. The literature suggests women's psychosocial adaptation during postpartum needs further study and postpartum care should include women's psychological needs and extend its temporal focus. Postpartum women's health care is an area to be improved and health professionals must find ways to offer it more effectively. Telephone Use for Health Care Intervention Various modes of telephone use exist today, including provider initiated calls to clients or family, client initiated calls to a helpline offering structured information and guidance, and client initiated calls to a provider for individualized care and support. Health care professionals using telephones identify the advantages: telephones are appropriate for routine patient assessment; they strengthen patient-provider relationships and offer convenience; they decrease patient and provider travel while they increase treatment compliance, transcend patient's physical limitations, create an informal atmosphere in the caller's home environment, offer anonymity and safety with disclosure, and decrease the costs of personal follow-up (Bartlett, 1990; Colon, 1996; Evans, 1995; Rao, 1994). Disadvantages are also noted: women do not experience the satisfaction of personal interaction; patient reporting may be less accurate; physical assessment skills are deprived of observation; and urgent treatment may be indicated upon phone assessment, requiring arrangements to be made. Also , providers using telephones need to be cognizant of the following: telephone use may be time consuming, accurate documentation is crucial, and close attention to communication techniques such as tone, silences, inflection, and language used is required (Bartlett; Colon; Davidson, 1991; 43 Evans; Rao). In the following section, helplines and provider initiated telephone follow-up are discussed. Helplines Helplines are viewed positively because of the great numbers of people who may contact them. Emotional support, advice, information, and the ability to reach underserved population groups or those not able to get out are some of the benefits noted by Anderson, Marcus, Duffy, and Hallet (1992) and Rainey (1985) when discussing cancer helplines. Helplines serve patients able to seek information and support; those who do not seek help w i l l not get it (Lechner & DeVries, 1996). For them, the telephone may feel too impersonal and distant when discussing health issues that are rightly perceived as personal and important; thus, these patients need the provider to reach out to them. Telephone Follow-up Research on telephone use for patient follow-up by health care providers, such as physicians, nurses, social workers, and lactation consultants, is growing. Eight studies on provider initiated telephone follow-up using either qualitative or quantitative methodology were found. Nurses, teams of physicians and nurses, or a social worker provided the telephone follow-up and the focus of the follow-up was adults or their children. Nurses in a pilot qualitative study called parents of children discharged two weeks from a pediatric intensive care unit (PICU) and explored their experiences in assuming care for their children at home (Bent, Keeling, & Routson, 1996). One theme emerging in the data was the parents' appreciation of the call ; all parents said the call was helpful, as 44 they needed information and emotional support. The focus of another qualitative study was patients' and their spouse's receptivity to nurse initiated telephone contact at five, 14, and 21 days postdischarge after acute myocardial infarction: 21 patients expressed appreciation for the telephone calls (Keeling & Dennison, 1995). Further research to determine i f telephone contact increases client satisfaction with health care is suggested by the authors. It would have been useful to know i f the timing of the telephone contact was appropriate to meet patient's needs during their convalescence. Another study compared two groups of men who attended a primary care clinic on their utilization of health care services and their health status (Wasson et al., 1992). The men were over 54 years of age, ambulatory, and diagnosed with a chronic illness. The experimental group received telephone contact from a clinician (nurse practitioner, internist, or physician assistant) in place of their usual clinic visit and the interval between clinic visits was doubled. The control group maintained their clinic visit schedule, based on provider recommendations, without receiving telephone contact. The health status of both groups was found to be similar, but the experimental group had less scheduled and unscheduled clinic visits, less medication use, and fewer hospital admissions. The telephone contact was found to decrease the cost of the clinical services. The experimental group felt satisfied with the phone contact and believed that the clinician could help them satisfactorily by phone. In a randomized clinical trial of patients undergoing radiation therapy, one group received phone calls weekly from a team of physicians and nurses as well as the usual care from a physician and nurse team during their radiation treatment (Hagopian & Rubenstein, 1990). The other group received the usual radiation treatment care from a 45 physician and nurse team. N o significant differences were found on variables of anxiety, coping, side effect severity, or well being. The result is not surprising as the variables measured may not be influenced by the telephone contact but rather by the process of receiving treatments over time, for example, the patients may gradually feel less anxious as the treatments become more familiar and as they develop more useful coping strategies over time. However, the patients felt the additional telephone contact was helpful and identified the importance of the caring and communication shown to them. Unfortunately, the quantitative study lacks consistent documentation and standardization of telephone contacts made by the team members and the sample size (18) is small. The authors support telephone follow-up as an intervention, and they suggest that a qualitative study be undertaken to examine the variables of caring and communication. In another study, the effect and cost of the telephone contact on dental follow-up was explored (Oda, Fine, & Heilbron, 1986). Families with children receiving a dental screening were telephoned by a public health nurse two weeks after being sent a letter encouraging them to take their child to the dentist. The authors found the phone call increased dental visit follow-up by 10% in the experimental group of parents as compared to the control group, with the greatest response from those parents lacking dental coverage. The telephone contact was found to be considerably less costly than a home visit by a P H N and both attained the outcomes desired. A study involving one control and two experimental groups focused on the benefits and cost effectiveness of telephone versus clinic counseling for patients with hypertension (Bertera & Bertera, 1981). The control group of 20 patients received the usual medical care given to all patients at the clinic while the telephone group of 10 46 patients received, in addition to the usual medical care, telephone counseling every three weeks for a period of six months. The clinic counseling group of ten patients received personal counseling every three weeks at the clinic in addition to the usual care. Subjects in both experimental groups had significant declines in blood pressure compared to those in the control group. Although the outcomes in blood pressure reduction were similar for the two experimental groups, telephone counseling was preferred because it was less costly. A strength of this study is that both experimental groups received counseling from the same person and each patient received the same number of contacts. However the sample size of 40 is small and the authors did not obtain the patient's feedback before concluding that telephone counseling is preferred over personal contact. The benefit of provider initiated telephone contact is noted by others. Polinsky, Fred, and Ganz (1991) followed 69 newly diagnosed breast cancer patients, receiving telephone contact by a social worker every six weeks for one year. The women were interviewed by the social worker prior to entering the study and the first telephone call followed several days after the interview. The authors found that the social worker was able to identify problems before they became too serious and required significantly more time, and women obtained health information when they were receptive to it. Brooten et al. (1996) studied the rates of readmission to hospital and acute care visits for seven different patient groups: (a) very low birth weight infants; (b) women having unplanned cesarean births; (c) infants of the unplanned cesarean births; (d) pregnant women with diabetes; (e) women, post-hysterectomy; (f) elderly with medical cardiac diagnostic related groups; and (g) elderly with surgical cardiac diagnostic related groups. The groups received follow-up by nurse specialists or routine care after 47 discharge. The authors found that the number of readmissions and acute care visits for each patient group did not differ significantly between those who received routine care and those who received nurse specialist care. However, the authors state that telephone contact and support offered twice weekly by the nurse specialists was very effective in the early detection of health problems. In the majority of the studies presented, provider initiated telephone follow-up was found to be an effective intervention. Other benefits of telephone follow-up were noted by the authors who advocate for greater telephone follow-up in health care: the follow-up enabled health care providers to give appropriate support and information (Polinsky et al., 1991), demonstrate caring and communication (Hagopian & Rubenstein, 1990), provide a cost effective service (Bertera & Bertera, 1981; Oda et al., 1986;Wasson et al., 1992), offer care when patients are receptive (Bent et al., 1996), detect health problems early (Brooten et al, 1996; Polinsky et al.), and give care that is well received by clients (Hagopian & Rubenstein; Keeling & Dennison, 1995; Wasson et al.). Telephone use in the postpartum period w i l l be discussed in the next section. Telephone Use in Postpartum Care Helplines Helplines are used during the postpartum period to meet the information and support needs of parents. A s well , research on helplines shows that use of the telephone offers convenience for many parents. Parents' first choice was a 24-hour phone line when asked what they needed for successful implementation of an early discharge program in Ontario, in 1987 (Rush & Valaitis, 1992). The Bright Beginnings Warmline of Pittsburgh found that 85% of the calls received were from parents of children age five years and 48 younger, and many of the calls were from mothers of children age zero to one month (Elmer & Maloni , 1988). Over half of the callers to the Hamilton-Wentworth, Ontario telephone information service or InfoLine (for parents of children up to five years of age) were repeat callers. Parents of infants between newborn to two months of age comprised the largest percentage of callers (Valaitis et al., 1996). The Vancouver/Richmond, B . C . Newborn Hotline was reviewed in 1996 following three years of service. A l l 158 families surveyed said they would use the line again, and 99% said the information received met their needs. Ninety percent of the callers had called the line more than once. It was noted that 36% of the calls related to infants less than one month of age, and 32% of the calls pertained to infants between one and two months of age (Buhler & Carty, 1997). In a study of factors influencing duration of breastfeeding, Bourgoin et al. (1997) found women desired a telephone hot line at three and six months postpartum to facilitate prolonging of breastfeeding. Parents' need for information and support is evidenced by the number of calls received by the telephone service. Further research on the effectiveness of telephone counseling and helplines is suggested (Jones et al., 1993; Rush & Kitch, 1991). The research to date on telephone information lines used by parents during the postpartum period suggests that many unmet needs may exist during this time. Although the emergence of helplines is useful to parents and practitioners, there are parents who w i l l not access helplines and they or their children may be left with unmet needs. Health care practitioners are responding by initiating phone contact to parents. 49 Telephone Follow-up Telephone contact with health care professionals during postpartum has the potential to enhance individual and family wellness (Bertera & Bertera, 1981; Bostrom, Caldwell , McGuire , & Everson, 1996; Brooten et al., 1996; Hagopian & Rubenstein, 1990; Keeling & Dennison, 1995; Marcus et al., 1993; Oda et al., 1986; Polinsky et al., 1991; Wasson et al., 1992). In this section, five studies on provider initiated telephone follow-up in postpartum are presented. Comments are then presented from several authors who support the use of extended nurse initiated telephone contact during the postpartum period. Rhode and Groenjes-Finke (1980) studied the effect of one nurse-initiated telephone contact at two days postdischarge on maternal concerns and maternal sources of information. Ninety-nine women were randomly assigned to either the experimental group that received telephone contact by a nurse two days postdischarge (approximately five days postpartum), or to the control group that received no telephone contact until six weeks postpartum. Women interviewed two days postdischarge were seen to focus on physical needs, but by six weeks postpartum their focus was on psychosocial needs such as rest, depression, and family adjustment. A t six weeks postpartum each woman received a questionnaire asking about her use of resources during this period and each was interviewed about her concerns and the intensity of her concerns. The authors found that the two groups did not differ in the nature of their concerns or the intensity of their concerns (Rhode & Groenjes-Finke) Women receiving the phone contact from the nurse used more resources during this period although 25% did not remember receiving the phone call. The increased use of resources by women 50 may not be due to the phone call but may be due to increased problems that occurred well after the phone call; and these women may have used other resources to obtain information. Likely, the phone contact at two days postdischarge did not impact maternal concerns because considerable time occurred between this intervention and the assessment of women's concerns. Other factors such as amount of family support, presence of other children, and physical healing, may have impacted on the intensity and the types of concerns expressed. The influence of other factors on the concerns of women was not assessed in the study. The timing of the phone contact at (approximately five days postbirth) to mothers in the Rhode and Groenjes-Finke (1980) study preceded the period when some of the difficulties of transition to motherhood may arise. The psychosocial concerns may not have surfaced at the time of the nurse's call; therefore, women may not have benefited from the nurse addressing these issues. The study design was altered during the course of the research as further nursing contact was made available to the women in the experimental group. The authors do not mention the number of contacts or the timing of them. The study outcomes are viewed with caution because these contacts could greatly impact the anticipated benefit of the study intervention: the telephone call. However, the authors encourage use of nurse initiated telephone contact to women in the postpartum period. In a randomized control trial three groups of low risk primiparous women were compared on infant-care behaviors and their attendance at a parent-infant support group (Edwards & Sims-Jones, 1997). PHNs phoned the first group of women one to two weeks after discharge to the assess mother's emotional health and support, the possibility of a 51 smoking environment in the home, the infant's nutritional status, and the mother's awareness of community resources and crib and car seat safety. A clerk phoned the second group of women at five weeks postpartum to remind them of the infant-parent support group; no contact was given to a third group of women. A l l women were mailed an information package approximately ten days after hospital discharge containing an invitation to the support group and they were interviewed by phone at three months postpartum. Two scales, the Infant-care Questionnaire and the Edinburgh Postpartum Depression Scale, were used to evaluate the effectiveness of the telephone contact. N o differences were found among the three groups on infant-care behavior scores or on attendance at the parent-infant support group (Edwards & Sims-Jones, 1997). However, the authors observed an increase in attendance at the parent-infant group by those women who were more socio-economically disadvantaged and who received the telephone contact from the nurse. Unfortunately considerable time passed between the telephone intervention given and the corresponding outcome assessment. Because of this, one cannot expect telephone intervention to greatly influence the scores on the infant-care behavior. Other factors may also affect infant-care behavior scores, such as, attendance at prenatal classes, use of written educational materials and community resources, presence or absence of smoking friends or family members, and support systems. These factors may also have influenced the other two groups of women. The phone call at one to two weeks may have occurred too early to note signs, either of impending depression or it may have been too late for women having difficulties with breastfeeding and who were contemplating weaning. For some women, the opportunity for the nurse to comment on the information package was lost due to the timing of the calls relative to when the 52 packages were mailed (packages sent out would have arrived later than the call). In this study many P H N s (21) made the telephone contacts. Despite receiving training in assessment by telephone, inconsistent application of the telephone intervention may have occurred. A s well , the Infant-Care Questionnaire used by the PHNs is noted by the authors to be valid, but no further information is given for readers to examine. In another study, Lee (1997), a lactation consultant, examined whether offering early telephone contact and ongoing telephone support would enhance those factors associated with increased breastfeeding duration, for example, co-sleeping with baby and using one breast per feed. The lactation consultant phoned women within 24 hours of delivery, daily for four to five days, weekly for two weeks, and monthly for several months. Lee found that many women co-slept with their baby to promote frequent feeding and to increase maternal rest. Also , none of the mothers reported that their baby desired to nurse from both breasts at a feeding. Women received on average, nine calls during the first three months postpartum; these women had no difficulty establishing breastfeeding and 23% of them were nursing at five months postpartum. Interestingly, all women received the lactation consultant's phone number but only 12% to 16% called. Lee suggests use of provider initiated telephone follow-up because her experience has taught her that many mothers do not call despite having needs. Donaldson (1988) studied the effects of ongoing postpartum telephone follow-up on maternal adaptation. L o w risk primiparous women, randomly assigned, received either the usual postpartum care or telephone calls from a nurse every week for six weeks postdischarge. The women were assessed (using a mailed questionnaire at eight weeks postpartum) on variables such as their feelings about motherhood, their perception of 5 3 their greatest concerns, and their rating of both their own and their infant's health. Although Donaldson found no significant differences among the groups she writes that many women added comments of appreciation for the telephone contact. The women wrote in their questionnaires that access to educational and supportive professional intervention, over time, was congruent with their perceived needs and they valued this offering of support. The women likely felt they obtained the information and support they wanted because nurses offered individualized care based on their requests and the care continued to be available to them as their needs changed during the postpartum period. However, Donaldson (1988) notes that many of the women seemed to need more time after the eight weeks, as many were still in a state of psychological dis-equilibrium. She suggests that when measuring intervention outcomes during the postpartum period one should wait until women feel more stable. She advocates that the lens of health care providers be refocused to consider 16 weeks as the postpartum period. Unfortunately, the study is limited by its sample size of thirty-nine. Importantly, Donaldson notes that although the benefits of receiving interpersonal sharing, caring, and support from phone contact were not measured in this study, these variables provide a basis for pursuing further research using telephone contact. Edwards et al. (1992) completed a cross-sectional survey of Ontario health care agencies on the provision of public health nursing follow-up to postnatal clients. They found there were significant differences amongst the agencies in the timing of the delivery of telephone contacts, home visits, and postnatal group sessions. Although the majority of telephone contacts to postpartum families had been made between eight to fourteen days postpartum, the administrators responding to the survey suggested 54 telephone contact should be made on average at six and one-half days postpartum. The authors do not provide the rationale for the administrators' choice, and their suggestion does not seem to coincide with the literature on the concerns identified by women during their postpartum transition. The authors indicate that the timing, definition, and content of postpartum telephone contacts is not well documented nor standardized in public health and the lack of policy and documentation of phone contacts makes accurate evaluation of them difficult. Fortunately, the authors noted that many of the nursing administrators indicated their policies for delivery of services were under review. The authors express hope that forthcoming changes w i l l offer useful opportunities to study the value of this type of intervention, as there is a paucity of research to use as a basis. Field and Houston (1991), Wilkerson (1996), and Donaldson (1991) encourage telephone use during postpartum noting that the telephone is a viable mode of extending postpartum contact to new parents. More specifically, authors note that telephone follow-up (a) offers a means to access parents regardless of distance or weather (Donaldson, 1988), (b) may help a mother in crisis who may know she needs help but is not able to get out (Hampson, 1989), (c) allows nurses to make personal contact to those families with additional needs (Donaldson), and (d) has support regarding its cost effectiveness compared to home visits (Bertera & Bertera, 1981; Oda et al., 1986; Wasson et al., 1992). In a review of 16 studies of nursing interventions (including home visits, telephone contact, group and individual education and support sessions) all intended to affect maternal adaptation during the first eight weeks postpartum, Donaldson (1991) writes that programs should, at the very least extend, interventions through the sixth to eighth postpartum week. She notes that, although the content of interventions to improve 55 maternal outcomes is important, interventions in the form of contact with caring, concerned, and available persons may be just as important. She suggests that future research must recognize the gradual process of maternal adaptation and, therefore, provide longitudinal interventions with multiple episodes. Summary Four areas of concern are summarized from the literature review. First, women need appropriate care and support in order that they can progress successfully through postpartum at their own pace. Although some authors recommend extending postpartum for a certain duration, others feel there should not be a specific time period in which mothers are expected to complete their adjustment. Presently, researchers have not reached consensus regarding the appropriate duration for postpartum care. They do agree that care given to women postpartum should be individualized and offered well after the traditional six-week postpartum time frame because this approach w i l l l ikely succeed in decreasing the distress seen in many women postpartum today. Second, since increasingly more postpartum care is being given in the community and in the woman's home, research on postpartum community care is required. A few authors have explored health care outcomes in postpartum community care but little research has been done which seeks postpartum women's perspectives. Fortunately, the literature displays a growing awareness that more data are necessary to discover the components of a quality home care postpartum follow-up program and this data should include women's impressions of postpartum interventions. Third, telephone follow-up is supported by many in the literature because of its potential to provide vast support needed during maternal transition and because this intervention is cost effective. It should be 56 implemented more frequently during postpartum. Lastly, more research and evaluation of telephone follow-up during the postpartum period is needed. Variables such as support, information, caring, communication, sharing, and appreciation should be explored in future research. Research to date shows that parents are positive towards and appreciative of telephone intervention, thus research to gather womens' views of this intervention as well as its impact on women should be initiated. 57 C H A P T E R T H R E E R E S E A R C H M E T H O D S The research methods used for this study are presented in this chapter. The section on research design discusses the choice to use Naturalistic Inquiry. The chapter also includes a discussion of the study setting, selection and description of the participants, how the data were generated and analyzed, qualitative rigor, ethical considerations, and limitations of the study. Research Design Since the study aims to explore, describe, and understand the perspectives of the providers and recipients towards the six-week postpartum telephone intervention and ultimately generate information to improve this intervention, Naturalistic Inquiry was chosen as the research method. Guba and Lincoln, (1989) note that Naturalistic Inquiry aims to discover "truth" defined as the best informed and most sophisticated construction for which there is consensus. Specifically, Naturalistic Inquiry can be used to identify and describe various (emic) participants' constructions with the intent of evolving a more informed and sophisticated construction than a single emic or the evaluator (etic) construction. Naturalistic Inquiry, a discovery-oriented approach that minimizes investigator manipulation of the study setting, focuses on variances in participants' experiences and attempts to present real stories documented through participant's own language. The stories represent, as closely as possible, participants' feelings, concerns, beliefs, perceptions, and understandings (Patton, 1997). 58 In Naturalistic Inquiry the researcher is interested in obtaining descriptive data concerning participants' outcomes but is uncertain of the variables that are most salient. The research design is "emergent", the researcher as a constructivist continuously seeks to refine and extend the design to help it unfold. Since the researcher does not attempt to manipulate the program or its participants for evaluation purposes, the researcher is able to follow whatever developments turn out to be important discovering both unexpected and expected effects or impacts of the program (Patton, 1987). Data obtained by the method of Naturalistic Inquiry are used to explore the meaning of the participants' experience. The data are rich in detail, reported in themes, and holistic in nature. The descriptive data offer participants' ideas in their terms while shedding insight into the nuances of participants' experience (Patton, 1987). The data are created through an inductive process of analysis, critique, and reanalysis connecting participants' positions or views. According to the naturalistic perspective, rules and procedures for analysis are not defined clearly at initiation of the analysis but are known clearly by the end. Categories for data are created during the analysis and by the end of the analysis all data are reviewed according to a similar rule set. Naturalistic Inquiry suggests that the context of the data obtained is accounted for during the analysis, that no generalizations of final outcomes are pursued, and that all outcomes determined are considered approximate (Guba & Lincoln, 1985). Using this method, researchers strive to have the evaluation reflect the participants' (emic) views as wel l as their own (etic) view; subsequently, the choice by a researcher of the constructs to include in further discussion with participants is part of the "craft" of evaluation. The final result is a joint construction 59 that represents the unique combination of the researcher and participants' views, feelings, and values (Guba & Lincoln, 1989). Study Setting The setting for the study was a community located in a densely populated, multicultural area of a large western Canadian city, Vancouver. C H N s from a health unit in the area conduct a telephone intervention at six weeks postpartum. Eleven women who received such a call were interviewed by telephone at about eight weeks postpartum. Following completion of these interviews, a focus group with C H N s who conduct the telephone intervention was held. Participant Sampling and Description Selection of the postpartum women participants who received the telephone intervention was done with the support of the C H N s at the North Health Unit of the Vancouver/Richmond Health Board. To familiarize the C H N s with the study, a package of information, including the sampling criteria, participant information letter and consent, and the participant information form, was provided to the C H N s prior to study commencement. The researcher also met with these C H N s to discuss the study and to answer questions prior to starting participant recruitment. To be considered eligible for the study, each participant met the following criteria; she was a recipient of H B program care, was conversant in English, had telephone access, was referred from a Vancouver hospital, was either multiparous or primiparous, had delivered a single, term (37-40 weeks gestation) infant without apparent morbidity or anomalies, was discharged together with her infant, was in a family not 60 receiving ongoing care for lactation concerns nor deemed a member of an "at risk" family, and had received the telephone call at six weeks postpartum. The C H N introduced the study to each woman during the six-week telephone call . Those women meeting the eligibility criteria, as determined by the C H N and those expressing interest in participating were considered 'potential' participants. The C H N informed each woman during the telephone call that a letter of introduction and a request for consent would be mailed to her (Appendix C) . The C H N completed the participant information form (Appendix B) and informed the researcher of the woman's interest and potential participation. Maximum variation sampling was used to obtain a sample of women with varied needs and concerns during postpartum. This type of purposeful sampling facilitates learning the most possible about the intervention (Patton, 1987). The researcher hoped to obtain a diverse group of women with respect to marital status, H B program interventions used, hospital length of stay, type of support systems, age, and birth experiences. Selection of postpartum participants for the telephone interviews occurred during M a y and June 1998. Eleven participants were selected. The two women who were part of the pilot study were combined with the total group because only minor changes were made after the pilot was completed. Following initial analyses, the researcher and C H N then selected women based on the emerging themes and participants' characteristics with the desire to obtain maximum variation amongst the participants. A letter of introduction and two consent forms were sent with a self-addressed and stamped envelope. Upon receiving the signed consent, the researcher contacted the C H N to obtain participant information. The researcher then contacted the woman to arrange the telephone 61 interview. During this initial contact and prior to being interviewed, the woman was given the opportunity to ask questions about the study, and her consent to participate was confirmed verbally. The demographic traits of the participants selected are contained in Table 1. The Table illustrates the variability of the women selected. Although the women varied in age, no young women (teen mothers) or older women were selected. The women experienced a range of birth experiences; however cesarean births are not well represented. The length of hospital stay reflects what is often seen today. The utilization of H B program care following birth reflects a variety of needs amongst the women. Primiparous women used the services more frequently, which would be expected. Since all of the women selected were partnered, greater variability would be attained with the inclusion of women without partners. The women selected were well educated. Education level is not obtained by the C H N during their practice and therefore, was not known to the C H N during selection of participants. The C H N ' s invited women with English as a second language to participate in the study, however, several of the women approached did not want to receive information on the study. Also , at least one woman with English as a second language received information on the study but chose not to participate. The researcher decided not to enlist the aid of interpreters for the telephone interviews, thus the participants needed to be conversant in English. Letters of information and consent forms were sent to fourteen women and eleven women responded, for a response rate of 79%. 62 Table 1 Description of Participants Demographic Features Age Range (25 to 36 years) l-(25), l-(26), l-(27), 3-(28), 1-(31), 3-(34), 1- (36) Parity 6-primiparous 5-multiparous Marital status 10-married 1-same sex partnership Education 1-grade 12 4-diploma 4-bachelors degree 2-graduate degree Ethnicity 5-United Kingdom 1-Italy 2-China 1-Ukraine 1-Japan 1-Phillipines First language 9-English 1-Chinese 1-Tagalog Number of children 4-two children 1-three children 6-no other children Age range of children of 16 months to 10 years multiparous women Birth type 10-vaginal (2-midwife) 1-cesarean section Attended childbirth education 6-primiparous 0-multiparous Length of hospital stay Primiparous Multiparous Day of birth One Day one Two Two Day two Two Two Day three Day four Two Healthy Beginnings follow-up Telephone calls Primiparous women(6) 2-one call 3-two calls 1-seven calls 63 Multiparous women(5) 2-one call 3-two calls Home visits Primiparous women(6) 2-one visit 1-two visits 3-three visits Multiparous women(5) 1-no visits 2-one visit 1-two visits 1-four visits Some of the women were approached by the C H N and selected for the study because they had expressed minimal concerns during their initial postpartum care while other women were selected because of the challenges they had experienced or were experiencing during their pregnancy or postpartum period. For example, a multiparous woman lacked family support and had been depressed during the first trimester of her pregnancy. Another multiparous woman received the six-week call following the birth of both her children. She became depressed after the birth of her first child. Lastly, one primiparous woman had moved just before her infant's birth, lacked family support, and experienced relationship difficulties with her partner during postpartum. Seven Community Health Nurses participated in the focus group held August 1998, approximately six weeks following the last telephone interview. C H N s providing the six-week telephone calls were given a written invitation to participate in the focus group session. Upon receiving an indication from the C H N s of their interest in participating, a date for the focus group session was confirmed. The researcher sent a letter of introduction and two copies of the consent form to each C H N prior to the session, and the signed consent forms were collected from the C H N s at the beginning of 64 the focus group (Appendix D). The C H N s were given an opportunity to ask questions of the researcher at any time. The C H N s were 39 to 49 years old. They had practiced as registered nurses for 16 to 26 years and they had practiced community health nursing in prevention for 7 to 26 years. None of the C H N s indicated that they had previous community health experience in home care although one C H N noted she had worked in the communicable disease area of community health nursing. A l l seven of the C H N s had baccalaureate degrees in nursing and one C H N was also certified as a lactation consultant. A l l C H N s indicated that they provided Healthy Beginnings program care. Four C H N s indicated that they gave the six-week telephone intervention on average, one to two times per month; two said they gave it three to six times per month; and one said she gave it as much as 12 times per month. Five of the seven C H N s had given the telephone intervention for two years, one had approximately one year of involvement, and one C H N had approximately seven months of involvement. Three C H N s contacted English speaking families only, three contacted both English and non-English speaking families, and one C H N contacted only non-English speaking families. Data Collection Telephone Interview-Postpartum Women In this section the process used for the telephone interviews of the women postpartum is described. The women actually received the telephone intervention (six-week postpartum call) between five and one-half weeks and eleven weeks postpartum. One woman received the call at five and one-half weeks postpartum, five women received it at six weeks postpartum, four women received it at seven weeks postpartum, 65 and one woman received it at eleven weeks postpartum. It was anticipated that the telephone interviews would occur at approximately eight weeks postpartum which would have been two weeks following the intervention; however, due to the actual timing of the six-week call , some interviews occurred earlier or later than eight weeks postpartum. The telephone interviews were done between seven to thirteen weeks postpartum with the average timing of the interviews being nine weeks postpartum. A l l telephone interviews were audiotaped. Semi-structured interviews were used because they allowed the researcher to enter into the participant's perspective, to learn their views, their terminology and judgements, and to capture their perceptions (Patton, 1990). The data collected contains detailed descriptions of each participant's views as well as those views that are shared by this diverse group of women. The interviews were scheduled at a time that was anticipated to be convenient for each woman and they lasted between 30 to 55 minutes. Interviews took place during the day and evening and women were reached by telephone at their homes. Despite scheduling the interview time, some women chose to reschedule and some engaged in the interview despite having to attend to their infant's needs. The researcher used questions to guide the interview (Appendix E) in order to explore (a) the content and process of the six week telephone call as it related to infant feeding or care, support systems, community resources, and family adjustment; (b) the helpfulness of the telephone call for women and their families; (c) the changes that occurred for women and their families following the call; and (d) their suggestions to improve the telephone intervention. The questions were pilot tested with two women and the researcher used these interviews as opportunities to assess, reflect, and revise the 66 interviewing technique. At the completion of the interview the researcher obtained demographic information that had not been revealed during the interview. The researcher sought and received permission from all of the women to contact them again i f clarification of information was needed. Focus Group-Community Health Nurses Since the telephone intervention was initiated approximately two years prior to the focus group, the researcher anticipated that the nurses would have many ideas to offer about this intervention (Krueger, 1994). The use of a focus group format enabled the researcher to obtain the perspectives of the nurses offering the telephone intervention. Since only a few of the C H N s at the health unit give the telephone calls, one focus group was able to accommodate the group. During the focus group, the researcher used guiding questions (Appendix F) to help the C H N s reveal their perceptions of (a) the benefits of the telephone call for women and their families, (b) the benefits of incorporating the telephone call into the C H N role, (c) the challenges of offering the telephone contact, and (d) the improvements needed to enhance the telephone intervention. The focus group was held at the North Health Unit in Vancouver. The location and room were chosen in consultation with the C H N s to foster comfort, with provision made for everyone to be seen and heard well . The researcher conducted the session and relied on her perinatal and community experience of twelve years to ensure that comments were considered in their proper perspective and to enable critical comments to be pursued during the discussion. A graduate student was present as an observer. Her role was to note the C H N ' s non-verbal behaviors, the questions that needed rephrasing or 67 exploring further, and the milieu of the session. The focus group was tape-recorded and was approximately 75 minutes long. The researcher started the focus group by introducing both herself and the observer and explaining the purpose of the observer's presence. The researcher clarified the purpose of the study and focus group and how the information would be used. C H N s were asked to introduce themselves and to briefly describe their experience in providing the telephone intervention. During the focus group the researcher found it useful to clarify and summarize points discussed. A t the end of the focus group session, the researcher provided the participants with an opportunity to raise information not yet discussed. A s well , the researcher summarized the main points discussed, and the nurses were asked to verify the perspectives (Krueger, 1994). Data Analysis The constant comparison method of content analysis was used for both the telephone interview data and the focus group data. Content analysis is described as identifying coherent and important examples, themes, and patterns in the data (Patton, 1987). In evaluation, the researcher attends closely to variations in the process of the intervention or to the ways in which participants respond to and are affected by the intervention. After completing each interview the researcher listened to the tape at least once and sometimes twice. Listening to the tapes following the interviews was beneficial for several reasons. The researcher quickly assessed the effectiveness of the interviewing techniques used and noted this for future interviews. Also , the researcher's familiarity with the interviews proved valuable during the analysis of the data as information and 68 context were recalled with ease. The researcher also noted common or new themes or ideas, which were explored with women in subsequent interviews. For example, the first woman interviewed, when asked about the C H N ' s use of the telephone to give care, said "I suppose I would feel probably more invaded i f someone was knocking at your door and dropping in . " The theme of the telephone offering privacy was noted. The researcher then asked several women "some women may like the use of the telephone because they can speak with someone they don't know, ask questions and get information, while others might prefer to know the person because of the lack of face-to-face, or non-verbal. How do you feel about its use? The second woman interviewed valued the convenience of using the telephone over knowing the nurse calling, but the fifth woman did not like the telephone because "you don't know the person over the phone." The researcher pursued a related theme of relationship to C H N or consistency by asking, "Is having someone that you've already met or that is familiar to you important?" The first woman interviewed and several others following, suggested the call be given earlier. Therefore, to get a sense of the women's need for follow-up from the C H N , the researcher asked "would you like more than one contact?" The first woman interviewed discussed the resources she had used during the six weeks and there was a difference in how the woman perceived the Newborn Hotline and the C H N ' s call. The third woman interviewed concurred with this distinction. The researcher asked subsequent women about their perception of the Hotline and the content of the call, "So those were things [concerns] that you wouldn't call the Newborn Hotline about?" The women's responses formed a grouping of themes that reflected their understanding of the call 's purpose. 69 Constant comparison analysis uses a process whereby categories are initially derived based on feeling and tacit knowledge of the researcher (Guba & Lincoln, 1985). Five categories were initially delineated from review of the first transcript and from awareness of the research questions. Phrases and sentences in each transcript were colour-coded. Initial themes were noted on the transcript and the data were placed into one of the five initial categories according to theme. Data were coded into categories based on their similarity with or variation from other data or themes already entered (Guba & Lincoln). The themes noted formed the basis for further development of categories. The researcher went back and forth between the data to check the accuracy and meaning of the categories to ensure correct placement of the data (Guba & Lincoln, 1989). The themes were compared and contrasted within each category and themes were moved between categories to ensure best fit. As well , the researcher documented ideas or feelings about the data in order to assist with formulation of criteria for the categories under development (Guba & Lincoln). This helped when there was difficulty deciding where to place data. The themes or constructs were assessed by the researcher to ensure they were induced directly from the expressed opinions of the women postpartum themselves. The data analysis proceeded as follows: A l l interviews were transcribed verbatim and the researcher checked each transcript for accuracy. The researcher read the transcript at least once in its entirety to obtain an overall sense of the woman's ideas. The first two interviews were analyzed as previously indicated. These data were reviewed again as were the themes and categories initially selected. The third interview was completed and analyzed similarly with the fourth interview being completed and 70 analyzed shortly thereafter. The emerging categories and themes were then compared and contrasted and themes moved as indicated. Feedback was obtained from the thesis chairperson on the first two interviews. The next three interviews and analysis were completed similarly with the themes and categories again being reviewed and changed as needed. The last four interviews were completed and each analyzed similarly. The process continued until new information was deemed redundant or was similar to some constructs that were dissimilar to the others (Guba & Lincoln, 1989). A s Sandelowski (1989) states, the final sample size and composition occurs when data saturation occurs -when no new themes or patterns emerge. In this case, saturation with respect to the telephone intervention occurred; however saturation regarding the concerns or challenges women faced during the six postpartum weeks was not evident upon completion of the eleventh interview. Data collection using purposeful sampling and the concurrent data analysis enabled the researcher to f i l l in gaps noted in the data during the collection (Guba & Lincoln, 1985). The C H N s and the researcher selected women that had experienced or were experiencing varied concerns or challenges during their pregnancy or the postpartum period to gain greater understanding of the intervention being studied. The data collection and analysis process is to be creative as the researcher determines what is significant and meaningful in the data (Guba & Lincoln; Patton, 1987). Directly following completion of the focus group, the researcher and observer discussed the observer's comments regarding the focus group. The observer and the researcher documented observations, important themes or ideas expressed, and participants' nonverbal behaviors (Krueger, 1994). The researcher listened to the focus 71 group tape twice before having it transcribed. Notes were made during the listening of the tape. The researcher checked the accuracy of the transcript and ensured that the session was transcribed verbatim. A n analysis process similar to that used for the interviews was completed. Phrases and sentences were colour coded and placed into potential categories, again based on the focus of the research questions and on the tacit knowledge of the researcher. The categories corresponded to the research questions with an additional category being identified: purpose of the telephone intervention. During the focus group analysis, the researcher paid particular attention to the discussion context and shifts in opinions or changes in the flow of the discussion as well as to what was said frequently, what was not said, and what would have been expected to be heard (Krueger, 1994). Themes and subthemes were identified within each category and the data were massaged several times as themes and subthemes were combined or moved within or between categories to ensure best fit. Two members of the thesis committee reviewed the categories, themes, and subthemes for both the interview and the focus group data. Ethical Considerations The University of British Columbia Behavioral Research Ethics Board approved the proposal for this study, A p r i l 1998. Consent was also obtained from the Research and Evaluation committee of the Vancouver/Richmond Health Board prior to commencing the study. During the study, the researcher sought to respect the participant's confidentiality as well as their views and their context. The dialogue between researcher and participant was open, honest, and respectful. 72 The researcher realized that the evaluation process or telephone interview may exert an effect upon both the participant and the researcher, therefore, the researcher tried to balance attention between the research or evaluation process and nurturing concern for the participant's welfare (Ramos, 1989). If participants requested further support after the telephone interview, they would have been asked by the researcher for permission to refer them back to the services of a C H N at the health unit. None of the participants requested further support. C H N ' s discussed the study with each woman during the six-week telephone contact, and, upon receiving an expression of interest to participate, the C H N notified the researcher. The C H N then provided the woman's name and address to the researcher and the letter of introduction and two copies of the consent form were sent. The letter assured women that they could withdraw from the study at any time without jeopardizing their care. None of the participants withdrew from the study. The women signed the consent form and returned one copy to the thesis committee chairperson. The chairperson notified the researcher of receipt of the consent form and consent forms remained with the thesis chairperson during the study. The researcher then obtained the participant information from the C H N . The completed participant information sheets remained with the researcher during the study. Women were referred to by first name only and a code number was assigned to each. The C H N s were given a letter of introduction and a consent form prior to the focus group. The letter outlined the purpose of the study, the need for their participation in a focus group, and how the information would be used, as well as assured them they could withdraw from the study at any time without jeopardizing their position. They were 73 encouraged to contact the researcher with questions about the study or focus group session prior to agreeing to participate. None did and none of the C H N s withdrew from the study. The C H N s provided written consent and they were given the opportunity to ask questions prior to commencement of the group. A copy of the consent form was given to each C H N while the researcher retained a second copy. Each C H N was assigned a code number by the researcher. Participants in the interviews and the focus groups were assured that all information was considered confidential. Audiotapes were labeled with the participant's number and the interview date. Only the interview date and participant code number appeared on each transcript. First names were used during the telephone interviews and the focus group, and, thereafter, the names were transcribed into a first initial only. Participants' names were not discussed in any conversations involving thesis committee members, and they do not appear in the study, nor w i l l they appear in any future documentation or publication of the study. Rigor in Qualitative Research Measures to ensure rigor of the Naturalistic Inquiry process are interwoven throughout the methods used (Sandelowski, 1989). The first criterion of qualitative rigor is credibility. The researcher endeavors to conduct the study to enhance the likelihood that the findings w i l l be considered credible (Guba & Lincoln, 1985). A study is deemed to be credible as having truth value when it describes or interprets adequately, through the researcher's reconstruction, the participants' experiences or multiple mental constructions (Guba & Lincoln; Sandelowski, 1986). Thus, the study describes the 74 experiences of its participants such that those having the experience (women postpartum) would recognize it as their own (Sandelowski). Researchers use some of the following means to achieve credibility, member checks, prolonged engagement, persistent observation, triangulation, peer debriefing, negative case analysis, and referential adequacy. Morse (1998) suggests that the factual and interpretive content attained are not to be verified at the end of the study, the content is verified step by step during the research process. In this study, several efforts were made to ensure credibility. A n informal member check was done following every interview; the data were summarized and reviewed with each participant (Guba & Lincoln, 1985). Participants were able to clarify any misunderstandings and each woman was asked i f she had any further thoughts to add (Guba & Lincoln, 1989; Krueger, 1994; Sandelowski, 1986). A s well , upon review of the interview tapes, the researcher noted that she clarified and summarized information as the interview progressed. This also offered each woman the opportunity to elaborate on what was said. For example, when the researcher reflected, "so you're saying that women could certainly get adequate care over the phone versus the personal face to face contact," the participant replied, "No, I think that that's different than what I 'm saying. I think that it [telephone intervention] as an assessment tool it can work quite well initially. I don't know that it provides, necessarily provides adequate care but it's the first step. During the focus group session, the researcher clarified information, summarized information at the closing of a particular topic or focus of discussion, and provided a detailed summary to the group at the end. The participants were asked i f they had additional information to offer and whether they wished to alter any of the points 75 discussed. The focus group was also observed and the process documented by the observer who expressly stated to the researcher that the researcher clarified and summarized information well throughout the session. Also , by audiotaping the interviews and the focus group, and ensuring accuracy of the verbatim transcripts, the researcher confirmed that the participants' experiences (during the postpartum period and with the telephone intervention) were collected in their own words (Morse, 1998). The researcher maintains the belief that the most important indicator of credibility is the actions of the researcher to adhere to the principles of honesty, sensitivity, and integrity throughout the research process. The researcher believes these principles were upheld during the interviews, focus group, and the data analysis. The second criterion of qualitative rigor is transferability. The researcher provides sufficient contextual description in the data reported (thick) so that others, considering application of the study findings to similar situations or contexts, are able to conclude whether a transfer is possible (Guba & Lincoln, 1985). A study meets this criterion when its findings fit into contexts outside of the study situation. The study's audience views its findings as meaningful and applicable in terms of their own experiences (Sandelowski, 1986). A s Burgess (1966) states, an individual's experience belongs to a specific group's experience and as such represents just one experience or impression of the group's many experiences or impressions. This one experience may be representative or typical; therefore, only some degree of generalizability can be made to others who are similar or typical. The postpartum women selected created a sample of participants whose experiences and descriptions illuminate the phenomenon under study — the value of the telephone intervention for women postpartum. The sample, with respect to parity, childbirth education attendance, hospital length of stay, needs and concerns during postpartum, and ethnicity reflected variability. This variability may assist others to consider transfer of the findings to similar situations or contexts. Yet, further variability might have been attained i f younger or older women had been included in the sample. Women in their late teens or early twenties may have offered valuable descriptions of how the telephone intervention assisted their postpartum transition. Since women are often waiting until they are older to begin a family, obtaining women in their late thirties and early forties again may have contributed insights about the postpartum not given by this group of women. The women's education level, marital status, language skills, and birth type are not varied, therefore limiting the transferability of these findings. Third, auditability is achieved when the process or the steps of the study are documented, enabling other researchers to follow clearly the decisions made by the researcher such that when given the data and context, other researchers would reach similar conclusions. The use of a journal facilitated the recording of my thoughts about the research process as well as decisions made related to it. For example, after interviewing the fourth woman I moved data related to the theme of using telephone to provide care and added it to data with the theme of consistency of call and home visit nurse as data were emerging pertaining to consistency of care provider. Also , under a broad category of content of the call I initially had data related to a theme of women's perceptions of the content which differed from themes identified on content discussed 77 during the call and challenges discussed with CHN during call. The themes pertaining to perceptions of the content did not fit with the others, thus they were pulled out and eventually became a collection of themes pertaining to purpose for the telephone call. This category was not anticipated initially. Because this category arose during the interview data analysis, it was anticipated for the focus group findings although no questions about purpose were asked. Documentation proved valuable in assisting me to see clearly the linkages, similarities, and variances in the data obtained. Thus, the documentation of themes, subthemes, and the corresponding decision making was ongoing throughout the analysis. Confirmability in qualitative research refers to the neutrality of the findings. Neutrality is explained as the freedom from bias in the research process and findings. The data in qualitative research emphasize the participants' subjective reality, achieved by engagement of the researcher with the things to be known (participants) in order to seek truth. When credibility, transferability, and auditability are established in the research process then confirmability is achieved (Sandelowski, 1986). Assumptions The following assumptions were made (a) women interviewed openly express their issues and concerns as well as offer an honest evaluation of the usefulness of the six week telephone contact; (b) when choosing interviews as a method for data collection, participants' perspectives are considered meaningful, knowable, and able to be articulated (Patton, 1990); (c) short term changes made by women postpartum are implicitly linked to long term or ultimate health changes that may impact maternal, child, and family health. 78 Limitations of the Study The following limitations may have influenced the results of this study. Cultural perspectives may have impacted on women's views of receiving C H N contact by telephone. The sample consisted of English speaking women postpartum; consequently, greater richness and diversity of responses might have been obtained i f non-English speaking women from other cultural groups, not selected as part of the sample, were interviewed. The data gathered using Naturalistic Inquiry contained postpartum women's views; thus, the study reflects only the perspectives of those women selected. Also, some of the women selected had unresolved concerns and these might not correspond to concerns expressed by other women postpartum. In doing a formative evaluation there was no intent to generalize the findings beyond the specific setting of the health unit community (Patton, 1990). Giving one telephone contact to women at six weeks postpartum might have limited influence on health behavior changes anticipated; one phone contact may not allow for sufficient development of rapport and trust, both important when offering teaching and support. A single intervention may not adequately address the complexity of maternal adaptation over time, and any effects seen may not endure as they are subject to many influences during the process of maternal transition (Donaldson, 1991). The use of a focus group session with a group of community health nurses who work together may have provided risks as familiarity of the group members may have inhibited the discussion. Also , data analysis may be difficult because other factors amongst the group members, and unknown to the researcher, may have impacted on the answers or discussion offered (Krueger, 1994). 79 Summary In this study, the Naturalistic Inquiry method was used to evaluate the telephone call intervention. Purposeful sampling was used to select eleven women postpartum who were interviewed by telephone, seven to thirteen weeks following the birth of their infant. Trigger questions were used to guide the interviews. In addition, seven C H N s participated in a focus group six weeks after the telephone interviews were completed. A topic guide facilitated generation of their views about giving the telephone intervention to women postpartum. Content analysis began with the first interview and attention to qualitative rigor was maintained throughout the evaluation. Ethical considerations and limitations of the study were acknowledged. The research methods have been described; the findings are now discussed. 80 C H A P T E R F O U R P R E S E N T A T I O N O F FINDINGS The results of the analysis of the interviews with the women postpartum and the focus group with the C H N s are presented in this chapter. The findings of the interview analysis are presented first and are outlined in three sections. In order to offer contextual understanding a brief description of the women's experiences during the first six weeks following the birth of their infants, the care they received, and the resources they used prior to receiving the call are presented. The first section includes the types of challenges and concerns faced by women prior to and at the time of the six-week telephone call following the birth of their infants. In the second section, the women's impressions of the C H N ' s telephone call are given. The changes the women and their families attributed to the call are detailed in the third section, and the women's recommendations for improvements with respect to the telephone call are also presented. The findings of the focus group analysis with the C H N s are presented as a summary of their perceptions of the telephone intervention. The findings are presented in four parts: (a) C H N ' s perception of the purpose of the telephone call intervention, (b) C H N ' s perception of changes for women and their families from receiving the telephone call , (c) the advantages and disadvantages of telephone use, and (d) the impact of the . telephone call on the C H N ' s and their practice. The C H N s ' recommendations for using the telephone as an intervention complete this chapter. 81 Postpartum Women's Perceptions of the Telephone Intervention Care Received and Resources Women used during the First Six Weeks Women received care in the form of telephone calls and home visits from the C H N s as part of the Healthy Beginnings program, prior to receiving the six-week telephone call. The women described the care they received during the calls or home visits very positively: "Very helpful," "It was fabulous," "The care is excellent," and "Very supportive." They appreciated that the C H N cared not only for their infant but also for themselves and that the care included both physical care, for example, checking perineal sutures as well as "mental care". One woman praised the C H N ' s care because it was directed to all family members. "She treated the whole family." Another woman summarized her thoughts about the care by saying, "They're friendly and easy to talk to, but I could also really tell they were very experienced and, they knew their stuff." These women, when faced with a variety of challenges, turned to resources in the community or to their families or friends for help. Community resources such as the Newborn Hotline, other breastfeeding mothers, their family physician, and the C H N were used and consulted as well as their reading of books on parenting and childcare. Some women stated they were unsure i f their concerns could be directed to resources known to them in the community, therefore, they hesitated to use them, and in fact, did not take advantage of this support. For example, a woman, who was worried about experiencing postpartum blues did not contact the same C H N who had visited her. Another woman was unsure whether the Newborn Hotline addressed concerns other than those related to 82 newborns. She had experienced rapid breast milk letdown and was not aware that she could call this line about her own physical needs. Women turned to their family and friends, especially sisters and sister-in-laws, for support during the six postpartum weeks. Women viewed relatives or friends who had recently delivered as knowledgeable and experienced and subsequently, sought their advice. Parents of the women were not often mentioned because they were busy working or they lived too far away to help. Challenges or Concerns Women Experienced Prior to the Six-Week Telephone Call Some women identified challenges and concerns prior to the telephone call with respect to: (a) feeling stressed because they were unsure of how to care for their infant, (b) wanting adult contact, (c) feeling down, and (d) feeling overwhelmed. Other women expressed confidence and competence during the six weeks after the birth of their infant. The women who stated they were coping well with the postpartum experience were more likely to be multiparous. They commented, "I really didn't have any questions.. .like this time around, I wasn't concerned about anything," and "I didn't really have any questions this time around." A few women who had their first infant viewed the initial six weeks as an adjustment, not a challenge, "it was more of an adjustment...there hasn't been any real concerns." While some women, both primiparous and multiparous, said that their infants were "good" and were sleeping and feeding well , other women, faced varied challenges prior to receiving the six week call as illustrated by the following four themes. 83 Feeling stressed because they were unsure of how to care for their infant. Women felt stressed because they were unsure of how to care for their infants. This uncertainty, coupled with knowing that their infant depended on them, was a source of stress. " . . .Sometimes when the baby is crying, I cry too.. .because you don't know what to do with her," and " . . .Once you come home you don't have this professional care anymore, you're on your own. . .it's quite scary with a new baby." The women implied there was a progression in their focus during the first six weeks; from a place of "newness" with their infant where they were often inexperienced, to gaining understanding of their infant's ways and needs that led to their feeling more competent. One stated: "I think because I know that for me by the sixth week I was feeling a lot more confident, but the second and third weeks you're very unsure as to what the best thing to do is." Another woman commented: .. .Because this little human being that's dependent on you.. .you don't know what to do, that you have no experience for it, whereas when you're working before, you know the job, you know how to do it, and this is easy whereas this is, you don't know and you've never done it before. It's quite difficult. Wanting adult contact. Several women talked about desiring adult company during postpartum because they spent much of their time alone caring for their infants. "I think having a nurse to come in and chat with you for awhile and I think it's really important that contact, that human contact." and "You're used to working five days a week... having busy schedules and.. .a lot of pressure and now it's like you have no contact with the outside world." The only concern I have is . . .you're at home all day with the baby and it [would] be nice to have someone to talk to, not that I have any real pressing issues but.. .getting out of the house and socializing is probably the biggest concern. 84 Feeling down. A s well as wanting more adult contact, women experienced feeling "down" or postpartum blues following the birth of their infant. One woman, who received the six-week telephone call following the birth of both her children, stated "you have your depression and.. .it was just.. .1 honestly didn't want her [CHN] to leave when she came for that visit, I didn't want her to leave, I really didn't." Other women also commented that they had experienced postpartum blues: Like I had the blues, I think it was the first few weeks.. . I 'm taking care of the baby, all twenty-four hours a day because I 'm nursing the baby. There's nothing my husband can do.. .1 have to wait until my milk flows, is more steady before I can pump.. .and then there's your engorgement and all that and it's just like a nightmare. Yeah, it was in between the six weeks and the first visit. I just relied on my friends. During the initial weeks at home women felt down due to the enormity of the task of caring for their infants. These tasks seemed to overwhelm them. Feeling overwhelmed. Women commented that they felt too overwhelmed to think about doing other things or to get out of the house, for example, to attend a drop-in during the first six weeks postpartum. One said: I knew about it [drop-in] but.. .either I just couldn't get my act together to get out there on time or the weather was crappy and I didn't want to go.. .or I just forgot it was Tuesday and.. .the next thing I knew it was l ike . . .it was too late or Wednesday. The first nurse had mentioned them [drop-in] but... in the first couple of weeks of coming home I was really too overwhelmed to even think about doing anything like that [attend drop-in] and I 'd had a really difficult delivery and C-section so... I just...couldn't sort of get my head around it. Some women were overwhelmed not only with the adjustments related to the postpartum but with the additional stresses related to other life experiences that occurred during their first six weeks postpartum. For example: 8 5 We talked a lot about the stress in my life because I just moved into a house.. .the baby was born what three days later. We had moved back.. .from Japan in November, my husband was starting his job the day after the baby was born so there was a lot of [stress] and then I was having my gall bladder removed four weeks later. Having this baby is a new thing for me so there's a lot of frustration I had and a lot of stress that I wanted to talk more about. In summary, prior to receiving the six-week telephone call, women experienced the enormous changes that occur with the birth of an infant. They described a sense of life passing them by as they tried to stay on top of their infant's demands and care for themselves. They said, " . . .when you're first [home], everything.. .was almost like a blur."and " . . .1 suppose you're a bit more scheduled by six weeks, but in the first couple of weeks you're.: . in a daze." The themes discussed reflect the intensity of the immediate and early postpartum period. A strong focus on meeting the physical demands of their infant illustrates the magnitude of this task that coincides with feelings of loneliness, sadness, and being overwhelmed. At the Time of the Six-Week Telephone Call The telephone call conversation at six weeks indicated that women continued to be challenged in similar ways. The main challenges or concerns women identified at the time of the telephone call were: (a) managing their physical health, (b) feeling unsure about what to do or expect when caring for their infant, (c) feeling fatigued, and (d) managing life and family demands. However, some multiparous women felt they had resolved their concerns by the time of the C H N contact at six weeks postpartum, "I didn't really have anything to talk about." Managing their physical health. Some women were still coping with physical concerns such as continued bleeding and sore nipples at the time of the call. For one 86 woman, the unavailability of her physician resulted in her feeling anxious about her continued bleeding: I had that bleeding.. .1 couldn't even make an appointment [with my physician] until the following week. I was supposed to go back at six weeks and I didn't go back until the seventh or the eighth week.. .so that was my main challenge. Feeling unsure about what to do or expect when caring for their infant. A t the time of the six-week call, some women still felt uncertain about caring for their infant. They stated: "I asked them about...why is the baby crying." and "Needing information about different things...like bottles, like sterilization and expressing milk and things like that." Women were also unsure of how to cope with normal changes occurring in their infant's behavior and what those meant, such as their infant's increased feeding pattern and fussiness. The infant's changing behavior often coincided with developmental changes seen in newborns, for example, growth spurts often occur at six weeks of age. They noted: She [CHN] says.. ."I know you're having a hard time because the baby was feeding every hour and a half, two hours at night".. .1 was more tempted to start to feed her, giving her a teaspoon of cereal to see i f it would help her to sleep through the night. I didn't know what to expect from a growth spurt. She was such a good baby and then just for two or three days there I just didn't know what to do with her. I 'd hold her and I 'd feed her and I just didn't know. She was just so fussy and I couldn't get her to stop crying and then she was vomiting and I just thought oh my God. Feeling fatigued. The women felt much more tired during this time due to the fact that their infants needed more attention and were waking them frequently to feed. One said: " . . .So I was just getting really tired.. ." and "[the infant was] up quite a bit and eating quite a bit more.. .[and] you're a little more fatigued because they're not sleeping 87 through the night and not that he was but at least he was going for four hours." Another stated: I suppose he was feeding more.. .it was the fussy time at night. Because he wanted to feed more than once in the three-hour period. He wanted to be on the breast.. .off and on for three hours before he actually settled for the night. Managing demands of life and family members. A long with the birth of their child, women continued to cope with other challenges related to life events and demands of family members. Husbands were mentioned occasionally, and when they were mentioned it was because they had other demands that took them away from helping women with infant care or with their recovery. A s one woman described, "being a new mother, there was nobody else in my house. M y husband had just started his job." One multiparous woman with a young child and the new infant had returned to work prior to the six weeks. She found the many demands difficult to cope with. She said: W e l l I was [working and].. .at six weeks I still had a nanny and right now my nanny is on vacation and we're self employed so we're just addressing the fact that my husband doesn't feel like I spend enough time with the business and he feels that we should get a replacement nanny. Only one woman stated that a major challenge at six weeks postpartum was difficulty with the adjustment of family members to the new infant. This woman said: "my older son, just his aggressiveness towards the infant." Concerns about the infant and herself had resolved by six weeks but the infant's presence challenged her other children. In summary, the challenges described by the women prior to the six-week call and at the time of the call varied; however, challenges related to their family members and to both the women's own emotional and physical dimensions. 88 Women's Impressions of the Telephone Call The women's perceptions of the telephone call are presented with respect to; (a) the purpose for the call, (b) the helpfulness (knowledge and approach) of the C H N , (c) the timing and length of the cal l , (d) the content of the call , (e) the relevancy of the call 's content to their issues, and (f) the advantages and disadvantages of the telephone as a means for communication and intervention. Generally, the women spoke positively about receiving a telephone call from the C H N at six weeks postpartum. They remarked, "I was very happy to be able to talk to someone about.. .what the six weeks was l ike," "I think having a nurse follow-up is good." Other women, however, mostly multiparous women, did not feel as strongly about the usefulness of the call: "It probably wasn't that big of a deal.. .because it's the second baby and I 'm pretty comfortable with parenting," and "Because it was my second, I didn't have any questions really." However, these multiparous women indicated that the call would have been helpful to them with their first child, "I can tell you from my first son where I didn't have a call at six weeks. I didn't know about these baby groups." "It would have been more helpful with my first child." Perceived Purpose of the Telephone Call The women perceived that the purpose of the telephone call was (a) to detect health concerns early, (b) to provide information and opportunity to ask questions, and (c) to offer support and reassurance. They seemed aware that not all women coped effectively with the changes arising during postpartum and consequently some women were likely to benefit from further contact so that concerns were identified early. One 89 said: "It was just nice to know that somebody is following up in case it isn't going very wel l ." Another described her perception of the call 's purpose stating: So I could see.. .it would be.. .an outreach may be a saving grace.. .and also to stake out mum's that are really having a hard time.. .who don't know what the resources are. I think it's very useful.. .And to be honest with you.. .1 think that i f a nurse is concerned that maybe she could follow-up on that as well . For the needs and the safety of the baby. Women believed that another purpose of the telephone call was to offer information and provide an opportunity to answer questions. "With someone calling you, you can ask these questions that aren't immediate but you can.. .think of during the week and write down." They noted: It would be nice to have the calls.. .in the first month.. .sometimes it's just concerns like how are you feeling or.. .how much milk did you, i f you're pumping out this much milk, does that mean he's not getting enough to eat, those kind of questions and they're not immediate questions but it would be nice to have someone to ask them. Y o u have certain questions as I said.. .so having someone to talk to and say...is this normal or does that mean he's not eating enough or how can I tell. Those kind of questions that you wouldn't necessarily phone the hot line for but want an answer to. The women suggested that another purpose of the call was to offer emotional support. They stated, "I think it's very useful. I think the support, [when asked why call is useful]" and "The general support when being at home alone with the baby." Helpfulness of the Community Health Nurse The C H N ' s knowledge and skilled approach impressed the women. Knowledge. Many women appreciated the C H N ' s level of knowledge. The women felt comfortable when talking with the C H N and felt confident in the answers they received. "There's a sense that they know what they're talking about because they're asking all the right questions about stuff that's going on." 90 Their [CHNs] knowledge...also makes it comfortable so then I know someone who knows about this stuff. A n d I trust their knowledge so I would ask them for their opinions and what not. She knew what she was talking about. Approach . Several qualities about the C H N ' s approach were helpful to these women. These qualities included that the C H N s were perceived as being caring, easy to talk to, nonjudgmental, respectful, skillful in communication, and flexible. A s well , women thought that the C H N initiating the telephone call was helpful to them. Women stated "It was nice to know that somebody is there that cares," "She, was really sincere and she seemed to really have a... warm, caring approach," and "She was just very caring.. ." and "She's very helpful because.. .the way she talks she is very concerned and more like, not only a nurse but really a mother, a friend, something else, she's just really nice to me." The women felt the C H N s were easy to talk to. "They come across as very friendly." and "She was easy to talk to." Since the women did not always know what to ask they appreciated that the C H N s shared their knowledge freely without the women having to request it. One woman noted: They're very approachable. They ask questions, they initiate, rather than they wait for you to ask a question. They're very talkative so they have lots to say about everything and.. .you may not ask the question but if . . .the topic comes up and you. . .then they'll talk about several things around that and any other topics so that's pretty good. The C H N s were perceived to be nonjudgmental and respectful during the telephone call and women appreciated this attribute. They volunteered, "I like that way [how the C H N talked to her] because you never know.. .they not take you for granted." I wasn't afraid to ask them, I felt very, very reassured that they were a health nurse and that I wouldn't get a slap across the wrist which a lot of people say.. .you shouldn't do this and you shouldn't do that. They're very reassuring for everything that you have or you didn't do or you don't know how to do. 91 The nurse that I spoke to seemed very kind and it was never a concern that I didn't know her, that she seemed judgmental in any way. She treated me like somebody that was also capable.. .like I was an intelligent person even though I'm a new mum.. .and I have enough wits about me to make some choices. The following quote illustrates how the women perceived the C H N ' s to be skilled in communication: "So she was really good just drawing out questions and then I started asking questions." Other women commented that the C H N delved into the woman's responses so their needs were assessed accurately and explored fully. She was just very interactive.. . i f she had just said.. .how are things going and just kind of left it at that and I was [saying] things are going fine for today and see you, I don't think that would have been all that helpful. It seemed like important, .. .that she draw out what was going on for me. Women felt the C H N was flexible during the telephone call. They thought the C H N recognized and acknowledged that their needs at the time of the call were important, consequently, the call was not driven by the C H N ' s focus but by the woman's needs. Hence, women were able to raise any concerns that had not already been discovered. They commented: "She asked questions but she also really encouraged me to just talk about anything I wanted to bring up." and "She answers all my questions and she even ask[ed] i f you had some other questions." Lastly, the women liked that the call was nurse-initiated. They suggested that they were too busy to reach out for assistance or support soon after giving birth. One woman stated: "I don't think women would reach out right after having a baby, it's really stressful." Other women supported this opinion: .. .You're so busy taking care of the kid, trying to.. .get some sleep, feeding the kid, changing the k id and then you're trying to eat yourself, trying to have dinner that you really don't have the time to call the nurse in those first four weeks. Y o u w i l l have issues or I had issues anyway during that time and i f someone called me then it would have been good to talk it through. 92 Oh yes, because you don't have time or anything. It's nice that someone else...So I think it's enough to just get up and out the door and mobilizing yourself, without something else. Timing and Length of the Telephone Call Just as the women valued the approach and knowledge of the C H N , they also desired sufficient time to explore their needs and wanted to be able to attend to the call to gain its benefit. The timing of the call to the women and its length influenced the women's impressions of the telephone intervention. Timing. Many of the women were attending to several tasks at once when they received the telephone call. Although they tried to focus on the call, they often found this difficult. Some women felt they were unable to concentrate solely on the conversation because they were distracted by their infant's needs: they preferred not to have their infant with them at the time of the call. They said: " Y o u never know when you have kids, sometimes it's hard to just sit down when somebody calls and give them the attention." and "For me it 's . . .is the baby giving me some space to talk?" and "Wel l the baby was fussing [when the C H N called] but then I picked him up.. .he stopped fussing.. .1 'd rather.. .not have him around when I'm talking and thinking through issues. It just kind of distracted me a bit." Women had difficulty attending only to the conversation with the C H N . They mentioned that scheduling of the research interview allowed them to plan their time so they could listen to what was discussed. Length. The activities previously mentioned influenced the length of the six-week call, or the amount of time women could spend on the call. " [Did you have sufficient time during the call?] Mysel f no, I didn't have a whole lot of time to talk to 93 her." Thus, the women's responses were mixed when asked about their perceptions about the length of the telephone call. Many women were very satisfied with the amount of time given for the call: "It was good...she definitely answered all the questions that I 'd been having." Others were somewhat satisfied and would have been more so had they been reached at a time when they were not attending to their infant: I thought it was pretty good. I had enough time to ask the questions I needed to and I think I would have, i f my baby wasn't there I would have talked a bit longer. But i f I had had more [questions] as she was talking and giving more information I wouldn't have been able to ask them. The length of the call for one woman seemed to be determined by the C H N rather than the woman not having further questions or concerns to discuss, therefore, this woman was not as satisfied with the call and wanted more time or another call at a more convenient time. She said: We [woman and C H N ] didn't get through all of it because we had been talking for awhile. But she had given me a lot of time. Maybe she could have offered.. .or say do you want me to call you back. I felt l ike. . .you've got twenty or thirty minutes, twenty minutes and then they knew they had to wind things up and get off because there was another one they had to call. So maybe that's what I didn't like. The telephone call 's potential to benefit women (based on the timing of the call and the call length) was influenced by whether women were reached at a convenient time. The timing of the call or when women were reached by telephone influenced how well women were able to focus on the content of the call. Because the call was unscheduled, women were reached when they were in the midst of a family or household task. They were not always able to completely attend to the call. Also , i f reached when busy, the women were not always able to make time for the call. The length of the call was determined by their demands. They may not have been able to discuss all of their 94 concerns or discuss them completely. The potential of the call to meet women's needs depended on when women were reached. Content of the Telephone Call The busy lives of women, postpartum influenced how easily they were able to accept and participate in the telephone call. Despite not always having much focused-time for the call, the women easily remembered the content of the call and the information they received. Women remembered content related to (a) infant's health, (b) mother's health, and (c) community resources. Infant's health. The women remembered the C H N inquiring about infant feeding and infant weight gain. One woman recalled: "She asked me about how the breastfeeding was going and about how his weight was and I hadn't weighed him in a little while." A s well , women talked to the C H N about Sudden Infant Syndrome [SJDS]: "We talked about SJDS. I guess the one thing she really stressed about the SUDS is any contact with cigarette smoke. She stressed that.. .the most important factor was actually the contact with cigarette smoke." Also , childhood immunizations were discussed during the telephone call: " A n d she told me about the immunization of the baby, she asked me where am I going to bring my baby, I said to my doctor." Mother's health. Women were grateful that the C H N s inquired about their own health, for example, whether they felt fatigued or lonely, experienced mood swings and whether they knew other new mothers close by. One women noted: " A n d [she] asked how I was, you know, that's one thing I think a lot of times it's always the baby, the baby, the baby, and not how the mum is doing and so, that was good." 95 Community resources. Women easily recalled talking to the C H N and being given information about community resources such as the Newborn Hotline, the North Health Unit parent and infant drop-in, and the breastfeeding drop-in. They remembered: " A n d then she told me about resources in the community...the various [resources], the lactation clinic and also the North Health Unit and the drop in group." and "She also told me about the mum and tot group as well right, have I been able to get out to meet other mum's who are going through the same things, so that was good." I had the six week phone call and they said that there's all these different topics, they talk about eating and nutrition and it [drop-in] was every Tuesday and you can weigh your baby first and then there's the topic.. .there's discussion groups and that a lot of friendships can be built from the groups and stuff like that. During the call, the C H N encouraged women to use the resources available: "She encouraged me to come back to the mum's group." The women were glad to hear of the resources available. Although they had not always used them they valued knowing about their existence. One of the things she suggested was that I go to the drop-ins. I never did get around to doing that. I was quite busy I had family coming in and the whole nine yards and then I just never did go. But I always had that option. Relevancy of the Content of the Call Women were asked i f they felt the questions the C H N s asked were pertinent to their needs at six weeks postpartum. They replied that the questions were "relevant", "supportive", and complete. They appreciated that the C H N ' s asked about their feelings. One woman stated: "I think it's good that she brought up the postpartum depression because that might be one that people don't want to talk about." Women were asked i f they would add anything to the questions asked. For most of the women the range of questions posed was thorough, and consequently, they felt the 96 call was complete. They said: " . . .1 felt like she covered the ground." and "I think she was pretty thorough, she asked everything she could." While most women were very positive about the questions posed by the C H N , they did offer suggestions. They wished that the C H N had given them her name and telephone number for future contact or inquired about the family situation, " Y o u know the family situation, how are people adjusting." A s well , they stated it was easy to forget when the first immunization was due; therefore, it would be helpful i f the C H N s during the call gave them "a reminder to set up the schedule." Advantages and Disadvantages of Telephone Use as a Means of Intervention Women described their thoughts about using the telephone to talk to the C H N about their health and their family's health. The women noted that use of the telephone provided several advantages. It (a) offers convenience, (b) offers privacy, (c) offers a cost efficient means to obtain information for an initial health assessment, and (d) allows other family members to access the C H N . They also commented that a disadvantage of telephone use was the difficulty experienced when establishing rapport with a C H N not known to them. Several women talked about the convenience of having the C H N contact them by telephone instead of them going out to see a health care practitioner. They said: "I think it's great. I think that some people.. .they're too tired to get out or they don't have.. .access to a car." and "I find it's a lot better than having to go somewhere to get help, it 's a lot more convenient." and "I enjoyed the convenience of not having to drive across town, and the fact that it's as easy as a phone cal l ." 97 Women generally felt comfortable discussing sensitive issues and their feelings over the telephone indicating that the telephone, for some women, may offer a greater sense of privacy than face-to-face contact. They noted: Oh really comfortable actually [when asked how she felt using the telephone]. I think it's probably better having it over the phone. I 'd never met her [CHN] before because the woman that did my home visit was a different nurse, but I felt really comfortable with this woman and I think it's easier not being face-to-face. If I had been feeling depressed I don't think I would have any qualms about telling her about it. [What did you talk to the C H N about?] Having this baby is a new thing for me so there's lots of frustration.. .and a lot of stress that I was wanting to talk more about.. . in private because in my baby group I wouldn't talk about that. The telephone was viewed as a cost efficient approach to obtaining information for an initial health assessment of the woman and her family. One woman described her views: There's a cost.. .efficiency using the telephone that I think is quite valuable. I think that it [telephone call] as an assessment tool it can work quite well initially. I don't know that it provides necessarily adequate care but it 's the first step in terms of knowing i f someone is in crisis or needs further assessment or needs to actually be seen. The telephone call facilitated/am//y members gaining indirect access to the CHN and her knowledge. One woman mentioned that her spouse was interested in obtaining information from the C H N stating: "But with my last child it was very helpful because.. .we knew they were going to phone and my husband just kind of said okay can you please ask this, this, and this." Some women felt uncomfortable when contacted by a C H N they did not know or had not met; consequently they had difficulty establishing rapport with the C H N by telephone. They preferred follow-up contact by the same C H N . They shared these thoughts: 98 But it's hard.. .talking to someone [CHN] and not knowing who this person is and asking her all those questions. I don't know i f I trust that. Particularly since the questions are...very personal. Unless you've built up something with the nurse like a rapport... But because it was so personal.. .it was hard to open up. Phone contact would be fine after that [meeting the C H N ] . It [her comfort talking over the phone] was probably more so that I know her.. .1 think another follow-up by possibly the same nurse that saw you would probably be the best. It would be nice to have the same person call you that had done the house visit. I definitely prefer one-on-one. But, providing you get that first visit face-to-face, I think a phone call would be sufficient providing you have the same person.. .1 would prefer that it would be someone that I knew. In summary, the women valued the C H N telephone call at six weeks. The women identified several important purposes for the call, which reflected a strong awareness of their own and postpartum women's needs. They appreciated both the C H N ' s skills in conducting the call and the C H N ' s focus during the call. They seemed relieved that the C H N contacted them and generally they made good use of the telephone to address their needs. However, for some women, the telephone call came at a busy time interrupting the woman from her tasks and this may have decreased the perceived value of the telephone call. Yet, despite being busy, the women persevered with the call indicating that they felt the contact was useful. Perceived Changes Attributed to the Telephone Call The women noted that changes for themselves or their family occurred from receiving the telephone call. Women (a) felt more reassured, (b) had increased their awareness and knowledge, (c) felt better prepared to cope and coped better, (d) became motivated to make changes, (e) took action, and (f) were more receptive to future contact with the C H N . 99 Women Felt More Reassured The telephone call provided needed reassurance for women. They felt supported when caring for themselves and their infant. Some women found comfort in knowing that their experiences, often related to infant care and behavior, were 'normal' and that their style of parenting or approach was accepted. One woman commented: "Being first time parents we've done a lot of reading and.. .we know what's going to happen but even then, you just want to be reassured." Others said: I think for the most part she was just really reassuring because you read these things and there's one thing to read it but it's also another to...talk to someone about it. It [telephone call] was just reassuring more than anything else. The first time.. .she [CHN] definitely made me feel better all around.. .with being a new mum and.. .being quite depressed and being pretty unsure of several things you come across in the first six weeks of l ife. . .1 think it's exactly what I needed at the time. I needed someone that I could definitely talk to that wouldn't again slap my wrist and say no I 'm doing this wrong or I should be doing this instead. It was just very reassuring to talk to somebody that wouldn't. . .say what I was doing was in any way a negative thing. Women Had Increased their Awareness and Knowledge A s well as feeling reassured, women said they had greater awareness and knowledge about infant and self-care, and community resources. Their awareness and knowledge increased with respect to knowing, (a) what to do and what not to do, (b) what to expect, and (c) about available support and resources. One woman, who was concerned about her infant's risk of having SIDS, gained knowledge of the risk factors and how to reduce the risk for her infant. Another woman, whose infant was very fussy and crying often, learned ways to soothe her infant: " .. .then she told me that I can give him a warm bath." 100 Women became aware of what they could expect when their infant was likely going through a growth spurt. One woman recalled: I was very happy to be able to talk to someone about what the six weeks was like and what to expect. I did not know that at six weeks my baby would go through a growth spurt and would fuss and eat a lot. Learning about community resources was an outcome for several women. One woman described an experience when her infant became fussy following breastfeeding. The event appeared to relate to when the mother ate dairy and wheat products: So she [CHN] recommended that I get a referral from my doctor to see the allergist at V G H . The fact that it [telephone call] made me realize that there are supports there i f I need them.. .1 can turn to the health nurses and I can go to the group [drop-in] and that sort of thing. Another woman appreciated being advised of the many community resources available. Just the fact that it [telephone call] happened was good.. .because it was really helpful for me actually that they called and talked about the community support. It was really; it was really helpful for her to kind of reinforce that those things were available. Women Felt Better Prepared to Cope and Coped Better The telephone call not only provided women with the opportunity to learn and become more aware, it allowed them, upon gaining this knowledge and awareness, to feel better prepared and able to cope. One woman after learning of her infant's potential for a growth spurt and the accompanying fussiness, stated, It [telephone call] really set my mind up for that six-week's growth spurt. Because I knew there were going to be growth spurts up to a certain point, up to six weeks and that's not including or after the six weeks. So apparently there were some more. So. . .that kind of helped me to.. .prepare me for the fussiness and so I didn't find it difficult going through that six weeks. I had this impression in my mind already so it's more like okay it's a growth spurt so just let him have what he wants. Rather than, looking at it as why are you fussing? Y o u know it [telephone call] kind of prepared me better and I think i f I didn't get the call , I wouldn't have handled the growth spurt as well as I did. 101 Women Became Motivated to Make Changes A s is often the case, once a person gains a sense of being able to cope or manage in a difficult situation, he or she becomes motivated to take action. For some women, the telephone call and the discussion of the community support groups were sufficient motivation to return to the group. One woman remembered: "It [telephone call] motivated me to get going back to that mum's group again." Some said the conversation planted the seed to try to attend the drop-in. Although they had not attended by the time of the telephone interview, the telephone call helped "kind of get me going." A s well , women gained motivation from the telephone call to begin going to the drop-in. For one woman, the telephone conversation with the C H N created the awareness that she might be having difficulty adjusting postpartum; subsequently, she became motivated to take action for herself. She said: "Wel l I did [think].. .maybe I am having postpartum [blues/depression] a little bit and maybe I need to talk to somebody about it. So yeah it did trigger that." The motivation that resulted from the conversation with the C H N led these women to take action for themselves or for their infants. Women Took Action to Improve their Health or their Infant's Health Some women took action in seeking out community resources and supports to address their concerns. One woman whose infant was experiencing difficulty after breastfeeding had, upon the C H N ' s advice, sought a referral to an allergy clinic from her family physician. She was very pleased to hear about the clinic; "so hopefully that is going to be really helpful going there and my doctor wouldn't have thought of that idea. So potentially I think it's [telephone call] going to end up being very helpful." A woman, who expressed awareness of not adjusting well during postpartum, sought the advice of 102 her family physician after talking with the C H N . She was referred to counseling services for herself and her husband. Some women returned to the drop-in, I sort of thought that maybe I 'd gone [to the drop-in] too early.. .1 didn't really feel like I was ready for it at that point [two weeks postpartum]. So she [CHN] encouraged me to go back so I went back again a couple of weeks ago and I enjoyed it. Women said they attended the drop-in for the first time due to receiving the telephone call: "I started going to that group as a result of that conversation." and "I had never gone to the group and I went out. [Did the call help you decide to go to the group?] Yeah, she made it less intimidating for sure. Yeah, it did, actually it did." For others, taking action was illustrated in the changes they made for themselves or for their infant. One woman had been concerned about her infant's risk of SIDS. Because she learned from the C H N that cigarette smoke was a risk factor for SIDS, she became a little more conscious of whether she was around cigarette smoke. She chose to keep her infant away from cigarette smoke as a means to decrease her infant's risk of SIDS. Another woman who experienced nipple soreness became motivated to do more research on breastfeeding: I ended up acting on my.. .nipple soreness and I might not have, I might have kind of left it for another couple of weeks until I got quite desperate and so I think that in that way, it [telephone call] was very helpful. Women were More Receptive to Future Contact with the C H N Another outcome of the six-week telephone call was that women became more aware of the C H N and thus more receptive to using C H N services in future. They noted: "Thought it was great.. .that she'd given me a call. I really think that call is very important." and "It made me feel like they actually.. .want to make an effort to maintain contact with me.. .that they remember who I am. So. . .it felt pretty good." For one 103 primiparous woman, whose initial experience with the C H N during her home visits was described as "very discouraging", the six-week call changed her impression of the C H N . She and her husband initially felt " . . .it was very discouraging the way she approached it as far as the information" [ C H N was perceived as inflexible in dealing with the initial weight loss of their breastfeeding infant]. After the six-week telephone call she said, " . . .it was a different nurse and it was much more positive speaking to her." When asked how she felt now about seeking out C H N s for help, she replied: I feel much more comfortable actually after speaking to her. Dropping in when I felt like it at the community center, whereas initially I was quite turned off, I didn't think that was, a resource that I wanted to use. Women were asked whether or not they wished further contact from the C H N following receipt of the six-week call. More primiparous than multiparous women desired this contact stating that although they were doing well now, they anticipated the need to ask questions or seek advice later. They suggested the C H N be flexible when offering further support, and base the offer on assessment of the family's adjustment, their support systems, and how the woman seems to be coping, realizing that some women would need more support while others would not. Their desire for follow-up based on client need is evident in the following comments: If she was able to call back that would have been helpful like maybe another few weeks down the road to see how he's progressing. But keep it [telephone call] flex not something rigid that you have to do. If the person is handling it well and it's not their first [child], they probably don't need to talk to them at all . But I think maybe that's something that they should maybe ask. Say would you like another follow-up call like i f there's any common questions or anything that you wanted to know like had they asked me this time I would definitely say no, I don't need another phone call . But had they asked me the first time I would. . .have had for sure another phone call. I do believe it would be beneficial to anyone with their first ch i ld . . . 104 Some women did not wish further contact because they felt strongly supported; however, they were cognizant that other women might not be as fortunate and would, therefore, benefit from ongoing contact. If I didn't have that assistance [family] I would imagine it would be very reassuring or useful to have a phone call from her again or to have a reminder about.. .that's normal and i f you want to drop in at this time or that time at the clinic. A t this point for myself I don't feel it's necessary. I see myself just in terms of the nature of my situation as being extremely well supported. I would think that there might be, mum's who either have really challenging infants or challenging.. .social situations that might be red flagged for their contact down the road. When asked whether they would consider contacting the C H N about future concerns or questions, some women indicated that they would, "Oh I would do that [call C H N ] , like no problem."and "It's [calling C H N ] fine too because they're very helpful, they're wil l ing to help and they're wil l ing to answer all my questions." Some would not, preferring to seek information from their physician or other health care providers: "I don't know I have a pretty close relationship with my family doctor so usually I just call h im and ask him, what my concerns are." I have so many people that I can call already so I probably would not call. I probably wouldn't need to call them but I think like for other mum's that don't have the same kind of access I have to information that it 's really, really useful... and to me it could be a lifeline. In summary, the women said they gained knowledge, reassurance, and awareness from the C H N ' s telephone call. They not only felt better after the call but also understood more. This led to women coping better and feeling more able to cope. B y gaining a sense of being able to cope, women felt increased motivation to make changes. Ultimately, they acted to create positive changes for themselves or their family. Although more 105 primiparous than multiparous women desired future C H N contact, generally both sets of women were receptive to using the C H N even though they had other health care providers involved. Recommendations for the Telephone Call Intervention Women appreciated having the telephone call . They were eager to share what they liked and wanted unchanged about the call and their ideas for how it could be improved. The women made the following recommendations: (a) continue calling all women, postpartum by telephone; (b) make telephone contact earlier than six weeks, at three to four weeks postpartum; and (c) provide follow-up contact by the C H N who made the H B visit. Continue Calling All Postpartum Women by Telephone The women recommended that the C H N s continue giving the telephone contact to all women, postpartum as the women w i l l judge their needs for support at the time of the call. Both primiparous and multiparous women indicated that they would appreciate receiving another telephone contact with a subsequent birth. They replied: "For sure I would receive it and i f I didn't feel I needed to discuss anything I would just, tell her." and "I wouldn't mind. Just to see how, how sound I am. If I 'm still with it or i f I 'm pulling out [my hair], because I think with two kids it's a different scenario altogether." I don't know what issues might come up but it's nice that i f I didn't have any issues that I could just say that. But i f I did, you know, then it would be nice to have that contact for sure. Their wish for telephone contact from the C H N with future births showed that they valued this contact; therefore it was anticipated they would also indicate that all women would benefit from receiving the telephone contact during the postpartum period. 106 The women concurred that all women should receive the postpartum telephone call because they thought the call offered support, facilitated C H N ' s detecting concerns with mother or infant, and prepared women for future occurrences (anticipatory guidance). They stated: I think so. I know from going to the mum's group there are a lot of mum's much more isolated than I am. Either they don't have friends or families in the community or may be they have been depressed and they just haven't made the effort so I think it's a good idea. A n d that, you know, some mum's may have a very easy first child and a more challenging second child and, I think the experience is so different, I think that it would be worth while for all mum's to get the phone call . Make Telephone Contact Earlier at Three to Four Weeks Postpartum The women suggested that the C H N s give serious consideration to changing the timing of the postpartum follow-up call to three to four weeks postpartum. Women expressed to the researcher that they had solved some of their concerns or had obtained answers to their questions prior to the six-week call. Consequently, the women were unable to take full advantage of the wealth of knowledge C H N s provided and the C H N s were not able to fulfill the woman's needs as well as they might have. Although women suggested a variety of times for the telephone follow-up, they consistently wanted the telephone call to come sooner than six weeks postpartum. They described the first four weeks as being the most demanding. "I think a bit earlier.. .I 'd say four [weeks] because that's the kind of time I was starting to go oh my God, this is a lot of work." Others commented: Again it goes back to having the first child, I would probably say that maybe a little bit earlier than six weeks.. .you come across so many new things and you're not quite sure of anything. I would probably say.. .about four weeks. 107 There should be a call between the first visit and the six-week because the first four weeks is the most difficult. So maybe after the nurse visit . . . About the third week, cause then, the blues are starting to kick in and you're fully engorged by that time. Whi le there was much value in this intervention as it was given, its full potential for the women and the C H N may not have been realized. Provide Fol low-up by the Same C H N Women requested that the C H N that gave the women and their families their initial postpartum care also provide the six-week telephone contact. They stressed the importance of their being familiar with the nurse calling them; subsequently, they would likely be more comfortable talking to a C H N they knew. They mentioned their need to establish a rapport or relationship with the C H N as a prelude to sharing personal information and feelings. One woman discussed her desire for consistency so she would not have to tell her "story" to someone new. She wanted to be able to pick up where she left off at the home visit. Thus, the women hoped that the C H N s would strive to establish a means to facilitate consistency in their postpartum care and follow-up. In summary, the women recommended that the call should continue to be given to both primiparous and multiparous women. They also recommended the timing of the six-week telephone call be changed so that the call would be made between three to four weeks postpartum. A t that time they felt they were still in need of support and information while at six weeks they generally felt more settled in their parenting role. The women recommended telephone contact from the same C H N throughout the postpartum period. 108 Community Health Nurses' Perceptions of the Telephone Intervention In this section, the findings related to the C H N s ' perceptions of the telephone intervention are presented. C H N s ' perceptions are described in terms of (a) the purpose of the telephone call intervention, (b) the changes they have seen or expect to occur for women and their families from receiving the telephone call, (c) the advantages and disadvantages of telephone use as a means to give health care, and (d) the impact of the telephone call on the C H N ' s and their practice. The C H N ' s recommendations for the telephone intervention follow. The Perceived Purpose of the Telephone Call There was a consistent thread throughout the focus group discussion that described the C H N ' s sense of purpose for the telephone call. They identified several purposes: (a) to assess women's adjustment during the postpartum period, (b) to assess the need for support and to offer emotional support when needed, (c) to be a community resource to women, postpartum, (d) to give women anticipatory guidance, and (e) to obtain information about the effectiveness of nursing care in previous encounters. To Assess Women's Adjustment during the Postpartum Period The C H N s discussed the value of the six-week call for assessing women's postpartum adjustment. Sometimes C H N s identified potential concerns during their care in the early postpartum period and they felt comforted knowing that the women would be contacted again. Potential concerns could, therefore, be later assessed to see i f they were needing intervention. One C H N suggested: "With some mom's there are niggling things that don't really warrant a phone call. It's reassuring to know that at six weeks some of those things w i l l l ikely come up." Other C H N s mentioned: 109 One of the other things that has for me come out of the six week ca l l . . .is the numbers of people who have had images of how their labor and delivery should be and how it didn't meet their expectation. There's sadness; there's a grief that they have. I think that's a really good point about the labor and delivery, and I think it's a real red flag when you go and do an early visit and the woman is really not that happy about the labor and delivery, she's really upset about it. . .1 had one person that said she felt like she had post traumatic stress disorder after delivery, because I think she hoped for a natural delivery. A s well , the C H N s were aware that some women by six weeks postpartum would potentially be at risk: To find out how they're doing and certainly what's going on with them at that point. It's really useful to be able to talk to them about isolation, fatigue and other things come up at that time and family and friends are retreating, husbands are going back to work, the partner is no longer around, and they can become quite isolated. The telephone call was also an opportunity to assess women's coping with their health care needs after the birth of their infant. To Assess the Need for Support and to Offer Emotional Support when Needed The C H N s were aware that women's postpartum adjustment might be influenced by whether they receive adequate emotional support. They inquired about how women were feeling in order to facilitate women disclosing i f they needed more emotional support. They said: Some of the clients I see or it turns out that a lot of them are from ethnic groups and often, they are somewhat more isolated in that they might not have family support in town or it might be the husband's family or something like that and they are.. .quite often on their own so to speak at six weeks. Their husband has gone back to work and in some cultures there's not as much support, for the mum and that it is traditionally her role and I think they're pretty exhausted at times. I get them to talk about their sense of isolation, and I always try and introduce it [postpartum blues/depression] so that they're not the only ones and I always say to them that some mum's feel kind of lonely and isolated when they go home with 110 the baby, give them the option or the ability to say, yeah I really feel that way and some of them w i l l start crying. A s a result of identifying any lack of emotional support during postpartum, the C H N s then offered emotional support. The C H N s discussed two ways in which they extend their support. The first was to try to link women needing support with other women in the community. "Sometimes I also w i l l use that call to try and link a mum whose had a colicky baby so that they have some support." Second, the C H N s praised the women ".. . i t 's nice to be able to tell them they're doing a good job.. .mum's need to know that. A n d I think that's an important part." and "I think the fact that talking to somebody can give them a boost too to know that actually they are doing okay.. .so they feel that they're real good mothers." To Be a Community Resource for Postpartum Women The telephone call gave the C H N s an opportunity to discuss their own or other community resources with the women. One C H N noted: "I try to connect them to community resources because a lot of the time they're not aware of the community centre, the library." They found themselves often giving verbal and written information, making referrals, or inviting the women to take advantage of the health unit's own resources. Another C H N stated: "So it [telephone call] just gives us the opportunity to let them know that we do have a nurse on call, i f they want to talk so they can call, or use the hotline." Specifically, the C H N s stated the six-week telephone call enabled them to invite the women and their families to the Chi ld Health Clinics (CHC) for their infant's immunization. A C H N noted: "One of the other things we were trying to decide with our six-week call was to see whether we could fit [book] them into C H C . " The C H N was I l l often viewed by the women as a trusted resource; therefore, the women asked the C H N to clarify information or opinions received from family or friends. On the other hand when they [women] have family, it [the family] also poses a problem because so and so said so and so and they really want your opinion because they've had so many opinions or ideas about the baby. They don't know whom to turn to, so the six-week call again, that, that issue w i l l usually come up again. Should I do this or should I do that? A s well , the C H N s noted that the implementation of the six-week call was in response to a request from parents in their community. The parents felt they were overwhelmed with information once home from the hospital and in the early postpartum period; therefore, they wanted to receive some of it at a later date or at least have the opportunity to review it once again. It [telephone call] was their recommendation...because when we visited early they were so focused on the physical needs of their delivery and the care they needed, and they said that they would really appreciate it i f somebody would call them at six weeks and tell them about feeding and groups and some resources, a little more. The C H N s stated that a purpose of the call was to meet this request from their community: "But this request actually came from moms themselves. It is not your decision to call them; it was a request. Especially keeping in mind that's when the mum's felt that it [telephone call] was needed, that's when parents were asking for it." Hence, a third purpose of the telephone call was the C H N ' s desire to be a community resource, both giving information and making referrals, and importantly, also staying connected to the members of their community by responding to their needs. To Give Women Anticipatory Guidance Another purpose of the telephone call was to give women and their infants preventive health care and anticipatory guidance. The C H N s said: " . . .Give them some of 112 the prevention part of the visit. I think we miss this when we go to do our early visits. We aren't able to get that." and " . . .That this is our opportunity to give them, the anticipatory guidance that we maybe haven't had time for earlier." To obtain Information about the Effectiveness of the Nursing Care in Previous Encounters The C H N ' s mentioned that they had enjoyed receiving feedback from women either directly when making the telephone call or indirectly from their C H N colleagues who had contacted women they had previously cared for. The telephone call gives information that w i l l assist in assessing the quality of care. One C H N mentioned: Some of the moms have continued to breastfeed, that just makes my day! Because often time you're there and they are supplementing, and you leave after making a couple of visits and you wonder.. . i f she wi l l continue to nurse and some of those [women] have shown that they have a lot of faith in me. In summary, the C H N ' s outlined a sense of purpose underlying the telephone call intervention. They believed the purposes of the telephone call were to assess women's postpartum adjustment, assess women's need for support and to offer women emotional support, to be a community resource for women, postpartum, to give women anticipatory guidance, and to obtain information about the effectiveness of the previous care given. Changes for Women and their Families from the Telephone Call The C H N ' s commented about the benefits or changes they believed occurred for women and their families from the telephone call. The C H N s had some difficulty suggesting the changes they thought would occur from the call because they did not usually have contact with the women following the call and, therefore, they did not have a means of determining whether women followed through with suggestions offered or confirming that changes occurred. However, the C H N ' s believed that valuable changes 113 occurred for women and their infants from the call. They believed that: (a) women seemed more aware of self-care, (b) women were more aware of community resources, (c) women seemed less anxious, (d) women may contact their physician more appropriately, (e) women may have received greater support from their peers or other mothers, and (f) women got out more and used the community resources more. The changes presented in this section are therefore both anticipated and actual outcomes. Women Seemed More Aware of Self-Care The C H N s felt the telephone call would foster postpartum women's awareness about having a check-up by a physician at six weeks postpartum. They said that women of varying ethnic origins might not be aware of this practice especially i f this differs from previous postpartum experiences; hence, these women would not realize the importance of this visit to their physician. As well , these women were very busy by six weeks postpartum and their health care needs may not take precedence. One C H N commented: A lot of women, not all but some of them don't realize that.. .it's recommended that they have a six or eight-week physical check up. Especially with some of the ethnic women, it's important that they know that their own health is important.. .1 found that women sort of like forget that this is an important thing. Women Were More Aware of Community Resources The telephone call enabled the C H N to discuss (and in some cases review) the availability of community resources, hence, the C H N s thought that women would likely be more aware of these resources. A lot of the parents w i l l say I 'm sure that they must have already received one [pamphlet] but they have misplaced it. I offer to mail them the list of drop-in topics. Y o u know a lot of them; they haven't looked at anything yet. So then I again mail them out. 114 For some women, knowing about resources is a first step to making necessary changes to gain better health. A C H N suggested: ". . .One or two [families] that haven't been doing well that they pick up [become aware of during the call] . . .the availability of some things [community resources] that are available to them so that they can learn more." Women Seemed Less Anxious when Caring for Themselves and their Infants The C H N s indicated that the telephone call would likely result in women gaining confidence in caring for themselves and their infants, and consequently, women would feel less anxiety. The C H N s said: " . . . B y giving them the anticipatory guidance about the growth spurts and the day to day baby issues.. .they are not sure about, to clear their anxiety." and ". . .Answering questions about the pumping...they are starting to think about pumping and getting [out]. So they know that they can go out." Because of the six week call, they [are] doing more frequent breast feeding, is that they're more relaxed then about sitting and putting their feet up and drinking more fluid and just feeding the baby as often as the baby wants and not feeling that they don't have enough milk and that they're [not] going to make more. I think that's important, to reassure them. Women May Contact their Physician More Appropriately C H N ' s commented that the telephone call might result in women making fewer visits to a physician: " . . .Answering a lot of questions so they don't have to ask the doctor." I think that we do, we can save doctor's visits.. .By giving them the anticipatory guidance about the growth spurts and the day to day baby issues that they don't really need to see a doctor for but they are not sure about. Women May Receive Support from their Peers or Other Mothers One of the purposes for the telephone call was for C H N s to give emotional support to women. Since C H N s initiated the process for women to connect with other 115 women with similar interests, such as parenting, C H N ' s thought that women would link up as a result of the telephone call. Women did reach out and connect with other women, postpartum for support. The C H N s noted: "I find that a lot of mum's have.. . i f you can link them they get some networking going on with other mum's which has been really helpful too." and "So that there is an opportunity there for them to get, to talk to another mother." Women Got Out More and Used the Community Resources More A s well as creating informal linkages, the telephone call helped women to learn more about the community resources and encouraged them to get out more. The C H N said: "I see the changes more because I do drop-ins so I see them show up at drop-ins. So I know that they are now getting out because of receiving that information [telephone call] ." and "We get some of the moms out more. They start coming to our groups. They realize and hopefully they start using the resources." The C H N ' s felt women were accessing relevant (drop-ins and breastfeeding groups) and health related resources. I 'm seeing them at dental because I often w i l l have talked to them...about this because often they don't have dental insurance. They're coming out into the community more and they are accessing things more. Despite the C H N ' s best attempts to inform women about community resources, some women chose not to access the resources suggested. A n example is when the C H N identifies women needing support to cope with a potential postpartum depression. They do not always pursue assistance. One C H N explained: "Some mums I've referred to the Pacific Postpartum [Support Society] and out of five moms I think that I referred, only one mom made a phone cal l ." It is prudent to remember that the C H N s do not always 116 have contact with these women following the call or do not have a definite way of determining whether a woman has followed through with their suggestion. During the call, the C H N s encouraged women and their families to attend the health unit's C H C for immunizations. Despite frequent reminders of the C H C ' s availability, the C H N s find families go to their family physician instead. Because one of the questions as you know was to ask them i f they have an appointment for their first immunization yet and would they like me to book them an appointment with the baby clinic, and almost all of them come out and said their doctor, they're going to see a doctor. I hope to get them to come to the baby clinic. It's quite a frustrating time trying to get them. Y o u book them in on a date. The week before they'll phone you and say oh no I won't be coming my doctor told me to come to him. In summary, the C H N ' s believed women, as a result of receiving the call, were more aware of the care needed for themselves, were more aware of the community resources available, were less anxious, contacted their physician more appropriately, obtained support from their peers or other mothers, and got out more and used the community resources more. Advantages and Disadvantages of Telephone Use to Provide Intervention The C H N ' s indicated advantages and disadvantages of using the telephone as a means to provide health care to women, postpartum. The C H N ' s thought telephone use facilitated the women's privacy when receiving care. The C H N ' s found reaching women at a convenient time and establishing rapport were disadvantages of telephone use. Facilitating Privacy The C H N ' s said use of the telephone facilitated giving appropriate care to women. They noted that telephone use gave women privacy, particularly when C H N s wanted to discuss topics that were difficult to introduce, either in a home or group (drop-117 in) setting. They suggested: "Often time i f you're there [home visit], there's other members of the family there, that they're [women] very uncomfortable. So I find being able to use the telephone is easy to bring that topic [birth control] up." and "Postpartum depression. Because it's really hard to make that comment about depression when you do those groups." C H N s noticed that topics such as, birth control, marital problems, financial concerns, sibling adjustment, postpartum depression, and receiving contradictory advice from friends or family have all been raised during the call and discussed effectively. One C H N reflected: " . . . A n d sometimes they'll talk about their in-laws. . .they can talk about some of the advice they get, not just in-laws but some friends or family [advice] that are contradictory." The use of the telephone gave C H N s the choice to raise topics in a more effective manner. The use of the telephone allowed women to retain some privacy from the C H N when divulging personal concerns. A C H N commented: "There are so many issues that are easier for them when you're not face-to-face because they feel more comfortable talking about on the phone." Facilitating privacy was an advantage of telephone use when giving health care to women, postpartum. Difficulty reaching Women at a Convenient Time The C H N s found it difficult to reach women at a convenient time. The women were busy and distracted with family and household demands. One C H N stated: "If the baby is crying or there's somebody else in her house, or i f there is other children, or other family around [the woman wi l l not be able to attend to the telephone call] ." C H N s thought women would be most wil l ing to talk i f they were reached at a "vulnerable moment" or " i f she has time." The C H N s realized that they might need to call women 118 back "It might be better to call back." A disadvantage of telephone use was that C H N s did not know prior to calling whether women would be able to attend to the call. Establishing Rapport over the Telephone C H N s were challenged to establish rapport with the women over the telephone in order to assess concerns accurately and provide care effectively. Particularly, the C H N s who did fewer calls found the experience especially challenging when they contacted women not known to them as women responded reluctantly to their questions. One C H N noted: "I think it's difficult with someone you do not know it's hard to just jump into birth control, for example." She then elaborated: If I know the mother or the family that I am calling, sometimes because you've got a sense of what went on around the birth, sometimes, you might feel that it's easier to ask questions. Because I personally find it difficult calling a stranger basically.. .calling and saying you're the nurse, and.. .to get to really personal questions, it 's not always that easy and I find that having a relationship with the family prior to the six week ca l l . . .that might help. Yet, the C H N s seemed to be aware of the skil l required to successfully initiate and conduct the call. One C H N said: "I also feel that it's when you make the six week call, how you introduce the call w i l l determine whether or not the person either shuts you out and doesn't want to talk to you or, w i l l open up." A s well , the C H N s implemented a means to facilitate the establishment of rapport with the women, to increase the effectiveness of the telephone call . The C H N s accessed a list of the C H N s who had provided the women's initial care. When C H N s initiated the six-week call they referred to the C H N that cared for the woman and her infant in the early postpartum period. As well , they reassured women that the call was given routinely and not given due to the C H N having concerns. One C H N explained: 119 We do know what nurse did the initial visit. So that we can say.. .when so and so visited, did she mention that we would be doing a follow-up six-week call? Because it's really helpful to introduce by saying that many mum's have asked us to call you back because they had questions so that they understand that you're not just signaling them and giving a call as though there's something wrong with them. In short, the C H N ' s believed telephone use, as a means for providing postpartum care, offered the advantage of privacy to women. Telephone use assisted the C H N s to give care sensitively and effectively. However, use of the telephone resulted in C H N s reaching women when they were not available to receive the call. A s well , establishing rapport with women by telephone was challenging especially when the woman was not known to the C H N . Impact of the Telephone Call on CHNs and their Practice The telephone call impacted the C H N s and the practice of community health nursing. On the positive side, the telephone call enabled C H N s to recapture the preventive component of community health nursing, a component that decreased when the Healthy Beginnings program began. Also , the call helped the C H N s to reinforce, in the late postpartum period, information previously discussed. C H N s received feedback on care given previously and they gained greater satisfaction in their work. However, implementation of the call altered the C H N ' s practice in ways of concern. C H N s had difficulty fitting the calls into their busy schedules, thus not all women were reached at six weeks, and C H N s could not ensure that all women, postpartum received complete information. Re-capturing the Prevention Part of Community Health Nursing The C H N s were pleased with the introduction of the telephone call because it enabled them to re-emphasize the preventive focus of community health nursing. They 120 stated: "I really feel badly about the loss of the prevention nursing with the introduction of Healthy Beginnings." and "The benefits are being able to.. .link up with them and give them some of the prevention part of the visit. I think we miss this when we go to do our early visits. We aren't able to get that." Reinforcing Information Since the telephone call enabled C H N s to contact women again, C H N s could reinforce information given to women during the early postpartum weeks. One C H N noted: "It allows us to re-invite them to groups, that's why I always mention the group [breastfeeding] at Kiwassa and the drop-ins and some of the community services that are out there." Even though when we did the initial visit we counsel mum about what to expect with the breastfeeding and the growth spurts around the six-week period, they're not ready to accept all that stuff yet. So it really needs to be reinforced when we do the six-week call. A s well , some of the postpartum information usually given to parents during the early postpartum period can be discussed, instead, during the six-week call when women may be more receptive to hearing it. One C H N mentioned: "I don't feel so pressured to get.. .through it all [at the initial home visit]." The only thing that's changed for me [at the initial home visit] is that I don't go into as great a depth. I don't spend as much time on the package of information that we take. I spend more time on the breastfeeding, and I talk especially about the groups that we have.. .1 now realize that they're not ready to assume, accept any of that information, they're just too overwhelmed with the whole initial newborn stuff. So that doing the six-week follow up I know that it w i l l be re-addressed at that time. Receiving Feedback The telephone call facilitated C H N s receiving feedback from the women. They noted: "The majority of the mothers are very appreciative to have the cal l ." and "The 121 bonus for me which would be nice for other nurses to have is the appreciation they have for the nurses." and "But for the majority of these mums they really do appreciate the contact." Gaining Satisfaction Giving the telephone call resulted in the C H N ' s expressing that they felt they were doing a better service and giving better nursing care. They said: "It's a better quality of nursing." "I feel we do a better service, that it makes me feel good.. ." and " . . .that makes me feel like we're doing a better job." Finding Time to place the Telephone Calls Finding a convenient time to place the calls was difficult for the C H N s , because the calls were interspersed in their busy schedules so the C H N s usually attempted to contact women only twice. They were dismayed that some women could not be reached due to their schedules. They said: I often don't call them at six weeks because I find that I 'm very busy. I think the time management thing again that's a problem that we have. I really want to and I make every effort to try and call them a couple of times. The problem simply becomes one of time. If you look at a health unit and you look at nursing time and you know that your priority for example is babies, then you have to then limit something. It becomes a time issue and in terms of staffing, we're really short staffed. Ensuring that all women, postpartum received a call was a challenge for the C H N s , given the C H N ' s workload. Ensuring all Topics are Addressed With the implementation of the six-week telephone call the C H N s discovered that some women received complete information during the C H N ' s care in the early postpartum period. Other women, received some of the information during their initial 122 care (home visits) and received the rest during the six-week call. The C H N s found discussing certain topics later was more appropriate to women's needs. For example, the topic of birth control may be discussed at the time of the six-week telephone call instead of at the initial home visit in the first few days after hospital discharge. C H N s were not always able to reach the women, postpartum with the six-week call. Hence, i f women were not reached they did not get this information. One C H N commented: "I think birth control is usually not addressed really anymore with the initial [home] visit. A n d i f you don't make a repeat visit [six-week ca l l ] . . . . " Thus the introduction of the six-week call resulted in a potential concern: The information previously given to women in the early postpartum period may be left to the six-week call and not received by some of the women, postpartum. The telephone call helped C H N s to focus on providing a preventive component to their community health nursing practice. They were able to reinforce information during the six-week call, receive feedback from women about their care, and gain increased satisfaction with the care they provided. Yet, the C H N s had difficulty finding time to place the calls and were not able to reach all women, postpartum. A s well , there were inconsistencies in the postpartum information given to women. Recommendations for the Telephone Intervention The C H N s offered several suggestions to improve the call and they identified aspects of the call that should remain the same. They suggested; a) continue offering the telephone call to all women, postpartum, (b) continue using the six-week call questions, (c) continue preparing women to receive the six-week call, (d) contact women, postpartum earlier than six weeks, and (e) provide nurse continuity for the six-week call. 123 Continue Offering the Telephone Call to all Postpartum Women When asked i f they felt both primiparous and multiparous women should continue to receive the telephone calls, the C H N s as a group, agreed that all women, postpartum benefit from receiving the telephone call and recommend its continuation. One C H N explained: We short change multips because there are a lot of issues. They have never had to deal with the interrelationship between the two [children]. A n d asking what do they need with two instead of one? A n d all the family dynamics too. Continue Using the Six-Week Call Questions The C H N s thought the questions used (Appendix A ) were helpful and should not be changed. B y using these questions they felt they were able to accurately sense how the women and their family were coping during postpartum. They believed the questions enabled them to know when they needed to further explore an area of concern. They stressed that the questions provided a strong starting off point for the telephone intervention: " B y asking those ones [questions] then you can get an idea i f you need to delve more into other areas. Yeah, a starting off point. I think those questions cover what's relevant." A s well , they said the questions addressed many of the typical concerns or issues that women, postpartum faced at six weeks postpartum. They concluded that they would not change or add to the questions they developed. Continue Preparing Women to Receive the Six-Week Call Some women, postpartum were not aware of the telephone call service at six weeks postpartum; consequently, the C H N s suggested consistently preparing women to receive the call in order to increase the effectiveness of this intervention: It really helps i f you really strongly remind them when you make the initial visit that there is going to be a call. Because that really helps to get started without any 124 kind of oh yes, I sort of remember hearing.. .that someone wi l l call and it's not such a surprise. The C H N s felt women appreciated being told of the call in advance so the women could prepare questions and be prepared to respond. If women expected the call, a better rapport would likely be created. Contact Postpartum Women Earlier than Six Weeks Several C H N s felt that women would benefit from also receiving a telephone call earlier than six weeks and suggested a call at three weeks unless the family was at risk. One C H N said: "I would give them a three week [call].. .1 think the more times we can connect [the better]." and another commented: "Three weeks to be introduced that would be great..." However, i f the call could be done only once, the C H N s believed that placing the call at six weeks was the best time. Provide Nurse Continuity for the Six-Week Call The C H N s as a group valued continuity in care. They recognized the benefit for themselves of knowing the women when making the six-week telephone call and the likelihood of greater receptivity when the women knew the C H N . One C H N noted: "So that would be one change is to have more of the nurses who did the care initially follow-up with the six-week cal l ." Another C H N offered: "The continuity wi l l be there and I see that as really positive." A third C H N suggested: "Each nurse would probably benefit from doing her own calls because she would get the benefit then of knowing how your client has moved and progressed." A fourth C H N commented: I find that when I call them because I have visited them they are very receptive to the call and to most nurses anyway. Sometimes I w i l l make little notes for my own memory. So I find usually they are very receptive. 125 In summary, the C H N s were quite satisfied with the telephone intervention in most respects. The C H N s wanted to continue giving the call to both primiparous and multiparous women and continue informing women during the initial postpartum care, of the six-week call. Several C H N s wanted to give women more than one call with another being done at three weeks postpartum, however, for now, the C H N s wanted the call to remain at six weeks postpartum. Lastly, the C H N s suggested the C H N who cared for a woman and her infant should also give the woman the six-week call. Summary of Findings In chapter four the findings of the postpartum women's and the C H N ' s perceptions of the telephone call were presented. The challenges women, postpartum encountered prior to and at the time of the six-week call provided a context for the telephone intervention. Women were challenged with concerns related to their own physical and emotional health, and the adjustments of other family members both prior to receiving the six-week telephone call and at the time of the call. The women suggested that the telephone call enabled the C H N s , to detect health concerns early, to provide information and an opportunity to ask questions, and to offer support and reassurance. The women felt positive about receiving the telephone call from the C H N . The women perceived the C H N s to be knowledgeable; consequently they felt confident in the responses they received to their questions. The approach used by the C H N s facilitated women feeling comfortable talking over the telephone and viewing the C H N as a valued resource. The women stated the C H N s were caring, easy to talk to, nonjudgmental, respectful, flexible, and skillful in communication. They appreciated that the C H N called them, as they were too busy to initiate contact with the C H N . 126 A t times, the telephone call occurred when women were busy with family and household demands. Thus, the call was not as beneficial to some women as it was for others. The women thought the questions asked by the C H N s were relevant and supportive. They appreciated that the focus of the C H N ' s questions included their own health as well as their infant's health. Use of the telephone by the C H N s was for most women helpful: its use offered convenience, privacy, cost efficiency, and the opportunity for other family members to access the C H N . Yet, a few women preferred personal contact or at least knowing the C H N they spoke to. Women gained reassurance and knowledge from the call that stimulated positive changes for themselves or their family. They became more aware of and receptive to seeking the services of the C H N in future as a result of the call. Many women would have preferred receiving the call earlier, at three to four weeks postpartum. The women suggested that all women postpartum receive the call and that C H N ' s strive to ensure that the C H N calling was someone known to them. The C H N ' s identified several purposes for giving the six-week telephone call; assessing women's adjustment during the postpartum period, assessing the need for emotional support and offering emotional support as needed, being a community resource, giving women anticipatory guidance, and obtaining information about the effectiveness of nursing care in previous encounters. They thought women would become more aware of self-care and the community resources, become less anxious, contact their physician more appropriately, receive more support from peer and other mothers, and get out more and use the community resources more. The telephone seemed to facilitate 127 privacy for women, but its use resulted in difficulties for the C H N s when trying to reach women at a convenient time and attempting to establish rapport with women. The introduction of the six-week telephone call enabled the C H N s to: re-emphasize the preventive component of community health nursing, reinforce information previously discussed, obtain feedback from the women on their care, and gain satisfaction from their work. A s well , implementation of the telephone call resulted in the C H N s having difficulty fitting the calls into their schedules and realizing that not all women, postpartum received the same information during their care. The C H N ' s suggested that the call be given to all women, postpartum and all women be informed that they w i l l receive a call. A s well C H N s wished to, continue using the questions currently developed for the six-week telephone intervention, contact women earlier than six weeks postpartum, and provide continuity of C H N doing the call. These findings and their implications for nursing research, nursing education, nursing administration, and nursing practice are discussed in the next chapters. 128 C H A P T E R F I V E DISCUSSION O F FINDINGS The findings of this study begin to address the need for evaluation of nurse-initiated telephone contact during the postpartum period. The study obtains the perspectives of women who are postpartum towards telephone use by community health nurses and explores the views of the providers of the nurse-initiated telephone contact. Obtaining this knowledge is important for community health nursing because, in Canada, C H N s provide an important health service and telephone use is a significant component of community health nursing practice. The findings offer further understanding of the challenges women face during the late postpartum period. A s awareness of the needs of women in the late postpartum period increases, we can not only understand their requests for care but we can also elect to meet women's requests by extending care into the fourth trimester. A s Donaldson (1988) suggests, diagnosis and treatment of mother's responses to health problems during the fourth trimester is a rich area for nursing practice. In giving the telephone call, the C H N s fostered an opportunity for women postpartum to express the concerns they had both prior to and at the time of receiving the six-week call. These concerns provide a context for discussing the usefulness of the telephone call for women postpartum. In this chapter, the content of the call that relates to the expressed concerns is discussed first and the concerns are compared and contrasted to the concerns noted in the literature. Following, the women's and the C H N ' s perceptions of the process and outcome aspects of the call are discussed separately in view of the 129 research questions and the objectives outlined in the Logic Model . In addition, the perceptions of telephone use are compared and contrasted to those in the literature. The strengths and limitations of the telephone call are highlighted in this discussion. Finally, use of the Logic Model to evaluate the telephone intervention is discussed, and a refined Logic Model , reflecting the findings of this study and the literature review, is presented. The Content of the Call When reviewing the concerns the women had prior to receiving the telephone call and at the time of the telephone call , it is important to note some of the women received the telephone call earlier or later than six weeks postpartum. Consequently, the concerns expressed by the women pertain to the time period before they received the call and at the time of the telephone call. The women relayed these concerns to the researcher during their telephone interview, which occurred approximately two weeks following receipt of the six-week telephone call. Prior to the Six-Week Telephone Call The women in this study were feeling stressed because they were unsure of how to care for their infant during the first six postpartum weeks. Similar themes are seen in the postpartum literature. Primiparous women at 10 to 14 days postpartum say they feel uncertain about what to do for their infants. They also express negative feelings about postpartum that relate to lack of experience with infants, lack of knowledge about infant care, and all of the ensuing responsibilities of having an infant of their own to care for (Ruchala & Halstead, 1994). Woollett and Parr (1994) state women postpartum express feeling stressed especially by the responsibility of caring for an infant. Others have found that women postpartum express similar concerns such as inability to recognize infant 130 illness (Fishbein & Burggraf, 1998); uncertainty about infant safety, feeding, growth and development of the infant (Tobert, 1986); and anxiety about learning the infant's needs (Cadman, 1995). Erickson (1992) reports that women postpartum lacked knowledge regarding infant care. Brown and Johnson (1998) note 75% of the families they studied have knowledge deficits related to infant care and feeding during the initial postpartum weeks. The findings of this study reflect what authors of earlier reports have found; that is, women postpartum experience stress because they are not sure of how to care for their infants. The women in the study expressed wanting adult contact. The change from working and being very busy to being alone at home with a new infant was difficult for them. Women's comments about shifting from the work world to the infant at-home world agree with the literature that suggests women may experience a loss of role (Cadman, 1995). Fishbein and Burggraf (1998) determine women during the postpartum period feel tied down. Ruchala and Halstead (1994) found primiparous women feel "trapped" (p. 86) and both multiparous and primiparous women have described their social lives as "non-existent" because of the impact of their infants (p.87). Erickson (1992) reports women postpartum from two to six weeks postpartum are on their own and need to talk to someone. Certainly, the findings suggest the women felt the decrease in adult contact during the postpartum weeks, and they were aware that having contact with adults was important for their health. The findings indicate women were feeling down prior to receiving the six-week telephone call . A primiparous woman suggested this period of time was "like a nightmare." Similarly, Ruchala and Halstead (1994) found the experience of postpartum 131 described by primiparous women as a "total nightmare" (p.86). Fishbein and Burggraf (1998) note that women feel depressed or blue, and Ruchala and Halstead comment women feel down, tearful, tense, and irritable during this time. Ruchala and Halstead suggest the most common emotional symptom during postpartum is crying. Yet, crying was not mentioned often by the women in this study. Possibly fatigue (Cadman, 1995; Erickson, 1992; Fishbein & Burggraf; Woollett & Parr, 1997), adjustments to sexual relations (Ruchala & Halstead), a loss of role, receiving conflicting information from family and friends (Cadman), lacking personal time, and body image concerns (Fishbein & Burggraf), might have contributed to these women feeling down, although these specific concerns were not noted in this study. Some of the primiparous and multiparous women in this study felt overwhelmed with respect to trying to go out, trying to attend community events, recovering from difficult deliveries, and coping with family events such as recent moves and husbands starting new jobs. Ruchala and Halstead (1994) state primiparous women describe their experiences as "overwhelming" with their lack of experience in caring for infants contributing to this feeling (p.86). Feeling overwhelmed as a concern of women postpartum is not noted frequently in the literature; however, the literature offers many reasons for women having these feelings during postpartum. The frequency of breastfeeding (Gilhooly & Hellings, 1992), having to do frequent breast care (Fishbein & Burggraf, 1998), having to manage the household while also having to manage self and infant, not having enough personal time (Fishbein & Burggraf), receiving conflicting information (Cadman, 1995), and coping with a sibling's reaction to the infant (Tobert, 132 1986), could lead women, postpartum to feel overwhelmed. These specific reasons for feeling overwhelmed were not apparent in this study. Women in this study did not express concerns about weight loss or body image although Ruchala and Halstead (1994) and Fishbein and Burggraf (1998) respectively have noted these concerns for women postpartum during the first six weeks postpartum. A s well , some of the women, more likely those who were multiparous, had fewer concerns during postpartum prior to the six-week call than primiparous women. Multiparous women have described their postpartum experiences as "better" than their previous postpartum experience due to their increased comfort in caring for infants (Ruchala & Halstead, p. 86). Interestingly, Gardner (1991) reports that fatigue can peak at two weeks postpartum due to situational and psychological factors. Others identify fatigue as a concern for women during the first six postpartum weeks (Cadman, 1995; Erickson, 1992; Fishbein & Burggraf, 1998; Harrison & Hicks, 1983; Ruchala & Halstead; Tobert, 1986; Woollet & Parr, 1997). Gardner's found that women with increased education and more help experience less fatigue. Although there is support in the literature for the experience of fatigue during the first six postpartum weeks, as mentioned previously, the women in this study did not identify it as one of their concerns. A number of reasons can be offered to explain why the women in the study did not express this concern. The women selected for this study were well educated and partnered; therefore, they may have received support during the initial postpartum weeks, which decreased their fatigue. Also , they may have perceived fatigue to be the "norm" during postpartum and not considered this a concern to be noted. A s well , they may not have recalled their 133 experience of fatigue when they discussed their concerns during the telephone interview at approximately eight weeks postpartum. Or the women experiencing much fatigue at the time of the six-week telephone contact may have chosen not to participate in the study. At the Time of the Six-Week Telephone Call Women felt challenged with the management of their physical health at the time of the telephone call, around six weeks postpartum. They were concerned about postpartum bleeding, breastfeeding or nipple soreness, and recovery from surgery. A t six weeks postpartum, women in other studies have expressed physical concerns related to breastfeeding (Gilhooly & Hellings, 1992), but the mention in the literature of other physical health concerns around six weeks postpartum is not frequent. This infrequency might imply that physical healing is complete by six weeks postpartum (Olds et al., 1996); however, several concerns at this time are made evident by this study. The women postpartum felt unsure about what to do or what to expect when caring for their infant at six weeks. They were unsure about how to respond to their infant's fussiness and crying, how to cope with their infant's changing feeding pattern, and how to express breast milk. The literature does not indicate that women at six weeks postpartum feel unsure. Women in this study noted feeling fatigued around the time of receiving the six-week telephone call . This experience of fatigue is noted often in the literature. Mi l l igan and Pugh (1994) have found that women who are breastfeeding experience more fatigue at six weeks postpartum due to infant difficulty. They do not elaborate on why the infant is difficult; yet, the reasons may be similar to those expressed 134 by women in this study: infants need frequent feedings and they are often fussy at six weeks postpartum. The women at six weeks postpartum were concerned with managing demands of life and family members. These demands related to moving from another country, husbands starting new jobs, recovering from surgery, returning to work while also managing the care of other children and a household, and dealing with sibling adjustment difficulties. One woman who had returned to work in response to her husband's expectations was also coping with the difficult adjustment of a sibling to the infant. It has been documented that women at six weeks postpartum have had concerns that relate to managing family and life demands, specifically, adjusting to the new family (Rhode & Groenjes-Finke, 1980), being confused about personal roles, getting support, dealing with sibling acting out (Erickson, 1992), regulating demands of husband, housework, and children, getting personal time, and coping with friends and visitors (Harrison & Hicks, 1983; Logsdon et al., 1997; Rhode & Groenjes-Finke). In the present study, women were overwhelmed prior to six weeks and were not getting out of the house. Around the time of the six-week telephone call women expressed a desire and readiness to get out. Erickson (1992) notes that women at six weeks postpartum start to be concerned with making lifestyle adjustments pertaining to the ongoing requirements of their infants. Their concern indicates they are ready to widen their focus. Fishbein and Burggraf (1998) note that women at one month postpartum are involved in activities with family and friends but that they have not returned to their previous involvement with community, professional, social clubs, or religious activities. Tulman et al. (1990) report less than 30% of primiparous and multiparous women have 135 resumed their usual levels of household, social, and community activities by six weeks postpartum. The women in this study may not have re-engaged in their previous activities prior to six weeks postpartum, hence the activity of the women in this study appears to be supported by the literature. Depression was not a concern for the women in this study around the time of receiving the telephone call at approximately six-weeks postpartum. Beck (1995) writes that the incidence of postpartum depression is 10% to 26%. Women would not have likely consented to participate in the study i f they were experiencing a depression, especially since someone unfamiliar to them would have interviewed them on the telephone. Evidently, similarities and differences are noted in the concerns expressed by the women in this study that are not mentioned in other studies. A s qualitative methods were used in this study and most other studies to date have used quantitative methods, the methods used in this study may be the basis for the differences in the concerns revealed by the women. The concerns women experienced prior to receiving the six-week call are similar, with a few exceptions, to those reported by other authors. A n exception is the experience of fatigue, a concern frequently identified in the literature for women in the initial postpartum weeks. Concerns related to sexual relations, loss of role, conflicting information from family and friends, body image, weight loss, and lack of time for one's self are well documented and yet were not found to be the concerns of women in this study. The concerns of women at six weeks postpartum are similar to the literature with respect to fatigue and managing demands of life and family. Physical concerns for women during this time are not frequently documented, with the exception of those 136 pertaining to breastfeeding. The literature does not report that women feel unsure when caring for their infant at six weeks postpartum. It does suggest that depression is common around six weeks postpartum. The study findings indicate rather that women do feel unsure of caring for their infants at six weeks but that they do not feel depressed. The content of the call encompasses the concerns experienced by the women both prior to receiving the call and at the time of the call . These concerns provide the setting for discussing the perceptions of the women and the C H N s toward the process aspect of the call and the outcomes generated by the six-week telephone call. The Process of the Telephone Call B y giving the telephone call, the C H N s hoped to fulfill the two process objectives: offer preventive focused assessment, information, referral, and support to women during the late postpartum period and provide appropriate care to women by telephone during the late postpartum period (see Figure 1). Dwyer and Makin (1997) state one benefit of using a logic model is that not only are the objectives of a program or intervention listed but the indicators of the objectives are listed so that accountability for meeting the objectives can be achieved. In viewing the Logic Model , the indicators of these process objectives include the themes expressed by the women and the C H N s with respect to the process aspects of the telephone call. The perceptions of both the women postpartum and the C H N s about the process of the call are discussed in view of the research questions to indicate the adequacy of the telephone call to meet the process objectives. Some of these perceptions are compared to the literature on telephone use. 137 Women's Perceptions of the Process of the Call Helpfulness of the Call During the telephone interviews, the women recalled the aspects of the telephone call that were most or least helpful to them. The women stated that the focus of the C H N ' s questions during the call was relevant to their needs because the C H N inquired about the health of their infants and themselves and she discussed community resources. They stated they liked being asked about their health since others often focus only on the health of the infant. They suggested that telephone use was appropriate for the type of questions they had but that telephone use would not allow the C H N s to weigh their infant or assist with breastfeeding difficulties that require observation. For these reasons, they admitted that care given by telephone was limited. Yet, the women's comments indicate that the content of the telephone call was helpful to them and the focus of the C H N s during the telephone call was appropriate, therefore the telephone call assists the C H N s to provide appropriate care to women by telephone during the late postpartum period. The women remarked on the knowledge of the C H N s stating that the answers they received to their questions indicated that the C H N s knew what they were talking about. A s well , specific aspects of the approach used by the C H N s during the call enabled the women to feel comfortable when receiving care by telephone. The women appreciated that the C H N s were caring, easy to talk to, respectful, and flexible. Hagopian and Rubenstein (1990) suggest use of the telephone helps health care providers to demonstrate caring through use of interpersonal skills, and patients receiving contact by telephone value the caring displayed during the calls. Lechner and DeVries (1996) note clients who receive care by telephone are most satisfied with their care because they feel 138 they are on the receiving end of respect, support, sincerity, and reassurance. In addition, Donaldson (1988) has found, in her study on the effects of postpartum telephone follow-up on maternal adaptation, that women postpartum value the interpersonal sharing, caring, and support they receive from telephone contact. The women postpartum noted the approach used by the C H N s indicated they were skillful communicators. Specifically, the women remembered that the C H N s were able to draw out their questions and ascertain what was going on for them. Certain skills are required of providers in order to give care effectively by telephone: Providers are advised to be aware of the need for close attention to tone, silences, inflection, and language used (Bartlett, 1990; Colon, 1996; Davidson, 1991; Evans, 1995; Rao, 1994) along with good general listening skills (Wilkens, 1993). In addition they need to possess a style of communication that is clear and direct and that uses common sense (Wilkens). The C H N ' s knowledge and their approach when giving care by telephone was helpful to the women, and this aspect of the call supported the C H N s to meet the process objective to give appropriate care to women.by telephone during the late postpartum period. The women found they gained privacy when the telephone was used to give care, and they commented they felt freer to discuss certain topics with the C H N s by telephone than they would have in a face-to-face encounter. Telephone use may help to decrease the discomfort that potentially arises when an inquiry about health is directed to women in a group or a family setting. Also , an element of privacy from the C H N was extended to these women with telephone use and women could have elected to disclose more simply because the C H N did not see them. Use of the telephone, for some of the women offered a helpful yet private opportunity to ask health related questions. This aspect of telephone 139 use has been noted previously by Bartlett (1990), Colon (1996), Evans (1995), and Rao (1994) all of whom suggest telephone use can offer clients a certain safety with disclosure or privacy. As well , the women found that receiving care by telephone offered them convenience. They valued this time saving aspect of the telephone call because they did not have to leave their homes to receive information or have their questions answered. Bartlett (1990), Colon (1996), Evans (1995), and Rao (1994) state that use of the telephone provides convenience for the patient because its use can decrease patient travel. In addition, the women appreciated that the C H N initiated contact with them by telephone. The women noted that the telephone call allowed other family members to access the C H N . Although other family members are often present at the time of the C H N ' s visit and thus can access the C H N , family members can also continue to access the C H N with telephone use. The impact of telephone use on family members has not been documented in the literature. Keeling and Dennison (1995), in providing telephone calls to patients. and their spouses, acknowledge that telephone follow-up after hospital discharge can ease the physiologic and psychological adjustment of the family. They comment that the period after discharge is a time of disrupted family routines and roles resulting in family stress. Surely, the same w i l l be true for the postpartum couple and/or the family; thus a telephone call may offer support to family members other than the woman. In offering comments about telephone use being both timely and private as well as helpful to resolve direct health concerns, the women highlight components of telephone use that now assist 140 the C H N to fulfill the process objective, to provide appropriate care to women by telephone during the late postpartum period. Purpose of the Call The thoughts articulated by the women during their telephone interviews indicate their understanding of the purpose of the call . They believed the purpose of the call is for the C H N s to detect health concerns early, to provide information and the opportunity to ask questions, and to offer support and reassurance. Their views of purpose are reinforced by the literature on how use of the telephone assists providers to give care. Telephone use has been found to enable providers to give emotional support, to give information (Bent et al., 1996; Keeling & Dennison, 1995), to make referrals (Keeling & Dennison; Polinksy et al., 1991), and to do an assessment (Polinsky et al.). In suggesting these purposes for the call, the women lend support for the potential of the call to enable C H N s to meet the process objective to offer preventive focused assessment, information, referral, and support to women during the late postpartum period. More specifically, the women thought the telephone was an appropriate means for the C H N s to use to obtain an initial assessment of how women postpartum were doing. The women did not describe the telephone call as offering "adequate care", but they thought it would enable C H N s to assess whether further intervention was required or not. Bartlett (1990), Colon (1996), Evans (1995), and Rao (1994) all comment that use of the telephone offers the health care provider the advantage of doing a routine patient assessment. Donaldson (1991) writes that, for assessment, the telephone is an important means of obtaining information from and giving information to families as well as of monitoring the progress of families. Similarly, Polinsky et al. (1991) and Brooten et al. 141 (1996) note that telephone use enables health care providers to detect health care problems early. In expressing this purpose for the telephone call the women appear to have had an awareness of the importance of assessment during the postpartum period. A s well , their comments lend support for use of the telephone as a means by which the C H N s can offer preventive focused assessment. The women mentioned they thought the C H N s would be able to reach more women with use of the telephone. They suggested that i f C H N s were able to assess women by telephone then telephone use has the potential to enhance the efficiency of C H N practice. While increasing the efficiency of C H N practice was not of direct benefit to the women, the women indicated they were aware of the potential impact that telephone use could have on the C H N ' s practice. The women's awareness is supported by Bartlett (1990), Colon (1996), Evans (1995), and Rao (1994) who state that telephone use decreases provider travel and follow-up costs: Its use can be a cost-effective tool (Bertera & Bertera, 1981; Oda et al., 1986; Wasson et al., 1992). Suggestions to Improve the C a l l A review of the women's perceptions of the helpfulness of the call clearly demonstrates the aspects of the process of the call that require modification: establishment of rapport, the timing of the call, and the length of the telephone call. Because some of the women experienced difficulty establishing rapport with the C H N during the telephone call , their receptivity to use of the telephone as a means for health care intervention varied. For some women, talking to a nurse they had not yet met did not seem bothersome; in fact, the telephone may have provided them necessary privacy from the C H N . For other women, receiving the call from a nurse that they knew would have 142 increased their comfort and satisfaction. For them, talking to an unfamiliar C H N about topics of a personal nature was difficult. Yet, a few women were not comfortable with telephone use; they preferred face-to-face contact. The women who liked or expressed comfort with the use of the telephone stated this strongly and without hesitation, and those less enchanted with telephone use also indicated their feelings clearly. When women were not comfortable talking with a C H N they did not know, use of the telephone was less helpful to them, and it l ikely decreased the C H N ' s ability to meet the process objectives. The combination of an unknown C H N calling and the medium of the telephone may have created too much distance for these women; they expressed less satisfaction than optimal with the care given during the telephone call. The women expressed a desire for consistency in the postpartum care that they received. The literature mentions that providers of care are advised that clients might be more satisfied with personal interaction rather than telephone use (Bartlett, 1990; Colon, 1996; Davidson, 1991; Evans, 1995; Rao, 1994). In order for the C H N s to meet the process objectives consistently and to ensure that the telephone call is most helpful to women, the C H N s need to foster ways to develop rapport over the telephone. The timing of the C H N ' s call influences the length of the call , and these process aspects of the call impact on the ability of the C H N to adequately address the concerns of the women postpartum during the call. The women indicated that they were not always able to completely attend to the telephone conversation; nor were they always able to take the time needed to discuss their concerns completely because a family or household task distracted them. In these situations, the process aspect of the call was not as helpful and 143 consequently the timing and the length of the call influenced the C H N ' s ability to fulfill the process objectives. In summary, the women postpartum were generally pleased with the process component of the telephone call. The telephone call appears to have been helpful to both primiparous and multiparous women. Yet, the multiparous women expressed less appreciation for the call and stated that, although the call was helpful to them, it would have been more helpful with a first child; the call seemed to be especially helpful to primiparous women. The women did, however, recommend changes that could enhance the usefulness of the telephone call to women postpartum. They suggested that all women postpartum continue to receive the telephone call because the women would be able to judge their needs for information and support at the time of the call; hence, they anticipated that multiparous women would also continue to benefit from receiving the telephone call. They commented that they would have liked to receive the telephone call earlier than the six-week postpartum period because they felt women had concerns and questions needing to be addressed well before this time. A s well , the women recommended that the call be given by the same C H N providing their Healthy Beginnings program care to facilitate development of rapport between themselves and the C H N . The women's perceptions reveal that the timing of the call and the rapport between the provider and the recipient of the call do not always effectively meet the needs of the women postpartum. Modifying these process aspects of the call would enhance the C H N ' s ability to meet the process objectives. 144 CHNs* Perceptions of the Process of the Call Benefits to the C H N Role The C H N s shared their perceptions of the benefits for themselves of including the telephone call in their C H N role. These benefits pertain to the process aspect of the telephone call . The C H N s were initially concerned that the preventive focus of their practice had diminished with the introduction of the Healthy Beginnings program. B y giving the call , the C H N s said they were able to re-emphasize the preventive focus in their practice, thus enhancing the care they gave during the late postpartum period. The women's receptivity to the call indicates they were more ready to hear about topics of a preventive nature during the six-week call than they would have been during their initial days at home after hospital discharge. Thus, the implementation of the telephone call helped the C H N s to meet the process objective, offer preventive focused assessment, information, referral, and support to women during the late postpartum period. The C H N s were concerned that parents were overwhelmed with the information they received in the initial postpartum period, and in fact, the parents had requested the C H N s contact them again at a later date. A s suggested by Siegel (1992), mothers in the postpartum period are deluged with information and cannot absorb it all . In giving the telephone call, the C H N s were able to reinforce information with parents at a later date, and they felt less pressure to discuss all the postpartum information with parents during the initial H B care. In addition, the C H N s suggested the telephone call gave them the flexibility to give information to parents when they were most receptive during the postpartum period. Including the telephone call in their practice not only helped the C H N s to fulfill the parent's request, but it supported them to achieve the process 145 objective, to provide appropriate care to women by telephone during the late postpartum period. The C H N s benefited from giving the call because they were able to obtain feedback from the women postpartum. The C H N s realized they could offer a better quality of nursing care and, in turn, became more satisfied with their work. Thus, the C H N s were able to realize several benefits for themselves and their practice from giving the telephone call. Although feeling more satisfied with their work was not specifically outlined as a process objective, surely the gain of satisfaction is part of the process of giving the call. Benefits of the call—receiving feedback, realizing they provide a better quality of nursing care, and gaining satisfaction— provide C H N s with a sense of completeness. The literature reports that concerns exist pertaining to the postpartum care given today. Often minimal focus is given to psychosocial issues during care and the giving of care is restricted to the early postpartum period. The feedback from the women on what was found to be helpful about the telephone call and from the C H N s indicates that the telephone call enabled the C H N s to give individualized care that addresses the physiological and psychosocial concerns of women postpartum into the late postpartum period. This study supports Donaldson's (1988) work, which suggests women value access to educational and supportive interventions by telephone, and Erickson's (1992) research, which reports that women postpartum want educational information, validation (reassurance), and emotional support from health care providers. The importance to women postpartum of sharing, of caring, and of receiving support from telephone contact was identified by Donaldson and is verified by the findings of this study. 146 Purpose of the Call The C H N s articulated their views of the purpose of the telephone call: to assess by appraising women's support and postpartum adjustment, to intervene comprehensively by giving emotional support, providing community resource information, and offering anticipatory guidance, and to evaluate by obtaining feedback about care received. These perceived purposes of the call illustrate the C H N ' s application of the nursing process as a framework for the care they gave by telephone, an application supported by the Registered Nurses Association of B C ( R N A B C , 1999) and the American Academy of Ambulatory Care Nursing ( A A A C N , 1997). Use of the nursing process provides a standardized method for problem solving that w i l l also accommodate the varied needs of the client encountered in telephone nursing ( A A A C N ) . Nursing care given by telephone needs to include identifying client needs or assessment, providing nursing care or planning and implementation, and evaluating care ( A A A C N ; R N A B C ) . B y stating that receiving feedback is a purpose of their call , the C H N s acknowledged that obtaining feedback is part of the process of providing appropriate care. Their views of purpose for the call reveal that the C H N s were directed in giving the call to meet the stated process objectives and that these process objectives can be fulfilled by the telephone call. Challenges of Giving the Call While providing benefits to the C H N s and their practice, the telephone call resulted in challenges. The C H N s were challenged to establish rapport with women postpartum previously unknown to them. The C H N s did not receive additional preparation on use of the telephone to provide health care prior to implementation of the six-week call (S. Johnson, personal communication, February 9, 1999). Despite not 147 receiving training, the C H N s expressed an awareness of the need for skil l when initiating and conducting the telephone call. They noted the importance of delving into the responses of the women in order to gain an accurate understanding of how the women were doing. The nurses in Donaldson's (1988) study, supporting the comments of the C H N s , found establishing rapport with the women they called difficult. To overcome this difficulty, the nurses in Donaldson's study focused on the issues and the concerns of the mother when giving care by telephone, and the call tempo was based on the mother's cues, with active listening skills being used to foster development of rapport. Donaldson believes this approach appears to convey a message of caring. Noting this challenge, the C H N s realized establishment of rapport is critical to the success of the call and to their ability to meet both of the process objectives. Polinsky et al. (1991) notes telephone use may enable providers to offer care when clients are receptive. Yet, the C H N s at times found the opposite to be true as they were challenged to reach women when it was convenient for the women to talk. B y giving the call as an unscheduled call, the C H N s would on occasion make several attempts to reach a woman. A s mentioned, giving the telephone call at a time when women are receptive and able to focus on the content of the call is important to the success of the call or the value of the call to the women. This process aspect of the call impacts considerably on the C H N s ability to meet the process objectives. The C H N ' s awareness of this concern can lead to a positive outcome to this challenge. They can decide to schedule the call or call women back when it is more convenient for them to talk. Thus, there is potential for the telephone intervention to reach women when they are most receptive. 148 A s well , the C H N s were not always able to reach a family because their time limited the number of attempts they made. Giving the telephone call challenged the C H N s to find the time to be able to implement the call consistently in their practice. Although the literature does not mention that having sufficient time to provide care by telephone is a concern of telephone use, it does note that accurately assessing a situation and providing information by telephone can consume considerable time (Bartlett, 1990; Colon, 1996; Davidson, 1991; Evans, 1995; McLean, 1998; Rao, 1994). The difficulty of having enough time to achieve the best outcomes is worth remembering when considering to give care by telephone. Including the telephone call in their practice presented the C H N s with another challenge. Since the C H N s were not able to reach all of the women with the telephone call, some of the women did not receive information that is now given during the six-week call but was previously discussed during the initial H B program care. This process aspect of giving the call, specifically, the information given to women during the call, is not implemented consistently. This inconsistency of practice as a result of implementing the telephone call impacts on the C H N ' s ability to fulfill the process objectives. In addition, assessment of postpartum adjustment was difficult for the C H N s because of the use of the telephone to provide care. The C H N s stated they believe the occurrence of postpartum adjustment difficulties is more common than is recognized. Since women may not readily share their feelings and the telephone does not allow the C H N to view non-verbal behaviors, the C H N s require skil l to accurately assess women's adjustment by telephone. In addition, with telephone use patient reporting over the telephone may be less accurate and the provider's physical assessment skills are deprived 149 of use (Bartlett, 1990; Colon, 1996; Davidson, 1991; Evans, 1995; Rao, 1994). Providers may spend insufficient time listening to patients for accurate data collection, may use leading rather than open-ended questions, and they may collect inadequate data ( A A A C N , 1997). A s such, use of the telephone challenged the C H N ' s ability to identify women with postpartum adjustment difficulties and consequently its use impacted on their success in fulfilling the process objectives. Similarly, a challenge of telephone use can be the inability of the provider to see the expressions of the recipient such as when the listener does not understand (McLean, 1998). Although the women in this study were all conversant in English, language difficulty may or may not be apparent to the provider over the telephone. In a multicultural area such as Vancouver, language difficulties may in future impact the potential value of this intervention; those less conversant in English may not feel comfortable using the telephone and might be less receptive to its use in the postpartum period. A s Donaldson (1991) states, more research is needed to explain how variation in maternal traits affects women's responses to selected postpartum interventions. A woman's ethnicity or her cultural beliefs may also influence the impact of telephone use as a means of giving health care intervention. Cultural comfort may vary with respect to discussing topics of a personal nature or asking questions by telephone. C H N s need to acknowledge that this type of intervention may not meet the needs of every woman and that it needs to be applied to the health care of women postpartum with discretion. The literature does not mention cultural influences on telephone use; yet, the prevalence of telephone use in health care warrants exploring the relationship of culture and telephone use. 150 Suggestions to Improve the C a l l The C H N s offered suggestions for improving the six-week telephone call and their suggestions indicate an awareness of the need for the call to fulfill both of the process objectives but, in particular, to achieve the process objective to provide appropriate care to women by telephone during the late postpartum period. The C H N s thought that all women postpartum should continue to receive the six-week call because they believe primiparous and multiparous women have varying needs that can be addressed with the telephone call . Also , they suggest continuing to use the questions they developed for the six-week call because these helped them assess the health of a woman and her family during the postpartum period. A s well , the C H N s wished to continue informing the women during the early H B postpartum care they would receive a telephone call from the C H N at six weeks postpartum. They thought that women would be more prepared to receive the telephone call and that they would be able to initiate rapport with the women more readily i f the women were expecting the six-week call; Because of their awareness of the need to facilitate development of rapport with the women, the C H N s suggested the same C H N that provided care to women during the early postpartum period also gives the six-week telephone call. The C H N s stated they wish to continue giving the telephone call at six weeks postpartum but women would benefit from receiving the call earlier than six weeks. The women in this study felt down prior to receiving the six-week telephone call; the literature cites that, prior to six weeks postpartum, women are very likely to feel down and to want further support (Buhler & Carty, 1997; Griepsma et al., 1994; Leung, 1995). A s well , the women expressed that they had other concerns that occurred prior to 151 receiving the telephone call that may have been able to be addressed with the telephone call . Therefore, this study reveals that women may benefit more i f the telephone call is given earlier. Hence, the C H N s desire to address the women's concerns, to respond to their requests for care, and to ultimately fulfill the process objectives, may need to supersede their own recommendations for the timing of the telephone call. The themes expressed by the women and the C H N s provide evidence that the C H N s are able to achieve the two process objectives, with some exceptions, by giving the telephone call. Yet, the other process indicators of the Logic Mode l (see Figure 1) need to be reviewed in order to determine more completely whether the telephone call enables the C H N s to meet these process objectives. The Logic Model directs one to note whether the C H N s discussed all of the questions during the six-week telephone call in order to assess the consistency of the implementation of the call. Consistency in implementation would support the likelihood that the process objectives were met. The C H N s discussed all of the six-week questions with each woman, except where the question was not relevant (for example, those relating to siblings with a primiparous woman). Documentation of the type of information sent to the women, the number and focus of referrals made, and the number of women requesting or needing further support, also indicates whether the process objectives were met. These process indicators were not documented and therefore do not lend support or accountability toward the fulfillment of the process objectives. The formative evaluation discloses that although there are strengths in the process aspect of the telephone call intervention, as it is currently given, there are limitations. These limitations pertain to establishing rapport with the women, establishing appropriate 152 timing and length of the call , reaching women at a convenient time, and offering consistent implementation of the telephone call in the C H N ' s practice. The findings indicate that improvements to the process component of the intervention are needed for the C H N s to be successful in enhancing the health of postpartum women and their families, which is the goal of giving the telephone call. The Outcomes of the C a l l B y giving the telephone call, the C H N s hoped that healthy changes would occur for the women postpartum and their families. They sought to achieve several short-term outcome objectives: increase awareness of the breastfeeding and parent-infant drop-ins, increase awareness of CHN as a resource for family health, increase awareness of the benefits of increasing the duration of breastfeeding, increase knowledge of community resources, maternal and family adjustment, infant care/feeding practices, and women perceive support is available or express desire to seek support (see Figure 1). In addition, the C H N s hoped to fulfill the following long-term outcome objectives: increase the duration of breastfeeding, increase postpartum women's capacity to create health for themselves and their families, and increase the support given to women during postpartum (see Figure 1). To ascertain the ability of the C H N s to meet these objectives through use of the telephone call, women's and the C H N ' s expressed perceptions of the changes occurring for themselves and for their families are discussed in view of the research questions and the indicators for the short and long-term outcome objectives. Some of these perceptions are compared to the outcomes noted in the literature on telephone use. 153 Women's Perceptions of the Outcomes of the Call The women postpartum discussed the changes that occurred for themselves and their families following receipt of the telephone call. They recalled the C H N s mentioned the breastfeeding and parent-infant drop-ins during the call, and they valued learning about the drop-ins from the call. Several stated they planned to attend the drop-ins or had attended them since receiving the call. One short-term outcome objective of the telephone call, also noted in the Logic Model (see Figure 1), was to increase awareness of the breastfeeding and parent-infant drop-ins. The telephone call enabled the C H N s to fulfill this outcome objective. The C H N s hoped the telephone call would result in women obtaining increased knowledge of community resources, maternal and family adjustment, infant care/feeding practices, a short-term outcome objective. The women expressed that they gained knowledge and awareness of infant and self-care as well as community resources from the call. They said that they felt reassured after talking with the C H N because they learned their experiences pertaining to them or their infants were typical of many other women postpartum. Wi th gaining reassurance from the C H N , the women felt supported when caring for themselves or their infant. A s well , they gained understanding of their infant's behaviors from the call and felt better prepared to cope, adding they coped better with meeting their infant's needs more appropriately. The women's recall of the content of the call and the changes that occurred for them following the call indicate that the C H N s by giving the call can effectively increase women's knowledge of these areas and meet this short-term outcome objective. 154 The C H N s had been concerned prior to giving the six-week telephone call that women postpartum in their community were isolated and lacked support. The C H N s wanted to ensure that women postpartum perceive support is available or express desire to seek support as an outcome of receiving the six-week call. The women expressed that they gained awareness of sources of support in their community and that they became motivated to seek support from the call. A s well , the C H N s , as a purpose of giving the call, expressed they offer women emotional support and assess women's need for emotional support during the telephone call . Hence, the C H N s appear to have achieved this short-term outcome objective through providing the telephone call to women postpartum. The women said they became more aware of the C H N s as a resource for family health and more receptive to using the C H N s for needs in the future as a result of receiving the telephone call. One woman and her husband who were disappointed with their initial Healthy Beginnings program care found the six-week telephone call increased their receptivity to C H N s considerably. The women indicated also that they thought they would benefit from receiving the six-week telephone call with a subsequent birth, suggesting that they attained increased awareness of C H N as a resource for family health from the call. This short-term outcome objective appears to have been fulfilled by the C H N s , with use of the telephone call. The receptivity of women postpartum towards the C H N and the telephone intervention may be influenced by several factors. First, the way women perceive the C H N in relation to their own needs may determine whether women prefer to encourage this relationship or to remain distant from the C H N and use others as their primary 155 resources. Thus, a woman's preference for personal contact may express her desire to foster a relationship with the C H N . Those women relying on other resources and those not wanting the C H N as a principal resource may maintain that telephone use is quite satisfactory. Similarly, a woman's comfort with or response to telephone use may be influenced by the strength of her support system. Women who are well supported may not feel a need to cultivate a relationship with the C H N , and therefore they may be more comfortable with telephone use. Those women needing more support and those lacking personal contact from others (family, friends) may be more likely to seek future C H N contact and may value building a relationship with the C H N and hence desire personal contact. Therefore, personal contact for some women still derives the most benefit, and this preference needs to be respected. The literature suggests that the use of the telephone may strengthen the relationship between patient and provider (Bartlett, 1990; Colon, 1996; Evans, 1995; Rao, 1994). Telephone use may have strengthened the relationship between C H N s and the women in general, but the absence of a formed relationship between the two parties precludes thinking that the telephone call strengthened specific relationships. St i l l , the women did express a desire to build relationships between themselves and their providers of health care and the telephone call could begin to foster this. Prior to implementing the six-week telephone call, the C H N s had noted women stopped breastfeeding around six weeks postpartum because they did not understand their infant's need to feed frequently when experiencing a growth spurt. In implementing the six-week telephone call , the C H N s hoped women would gain increased awareness of the benefits of increasing the duration of breastfeeding, and subsequently, women would 156 continue to breast feed as a result of receiving support from the C H N during the call. Although the women mentioned the telephone call assisted them to better understand their infant's feeding behaviors, they did not recall gaining awareness of the benefits of increased duration of breastfeeding during their conversation with the C H N . This short-term outcome objective does not appear to have been achieved by the telephone call. When trying to understand why this group of women did not recall this information, it is prudent to note that this group of women seemed to be committed to breastfeeding. Their commitment may be explained partially by the fact that they were generally well educated. Bourgoin et al. (1997) found women with higher education levels (above grade 12) were more likely to breast feed longer than women with lower education levels. Edwards and Sims-Jones (1997) found that of the women who stopped breastfeeding by three months postpartum, 50% had stopped breastfeeding in the first month. A s well , an experienced lactation consultant suggests that breastfeeding women most often wean their infants before three weeks postpartum or around three months (12 weeks) postpartum ( M . Green, personal communication, October, 1997). Whi le the women in this study did not express a desire to stop breastfeeding at six weeks postpartum or soon after, those who anticipate discontinuing breastfeeding and who receive a six-week call w i l l have had an opportunity to discuss this during the call. The call thus offers an ideal opportunity to address this concern. CHNs' Perceptions of the Outcomes of the Call The perceptions of the C H N s were also obtained with respect to the changes occurring for women postpartum and their families from receiving the six-week call. The C H N s believed women might have received greater support from their peers or other 157 mothers as a result of getting the telephone call. They supported women directly by giving them information about community resources and indirectly by linking them to other women in the community. This type of support is useful as strengthening informal networks helps parents to adapt to their new roles (Hampson, 1989). The C H N ' s perceptions reveal they believed that use of the telephone call could assist them to meet the short-term outcome objective of women perceive support is available or express desire to seek support. The C H N s thought the women were more aware of self-care after receiving the telephone call . The C H N s believed women were less anxious when caring for themselves and their infant following the call and as a result women would contact their physician more appropriately. They thought women gained confidence from the call as a result of receiving anticipatory guidance from the C H N . In addition, the C H N s thought the women became more aware of the availability of community resources as a result of the telephone call. In fact, the C H N s had noted that women were getting out more and that women were using the resources in the community more, following receipt of the call. The C H N ' s perceptions suggest that by making the telephone call, C H N s are able to meet several short-term outcome objectives because women postpartum gain awareness of the breastfeeding and parent-infant drop-ins, knowledge of community resources, maternal and family adjustment, infant care/feeding practices, and awareness of C H N as a resource for family health. A n underlying premise of a logic model is that, when a program or intervention fulfills its short-term outcome objectives, it is l ikely the program or intervention has achieved its long-term outcome objectives. In viewing the long-term outcome indicators 158 of the Logic Model (see Figure 1) it is noted, as previously mentioned, that the women did not gain an awareness of the benefits of increasing the duration of breastfeeding, nor did they express a decision to increase their breastfeeding duration as a result of receiving the telephone call. Also , the C H N s did not specifically state they believed the women would increase the duration of breastfeeding after receiving the call . However, they did suggest they believed the telephone call would provide women with an opportunity to receive anticipatory guidance about breast feeding which would result in women feeling less anxious. Thus, the C H N s thought the telephone call would assist them indirectly to encourage women to increase the duration of breastfeeding. The ability of the C H N s to meet the long-term outcome objective increase the duration of breastfeeding, through giving the telephone call is not well supported by the expressed perceptions of the women and the C H N s . The C H N s , from implementing the telephone call, achieved as far as can be determined, the long-term outcome objective increase postpartum women's capacity to create health for themselves and their families. The women stated they became motivated to make decisions or changes to improve the health of themselves or their infant following receipt of the call. A s well , the C H N s thought that the women made changes that enhanced the health of their infant, themselves, or their family from receiving the telephone call . This objective appears to have been fulfilled since the C H N s were able to meet many of the short-term outcome objectives with the telephone call and since both the women's and the C H N ' s perceptions of the outcomes of the call indicate women made decisions to create health for themselves or their families. The evaluation reveals that the C H N s , during the telephone call, offered support or gave suggestions of where to 159 obtain support to the women, and the women indicated they received support during the call . The telephone call succeeds in meeting the short-term outcome objective of women perceive support is available or express desire to seek support. Because of these findings the long-term outcome objective, increase the support given to women during postpartum, can be achieved by C H N s through making the telephone call . In summary, the outcomes of the telephone call, as perceived by the women and the C H N s reveal at six weeks postpartum a C H N can effectively address concerns expressed by the women postpartum on the telephone. These perceptions lend support to the ability of the C H N s in giving the call to meet the outcome objectives of the Logic Model . Giving of the telephone call appears to enable the C H N s to create outcomes that not only fulfill their objectives for the telephone call but that create outcomes which foster the C H N ' s goal of enhance the health of women postpartum and their families. Use of the Logic M o d e l In this section, the usefulness of the Model to evaluate the telephone call is discussed, and changes to the Model are suggested. The formative evaluation identifies the value of using the Logic Mode l to evaluate an intervention. The Logic Mode l created for this formative evaluation (see Figure 1) depicts not only the components but also the desired process and outcome objectives and the ultimate goal of the telephone intervention. While most logic models depict the outcome objectives desired they do not always include the process objectives and indicators of a program or intervention. The inclusion of process and outcome objectives as well as indicators for each makes this Logic Model , based on Dwyer and Mak in (1997), a seemingly complete model. 160 Use of a logic model in qualitative research was initially questioned; however, the Logic Model developed for the telephone call applied easily to the needs of this formative evaluation. Use of the Logic Model ensured that the telephone call remained closely linked with its evaluation; thus, the aspects of the call needing revision were revealed clearly. If concerns about the call arose, the providers could look to the Model to explain why aspects of the call were unsatisfactory. The Model can then be revised in concert with the actual intervention. Most importantly, use of this Logic Model makes certain that the providers of care remain close to the intervention components so that they understand the intervention's goal (Dwyer & Makin , 1997). In summary, use of the Logic Model to evaluate the telephone call allowed the intervention to be portrayed clearly so the components can be evaluated thoroughly in order to ascertain the extent to which the call produces the desired outcomes. When developing a logic model according to Dwyer and Makin ' s (1997) framework, the outcomes are to be near the top instead of close to the bottom of the model. Dwyer and Mak in advise this purposely so that the desired outcomes or the end result of a program or intervention "drive" the selection of a component for a program or intervention (p.425). These authors define component of a program as "groups of activities" (p.423). To correspond to the authors' explanation, a logic model needs to display the component of a program or intervention after the outcomes sought. This would ensure that the outcomes desired influence the selection of the component. The component of the telephone intervention has been placed following the long-term outcomes/indicators to reflect that the desired end results influence the selection of the component. The researcher's refined Logic Model (see Figure 2) depicts this change. 161 Suggestions for changes to the Logic Model (see Figure 1) are now offered. Revision is needed of the resources listed at the bottom of the Logic Model . Questions used for the six-week telephone call (Appendix A ) should be revised to reflect the findings of the evaluation and the literature. The C H N s could develop a guide for the telephone call that includes various topics to discuss during the call instead of listing specific questions to be asked. The Health Unit written information and the Health Unit breastfeeding and parent-infant drop-ins can be consolidated under the heading of Community Health Area resources. The Health Unit recording document (Appendix H) should also be revised to assist the C H N s to document process aspects of the call. These aspects might pertain to the timing of the call, to whether the call was scheduled and/or to whether women were called back. The C H N s could review the process indicators of the refined Logic Mode l (see Figure 2) to determine what needs to be documented. Changing the component aspect of the Model to read, " C H N initiated postpartum telephone contact," is advised, as support, as previously documented, is actually a specific activity of the call . A s well , depicting the activities of the telephone call more specifically, such as, education, support, referral, and assessment, would be helpful. Since the C H N s identified obtaining feedback from the women as a purpose of the call, feedback could be added to the activities specified. The term appropriate care contained in the process objective to provide appropriate care to women by telephone during the late postpartum period, is of concern because indicators of appropriate care can be interpreted broadly. The approach of the C H N is very important to the success of the call, and aspects of the approach need to be captured in the process objective section of the model. Therefore, this study suggests 162 including objectives that focus on both the development of a relationship between the C H N s and the women and on respect, caring, and flexibility. The study reveals that the C H N s , by providing the telephone call can address not only postpartum women's health needs but also the needs of their infants and their family members. Therefore a process objective to reflect this finding has been included. Opportunities exist for the C H N s to develop the process area of the Logic Model to further assess how giving the call impacts the outcomes achieved. Based on the findings, the short-term outcome objectives could be altered to capture the changes occurring for women from the call . Concepts such as support, coping, understanding, confidence, and receptivity could be incorporated into short-term outcome objectives and corresponding short-term outcome indicators developed. The C H N s were able to meet two of the long-term outcome objectives through use of the telephone call. The long-term outcome objectives need to be reviewed in view of the findings to determine i f additional objectives are desired. The study results suggest that the long-term outcome objective, to increase postpartum women's capacity to create health for themselves and their families, be retained and that the other two long-term outcome objectives be subsumed within it, i f they are still desired. Since the women and the C H N s believe that the telephone call is useful to primiparous and multiparous women, the target group for the telephone call should continue to include both. The reference to the women being six weeks postpartum should be deleted from the target group since the timing of the telephone call may change. The goal of the telephone intervention has been revised to reflect an emphasis on the infants of the women as supported by the study. The C H N s may want to revise the goal of the 163 telephone intervention; however, their purposes for implementing the telephone call correspond well with the current goal. The Logic Model has been revised to reflect the changes discussed (see Figure 2). Summary The concerns expressed by the women postpartum were similar to the concerns noted previously in the literature. Yet, the timing of the concerns for these women differs somewhat from what has been previously reported, and the concerns women expressed, which relate to their physical health and feeling unsure about what to do or expect when caring for their infant, have not been previously noted for women at six weeks postpartum. Many of the advantages and challenges of telephone use identified in this study have been previously reported. The finding that telephone use may impact family members other than the women postpartum has not been noted in the literature. Since family wellness is a focus of postpartum care, this aspect of telephone use may prove to be particularly beneficial. Care by telephone, to members of the family other than the mother, is a possibility and a potential benefit of telephone use. Some benefits of telephone use, noted in the literature, were not found in this study. Although the literature reflects that telephone use strengthens provider and recipient relationships, this study's findings did not support this, as relationships between the C H N and the women had not been established prior to the telephone call. However, the findings suggest women were more receptive to using the C H N s as a resource following the call . The call may therefore have fostered the development of a relationship towards C H N s in general. Both the women and the C H N s were aware that a ski l l set is 164 necessary for effective telephone use. Some of the skills mentioned in the study are among the skills noted in the literature for giving care successfully by telephone. The study supports and confirms many of the advantages and limitations of telephone use already noted in the literature. While the study does not refute previous findings, it does support benefits of telephone use not previously discussed. The Logic Model was found to be a useful tool to use to evaluate the telephone call intervention. Its use can be adapted for qualitative research. Use of the Model provided a visual overview of the intervention that allows for the aspects of the telephone call needing modification to be easily revealed. Modifications to the intervention are suggested and corresponding refinements to the Model are recommended. The usefulness of the six-week telephone intervention for women postpartum is disclosed through the formative evaluation. The benefits of the intervention to the C H N s and their practice are identified and the challenges of giving care by telephone are highlighted. The evaluation of the telephone call indicates that the process objectives and the short-term outcome objectives are not met completely. Concerns remain pertaining to the timing of the call; the content of the call; the C H N ' s having adequate time available to make the calls; the relationship between provider and client (consistency of care); the ski l l set necessary for telephone use; and the offer of postpartum information in a consistent manner. The evaluation reveals that women, for the most part, believe their concerns can be alleviated, or at least can begin to be addressed, with receipt of the six-week call. A s well , the evaluation enables the C H N s to learn of the women's perceptions of the telephone call, and they can now make adjustments to this intervention to better meet 165 their needs. A s such, the evaluation provides evidence that the telephone intervention, in its current form, assists the C H N s to enhance the health of women postpartum and their families and offers a strong base from which to make improvements. The final chapter includes a summary of the study, limitations of the study, conclusions, and implications of the findings. Goal To enhance the health of women postpartum, their infants, and their families Target Group Women, postpartum who reside in the Community Health Area Long-term outcome Objectives Increase postpartum women's capacity to create health for themselves and their families Long-term outcome Indicators Women make changes that enhance the health of themselves or their families Component CHN initiated postpartum telephone contact Assessment-Education-Referral-Support-Feedback Short-term outcome Objectives -Women use the CHN as a resource for family health -Women obtain adequate support during the postpartum period -Women cope well during the postpartum period -Women understand how to care for themselves and their infant during the postpartum period -Women feel confident when caring for themselves and their infant T Short-term outcome Indicators -Women express awareness of and receptivity to using CHN resources -Women express awareness of sources of support -Women express that they have sought support -Women express feeling reassured and less anxious -Women express feeling better prepared to cope -Women express learning how to care for themselves and their infants T Process Objectives -Offer preventive focused care that addresses maternal, infant and family health -Develop relationship between women, postpartum and CHNs -Utilize effective communication skills when providing care by telephone -Offer additional CHN contact to women, postpartum -Provide telephone call to women, postpartum at an optimal timeframe -Offer care by telephone or visit -Contact women, postpartum at a time convenient for the women -Obtain comments on CHN care previously given T Process Indicators Document: -Concerns discussed and interventions made -CHN giving HB care and telephone call -Number of women requesting further contact -Timing of the telephone call -Preference for visit or telephone call -Feedback about previous care -Number of women called back -Number of scheduled calls Themes indicate: CHN approach is caring, flexible, and respectful Themes indicate: women develop rapport with CHN T Resources -Community Health Nurses -Guide for Telephone Call -Community Resources -Telephone Call Documentation Sheet -Community Health Area Resources Figure 2. The Researcher's Refined Logic Model for Six-Week Telephone Intervention, Based on Dwyer & Makin (1997) 167 C H A P T E R SIX S U M M A R Y , LIMITATIONS, CONCLUSIONS, A N D IMPLICATIONS Chapter six contains a summary of the study followed by a discussion of the limitations of the study with respect to the findings. The conclusions are then presented. Lastly, implications for nursing practice, nursing education, nursing administration, and future nursing research are discussed and recommendations are offered. Summary of the Study The telephone intervention has been implemented since July 1996 with women who are six weeks postpartum. Although the C H N s believed the telephone intervention was useful to the women, no evaluation of the intervention had been undertaken. The purpose of this study was to conduct a formative evaluation of the telephone call given by the C H N s at six weeks postpartum in order to identify the strengths and shortcomings of the telephone intervention. A Logic Model that is based on the framework of Dwyer and Mak in (1997) was used to illustrate the components of the telephone intervention and to evaluate the intervention. The literature review of studies and programs pertaining to community maternity nursing care in both the United States and in Canada indicated that inadequacies exist in the postpartum care currently offered. Rarely does the care extend to the late postpartum period and it is usually not individualized to meet women's needs. Additionally, care predominantly focuses on addressing the physical concerns of women and their infants. The literature on telephone use indicates that while much is said of the advantages and 168 disadvantages of using the telephone to provide health care, much less is said on giving care to women, postpartum utilizing the telephone. A constructivist research design was chosen to gain the recipients' (women, postpartum) and the providers' (CHN) perceptions of the telephone intervention. Naturalistic Inquiry, a discovery-oriented approach, was best suited to address the research questions. Wi th respect to women postpartum who received the call, the questions were: (a) what do they remember about the process and content of the call; (b) in what ways was the telephone call helpful or not helpful to them; (c) what changes did they and their families make following receipt of the telephone call; and (d) what changes might they suggest to improve the telephone intervention? From the perspective of the community health nurses who implemented the telephone intervention, the questions were: (a) what do they perceive as the benefits for women and their families of the telephone call; (b) what do they perceive as the benefits of including the telephone call as a component of the C H N role; (c) what do they find are the challenges of offering the telephone intervention; and (d) what changes might they suggest to improve the telephone intervention? Eleven women postpartum were interviewed by telephone, at a date that averaged, nine weeks postpartum. Six primiparous women and five multiparous women were selected, and they ranged in age from 25 to 36 years. They were well educated, partnered, conversant in English, and all but one woman delivered vaginally. Seven C H N s participated in a focus group held upon completion of the interviews. A l l interviews and the focus group were audiotaped and transcribed verbatim. Content analysis was done concurrently with the data collection, which allowed emerging themes to be validated and 169 further explored. Many themes emerged from the women's and the C H N s ' discussion of the telephone intervention. It was generally found that both the women postpartum and the C H N s valued the six-week telephone call . Women, particularly primiparous women, were grateful that the C H N contacted them again while others, usually multiparous women, expressed less appreciation for the call because of their comfort with parenting and childcare. Women thought the purpose of the C H N s ' call was to detect health concerns early, to offer information and provide an opportunity to ask questions, and to give support and reassurance. They asked non-emergent questions of the C H N , received emotional support from them, and viewed the C H N s as a valuable resource because of their knowledge. Women appreciated that the C H N s were caring, approachable, respectful, flexible, and demonstrated skillful communication during the call . A s a result, the women sought the advice of the C H N because the C H N s demonstrated the ability to respond effectively. The length of the telephone call was deemed by most women to be sufficient for raising and exploring their concerns, but the timing of the call resulted in some women not being completely satisfied. In these cases, the women's need to return to family and household demands influenced the value of the call. Some women were not able to focus completely on the conversation with the C H N nor did they have enough time to discuss their concerns adequately. The women stated that the C H N ' s focus during the call was relevant to what they needed to discuss. They were satisfied with the questions posed by the C H N s and grateful to have been given the opportunity to ask their own. Also , they appreciated that the C H N paid attention to their needs as well as to those of their infant. 170 The women postpartum viewed the use of the telephone for health care positively and realistically. Overall, they enjoyed the convenience of receiving support by telephone. In some situations, the use of the telephone offered the women an appropriate degree of privacy. A s well , its use facilitated other family members, indirectly, taking advantage of the C H N ' s expertise. The women believed that telephone use was likely cost-efficient because C H N s could deliver care to more people through its use. Yet some women found use of the telephone more difficult, and this occurred when they received care from a C H N with whom they were unfamiliar. Some women had difficulty establishing rapport with the C H N and in these cases they suggested having a consistent C H N contact as a solution. The women commented that for some women, face-to-face contact with a health care provider was a preferred approach. The telephone call offered women reassurance. Women became more knowledgeable and aware of infant care, self-care, and community resources as a result of the call. They coped better, became motivated, and acted to meet their own or their family's needs following the call. They became receptive to having future contact with the C H N following the call. Primiparous women, especially, wanted to be able to utilize the C H N in future because they anticipated having further questions. Some stated however, that they would prefer to use their health care provider rather than the C H N because of the already established and strong relationship with them. From the C H N s ' perspective, the telephone call provided them with an opportunity to assess women's postpartum adjustment and need for support, to give emotional support either by linking women to other women in the community or by supporting women directly, to be a community resource, to give women anticipatory 171 guidance, and to receive feedback from families about care given previously. The C H N s believed that valuable changes occurred for women and their families following receipt of the call. They thought that women seemed more aware of self-care and less anxious when caring for themselves or their infants. They thought women, because of the call, might contact their physician more appropriately, seek and receive more support from their peers or other mothers, be more aware of and use community resources more effectively, and get out more often. One of the advantages noted by the C H N s of giving care to women by telephone, was that they found raising topics of a personal nature with women by telephone was easier than discussing them in a face-to-face group or home setting. A s a result, they believed women gained and enjoyed privacy when the telephone was used. However, using the telephone challenged the C H N s as they found that some women, when they were reached, were contacted at an inconvenient time. The unscheduled telephone call sometimes interrupted women in the midst of family and household demands and occasionally the C H N s had to call the women again. In some instances, the C H N s found establishing rapport by telephone with women unfamiliar to them was challenging. The C H N s and their practice were changed in ways that were both favorable and concerning with regard to the implementation of the telephone call. The telephone call helped the C H N s give preventive nursing care in the late postpartum period. Because the timing of the call occurred well after women had settled in at home, C H N s were able to give health information to women when they were more receptive to it. Wi th the addition of the six-week call, C H N s were able to receive feedback on care given previously. The C H N s reported increased satisfaction with their work by being able to offer preventive 172 care. However, the C H N s were not always able to call the women at six weeks postpartum and not all the women could be reached. Consequently, postpartum information that should have been discussed during the call was not given to all the women. The women and the C H N s made the following recommendations: (a) continue calling both primiparous and multiparous women, (b) call women earlier than six weeks postpartum (the C H N s wished to give the call at six weeks postpartum and the women preferred to receive it at three to four weeks postpartum), and (c) increase continuity by having the same C H N that cared for the women during the initial H B care, provide the six-week call . The C H N s specifically recommended that they continue using the questions developed to guide the telephone call and continue advising women during the H B care that they w i l l receive a telephone call at six weeks postpartum. The women recommended that the focus of the call not be changed but that a contact name and telephone number (and the option to receive further C H N contact) be added as a point of discussion. The evaluation found that women postpartum had concerns both prior to and at the time of the telephone calls. These challenges pertained to members of the women's family and to the women's physical and the emotional aspects of self. Prior to receiving the six-week telephone call, the women felt down, wanted adult contact, felt overwhelmed, and felt stressed because they were unsure of how to care for their infant. A t the time of the six-week telephone call the women were concerned with, managing their physical health, feeling unsure about what to do or what to expect when caring for their infant, feeling fatigued, and managing life and family demands. 173 In summary, women postpartum, especially the primiparous women, benefited from receiving the telephone call and the C H N s benefited from providing it. The challenges women experienced during the postpartum period were revealed and the usefulness of the telephone intervention to address these challenges was identified. The findings offer insight into the components of a community postpartum intervention that were appreciated by women and their families. Limitations of the Study Since Naturalistic Inquiry was the research method used, generalization of the research findings is not possible or pursued. The reader of this study w i l l conclude that the study findings are transferable to similar situations given the rich description of context provided (Guba & Lincoln, 1985). Hence, the transfer of the findings, and some degree of generalizability, extends only to those women and their families who are similar to the participants in this study. The findings are to be viewed with an awareness of the participants selected. The following limitations were identified. N o single or teenage mothers, no women unable to speak English, few women over 35 years, few women giving birth by Cesarean section, and few women with low levels of education were selected. Data collection relied on the ability of the women to recall their concerns during their postpartum period and their ability to recollect the telephone conversation they had with the C H N . Also , several of the women that were selected to participate ultimately decided not to. B y using purposeful sampling, the researcher hoped to obtain a sample of women of varied age and marital status, with varied birth experiences, support systems, H B program use, and hospital length of stay. Although the sample does not include teenage 174 mothers or older women (over 36 years), the selected women did reflect a range in age. Since postponement of childbirth is quite common for women today, exploring the perspectives of older women on telephone use during postpartum is suggested. Obtaining the perspectives of teenage mothers on telephone use and their concerns during postpartum would also be useful. In addition, the inclusion of more women having a cesarean birth might result in different concerns being expressed prior to and at the time of the telephone call. The selection of women who received both midwifery and H B program care does reflect current community maternity practice. A l l of the participants in the study were partnered and it is reasonable to assume that women without partners would use their support systems differently and perhaps more frequently than women with partners. Therefore, exploring the perceptions of women without a partner (with adequate or inadequate support) on telephone intervention during postpartum is suggested. During the H B program care the C H N s did not formally document the support systems of the women, and therefore selection of women with variation in support systems was not possible. However, the concerns expressed by the women and the resources they used suggest that the women selected had varying degrees and types of support. The lengths of hospital stay for the women selected reflect current health care practices. The follow-up care received by the women indicates that they experienced a variety of needs. The home visits and telephone calls were, for the most part, given by the C H N s during the first and second postpartum weeks. This pattern of intervention generally reflects care given today. 175 N o attempt was made to obtain women with varying levels of education and the participants were generally well educated. Only one woman had terminated her formal education at the high school level while all of the others held university degrees or college diplomas. The level of education attained by the women may or may not be a predictor of the types of concerns arising during postpartum. Inclusion of less educated women might result in the discovery of postpartum challenges and of responses to telephone use not found in this study. Since women in the study were well educated and generally comfortable speaking English, an elite bias may well have been present. The women selected and those who agreed to participate may have been the most articulate or accessible members of the women, postpartum available to do the study (Sandelowski, 1986). The women that participated in this study were interviewed by telephone approximately two weeks after they received the six-week call. During the interview, they were asked to recall the concerns they had experienced during the postpartum weeks. Because the concerns may have occurred well before the women were interviewed, it is expected that the women may not have been able to recall all of their concerns. A s such, relying on the memory of the women is another potential limitation of this study. In addition it is possible that some of the women who chose not to participate in the study, may have chosen not to because they held perceptions of telephone use that differed from the findings in this study. Despite the limitations that are noted amongst the participants, the findings offer a picture of a group of women with varied needs during postpartum. The needs of the women postpartum that participated in this study do not seem unusual or atypical of those 176 of women postpartum in general. This statement is based on the literature and/or on the researcher's experience. It is possible that the data collected may have been influenced by the decision to conduct telephone interviews instead of personal interviews with the women in this study. It is considered that some of the women, as noted when discussing the telephone intervention, may have preferred to share their ideas in person rather than by telephone, especially with someone they had not met prior to the interview. The researcher did not purposely select the C H N s participating in the focus group. Instead, the C H N s all volunteered to participate in this study. The C H N s that did participate had a wide range of community health nursing experience. In addition, none of the C H N s participating in the study were newcomers to preventive community health nursing practice. Since telephone use is common in community health nursing practice, these C H N s were likely comfortable talking to people by telephone. Different perceptions of the telephone intervention might have been shared i f the C H N s doing the telephone calls had been novices at giving care by this means. A s well , the C H N ' s experience in giving the telephone call varied. The diversity of experience amongst the C H N s helped to highlight the difficulties they encountered when offering the call . O f note, is that in this study, one C H N provided most of the six-week telephone calls to the women and as such the positive response of the women to the call may be largely attributed to this C H N . Conclusions In conclusion, women and C H N s believe that the six-week telephone call benefits both primiparous and multiparous women, although the benefits of the call may not be as evident for some multiparous women. 177 It is likely that giving the telephone contact earlier, at three to four weeks postpartum for example would be more helpful to the women. Women value the knowledge of the C H N and feel confident in the information they receive. Women appreciate the approach used by the C H N when giving the call and the C H N being the initiator of the call. The use of the telephone as a means to give health care intervention is both advantageous and challenging for the provider and recipient of the call . Having a relationship established between the provider and recipient of care reduces some of these challenges. Care given by telephone is not the universally preferred method and ultimately the preference of the care recipient should be respected. The focus of the telephone call needs to be on women's health, infant's health, and family adjustment. The telephone call helps community health nurses identify women who are feeling isolated and lacking support. The call is a source of encouragement to women postpartum and ultimately results in women becoming more aware of the health care resources available. Women postpartum, especially primiparous women, continue to have concerns and questions into the late postpartum period. Community health nursing practice can begin to address these concerns by telephone. To help women achieve a healthy postpartum transition; it is necessary that postpartum care extend into the late postpartum period. 178 Implications for Nursing The implications of this formative evaluation suggest recommendations related to nursing practice, nursing education, nursing administration, and future nursing research. Nursing Practice The following section offers recommendations that pertain to the process and content aspects of the telephone call, to facilitate the implementation of the telephone intervention into nursing practice. 1. The telephone call is beneficial to the women and the C H N s , therefore the call should be added to the Healthy Beginnings program as a permanent component. The findings suggest that women may benefit from receiving the telephone call earlier than six weeks postpartum for example at three to four weeks. The evaluation provides the C H N s with helpful information from which to base a decision. In considering when to give the call, C H N s need to review when the majority of their care occurs during postpartum. They need to acknowledge that women postpartum have concerns that occur well before the six-week call . If the timing of the call is not changed, then the C H N s should either extend their initial care or offer two calls — one at three to four weeks postpartum and one at six weeks postpartum. 2. Because women and C H N s believe that both primiparous and multiparous women benefit from receiving the call , the C H N s should continue to give the telephone call to both of these groups. Since the interests and needs of these women may differ, the C H N s should ensure that the focus of the call addresses their individual needs. 3. The concerns of women and their suggestions for the content of the call are revealed in the evaluation. The C H N s have useful information from which to develop their 179 questions and/or the content. The focus of the questions they ask needs to be developed based on the expressed concerns of the women, the identified purposes of the call, and the literature. Topics such as infant feeding and infant care, women's health, and postpartum adjustment of the entire family could be addressed. Since the telephone call enables other family members to indirectly access the C H N , the C H N s should consider a focus on the family when they develop the content of the telephone call. It is important to remember that partners and family members have a significant impact on how well women cope and parent their new child during postpartum. The likelihood of women wanting more contact increases i f the call is given earlier in the postpartum period. Therefore, C H N s should offer further support along with a name and contact number as part of the content of the call. Obtaining feedback is identified as a purpose of the call and the C H N s are encouraged to include this in the content. Also , the components of the call — assessment, support, referral, and information — should be considered when the content of the call is being developed. Wi th these considerations addressed, the content of the call is likely to more accurately reflect the needs of women who are in the late postpartum period. 4. Developing a guide for the telephone call would be more helpful than listing specific questions to be asked (Appendix A ) . The C H N s could inquire about all of the topics listed but the depth of inquiry and the specific questions asked would be determined by the C H N based on the needs of the women. If a guide was used, C H N s giving the call would be less likely to just ask the questions one after the other and would be more likely to develop a context around the question they present or use the question to introduce a new topic or delve into a topic further. Use of a guide would give 180 C H N s the flexibility to pursue concerns in certain areas using their own communication style. Also , C H N s who are just beginning to give the telephone calls, can be encouraged, by using a guide, to build a conversation with women instead of focusing only on the listed questions. 5. The addition of the six-week telephone call results in some of the women not receiving the information usually given by the C H N s during the postpartum period because they do not receive the six-week call. To increase consistency of practice, the C H N s are encouraged to view the care they give as a continuum. Whether the call is given at three to four weeks postpartum or continues to be given at six weeks postpartum, the C H N s need to decide how and when postpartum information is given to women and their families. C H N s can ask themselves whether women need to receive a consistent set of information, or whether the choice of what information is given is best left to the discretion of the C H N . These decisions could be translated into guidelines, which would do well to be incorporated into the guide developed for the telephone call. 6. The lack of an established relationship between the C H N providing the call and the woman receiving the call was a concern for some of the women and the C H N s . The C H N caring for a woman during the initial postpartum period would likely know the most about her and could more easily assess whether she would be better served by receiving a telephone call or a face-to-face contact. The C H N ' s comfort in giving the calls would also increase i f they already knew the women they were calling, and thus the building of rapport with the women would be easier. The building of relationship 181 between provider and recipient of care would likely result in greater accuracy of assessment and more effective interventions. 7. The current practice of not scheduling the telephone call is a concern. The women's ability to focus on the call and its value to them is related to when the women are reached. C H N s are advised to schedule the telephone call, or to offer to call women back at a time that is more convenient, and also to inquire about women's preference for face-to-face or telephone contact. 8. Women postpartum suggest that they benefit from having care brought to them instead of their having to venture out to receive it. They are busy people and they generally find it difficult to reach out for assistance to address their health needs. Wi th the current provision of breastfeeding drop-ins and parent-infant drop-ins, there is an expectation by community health nursing that women w i l l be able to attend. A woman who does not seek out services or resources may also be a woman who has needs that a C H N could address. Because of this knowledge, C H N s can now know that they need to initiate care to women in the postpartum period and not to expect that women w i l l be able to reach out i f they have needs. 9. Additional documentation is needed on the process of implementing the call . Currently, the C H N s document the six-week telephone call on the telephone call documentation sheet (Appendix H). While the C H N s do ensure that the health care they give by telephone is recorded to some extent, the C H N s could document the following information on the documentation sheet: the outcomes of previously given care or feedback received; the timing of the contact to the woman (earlier or later than six weeks); how a woman is contacted (telephone or visit); the woman's concerns at 182 the time of contact; the recommendations or referrals made; the information (written or verbal) given or sent; and the need for ongoing follow-up. Nurs ing Educat ion Recommendations in this section pertain to: providing opportunities for skil l development with telephone use in nursing curricula, use of the nursing process when giving care by telephone, inservice education on telephone use for C H N s , and the addition of program evaluation theory and practice to nursing curricula. 1. The challenges C H N s encounter when giving the telephone call, specifically establishing rapport with women by telephone, indicate that development of skil l with telephone use for beginning community health nurses would be an area requiring further attention. Students interested in community health nursing practice should be made aware that telephone use is an important component of practice. The practice of giving health care by telephone is likely to increase given the status of current health care resources. Nursing students with an interest in community health practice w i l l therefore need to gain experience and comfort with doing assessments, establishing rapport, and giving referrals, support, and information by telephone. Students w i l l also need to be made aware of the communication skills (verbal and listening skills) that enhance telephone use. Nursing educators need to incorporate the theory and practice of telephone use in health care into nursing curricula. 2. The application of the nursing process by the C H N s to the telephone call is identified in the evaluation. Given that use of the telephone to give care w i l l l ikely increase in the future, nursing educators would serve nursing students well by incorporating 183 opportunities into the curriculum for them to develop care plans based on the nursing process that use the telephone as a tool to provide health care. 3. Currently some C H N s provide the six-week call more often than others do. A s a result, the ski l l and comfort levels amongst C H N s who make the calls vary. The six-week call as currently provided has some limitations. Women currently receive the call from a small group of C H N s , many of whom are not known, to them. The few C H N s that give the calls gain understanding of the types of skills to use during the telephone call and the types of approaches that help women feel comfortable during the telephone call. Yet, the other C H N s do not have the same opportunity to attain the comfort and skills required for its effective use. It would be helpful for all the C H N s doing the calls to receive information (perhaps by inservice), on the potential of telephone use and on the skil l set needed to provide effective care by telephone. Also , C H N s more experienced with telephone use could be encouraged to share their experiences with the less experienced C H N s . Building a strong team of C H N s to carry out this intervention is recommended. 4. The evaluation highlights the need for C H N s and nursing students to acquire knowledge and experience with program evaluation methods and frameworks to facilitate making improvements to nursing practice. Nursing educators need to incorporate program evaluation theory and practice into nursing curricula. It is suggested that the C H N s pursue inservice on program evaluation specific to community health nursing. 184 Nursing Administration This section contains recommendations that pertain to the influence of the telephone intervention on C H N services, legal requirements for documentation of the call, and viewing the call as part of the continuum of postpartum care. 1. The addition of the six-week telephone call to the practice of the C H N s has important implications. The evaluation reveals that the women were more receptive to having contact with the C H N in future following receipt of the call and the telephone call assists C H N s to identify women who need further support. For example, the evaluation highlights that the telephone call can help the C H N s to identify women at risk for postpartum adjustment difficulties. The women's desire to use the resources of the C H N s in future may mean that the C H N s w i l l need to ensure they are able to respond to the potential increase in service use. The influence of the call on nursing time and staffing requirements needs to be investigated. Time constraints have limited C H N s to being able to make only two attempts to reach a postpartum woman. A s a result, some women postpartum do not receive the call or some women are contacted at times other than at the desired six-week time frame. The time that women postpartum receive the call influences the pertinence and value of the questions the C H N s ask, and it impacts on the consistency of the implementation of the call. Given the potential of the call to alleviate women's concerns, time should be allotted to the C H N caseload to ensure that six-week calls reach all women postpartum. In addition, the C H N s are encouraged to evaluate the cost-effectiveness of the call with respect to the time spent providing the intervention and the outcomes achieved. 185 2. The legal implications of giving care by telephone are not pursued in this study. In particular, additional documentation of the content of the call would provide stronger evidence of the care given. The legal requirements for documentation of the care given by telephone should be determined and included in the telephone guide. 3. A s previously mentioned, the C H N s are encouraged to view the six-week telephone call as a part of their continuum of postpartum care. In doing so it would be prudent for them to review the H B program components in view of the recommendation to incorporate the telephone call into the H B program as a permanent component because changes to these components may become necessary with the addition of the telephone call. Nurs ing Research Suggestions for future nursing research are contained in this section. These relate to: conducting a summative evaluation, obtaining knowledge of the skil l set best suited for telephone use, evaluating the process aspects of the call, exploring the value of relationship between provider and recipient of care by telephone, exploring the concerns of women in the late postpartum period, and obtaining the perspectives of various groups of women towards telephone use. 1. The C H N s do not know exactly how the telephone call w i l l impact each woman and her family. Without the C H N ' s general belief that valuable changes result from the call , the motivation to do the calls (despite a busy schedule) might not exist. For the call 's continued success, C H N s must be able to definitively ascertain the positive changes occurring for the women and their families. The C H N s are encouraged to develop the means to document changes that occur for women and their families and 186 subsequently to conduct a summative evaluation to determine the effectiveness of the call. In particular, investigation into outcomes pertaining to the concepts of anxiety, coping, reassurance, knowledge, motivation, caring, and support, as well as the impact of the call on other family members (particularly partners) would be useful. 2. This study provides a beginning understanding of the most useful skills for C H N s to have when giving care by telephone, but further exploration is needed. The views of the recipients of telephone care should be sought when determining the skil l set that is most useful for providers to have when giving care by telephone. 3. Changes to the process of the intervention w i l l need to be evaluated. For instance, scheduling the call may result in greater satisfaction for the women and it has the potential to change the amount of time C H N s have to complete the calls. There are many areas of the process of implementing the telephone call that could be explored further. The C H N s are advised that not only is the outcome of an intervention important, but the process itself of an intervention holds much value. 4. The importance of relationship between the provider and the recipient of health care by telephone needs further investigation. If care is given by the same C H N for the initial postpartum weeks and for the telephone call, the C H N s could then explore the impact that relationship has on the women's and their own satisfaction with the telephone call. 5. Research that contributes to learning more about the concerns of women postpartum in the late postpartum period, specifically the differences in the interests and needs of primiparous and multiparous women, is encouraged. This is ultimately so that the interventions developed and provided during this time w i l l meet their needs. 187 6. Obtaining the views of teenage mothers, older women (over 36 years), women of cultural groups not represented in this study, and women without partners on telephone use as a means to provide postpartum care is needed. Since each of these groups of women have varying degrees of support during postpartum, knowing whether these women derive similar benefits from the call, when either well supported or lacking support, would be beneficial to understanding the effectiveness of this intervention. In summary, research on telephone use in community health nursing practice is important as C H N s rely extensively on the telephone as a means to give care. Many of the findings in this study would benefit from further examination. Research on telephone use in community health nursing practice needs to be continued so that C H N s can then adjust service delivery to better meet the needs of women postpartum. The perceptions of women postpartum towards use of the telephone by C H N s and the C H N ' s views of the advantages and challenges of telephone use for postpartum care had not previously been explored. Postpartum women's views of community based postpartum care are not yet well understood, and consequently the components of a quality community based postpartum care program are not well identified. This formative evaluation offers an initial picture of both the postpartum women's and the C H N ' s perceptions of telephone use in the postpartum period. The evaluation also identifies the concerns of women postpartum during the six-week period following birth and the impact of the call on these concerns. Giv ing care by telephone offers advantages to both the women and the C H N s . Women are receptive to receiving care by telephone and value receiving contact during the postpartum period. Although challenges arise when giving 188 care by telephone, C H N s can provide postpartum care successfully using the telephone, in the form of assessment, support, information, and referral, often addressing the concerns women express. This study highlights those aspects of the telephone call intervention that women and the C H N appreciate and those that require modification. It also creates a beginning understanding of the necessary components of a quality community based program for postpartum care and provides direction and recommendations for telephone use in the postpartum period for community health nursing. 189 R E F E R E N C E S American Academy of Ambulatory Care Nursing (1997). Telephone nursing practice administration and practice standards. Pitman, N J : A . J . Jannetti, Inc. American Academy of Pediatrics Corrunittee on Fetus and Newborn, American College of Obstetricians and Gynecologists Committee on Obstetrics (1992). Guidelines for perinatal care (3 r d ed.). American Academy of Pediatrics. 108-109. American Academy of Pediatrics, Committee on Fetus and Newborn (1995). Hospital stay for healthy term newborns. Pediatrics, 96. 788-790. Anderson, D . M . , Marcus, A . C . , Duffy, K . , & Hallet, C . D . (1992). Cancer prevention counseling on telephone helplines. Public Health Reports, 107 (3) , 278-283. Anderson, V . N . , Fleming, A . S. , & Steiner, M . (1994). Mood and the transition to motherhood. Journal of Reproductive and Infant Psychology, 12 (2) , 69-77. Arnold, L . S . , & Bake well-Sachs, S. (1991). Models of perinatal home follow-up. Journal of Perinatal Neonatal Nursing, 5 (1) , 18-26. Bake well-Sachs, S . , & Persily, C. A . (1995). Perinatal partnerships in practice: A conceptual framework for linking care across the childbearing continuum. Journal of Perinatal Neonatal Nursing, 9 ( 1 ) , 31-37. Ba l l , J. A . (1994). Reactions to motherhood. The role of postnatal care (2nd ed.). Cheshire, England: Books for Midwives. Bartlett, E . E . (1990). The telephone: A n under-exploited patient education vehicle. Patient Education and Counseling, 15 (3) , 215-216. Beck, C . T. (1991). Early postpartum discharge programs in the United States: A literature review and critique. Women and Health, 17 (1) , 125-138. Beck, C . T. (1995). Perceptions of nurses' caring by mothers experiencing postpartum depression. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24 (9) , 819-825. Bent, K . N . , Keeling, A . , & Routson, J. (1996). Home from the P I C U : Are parents ready? The American Journal of Maternal Chi ld Nursing, 21 (2) , 80-84. Bertera, E . M . , & Bertera, R. L . (1981). The cost-effectiveness of telephone vs. clinic counseling for hypertensive patients: A pilot study. American Journal of Public Health, 71 (6) , 626-628. 190 Bostrom. J . , Caldwell , J . , McGuire , K . , & Everson, D . (1996). Telephone follow-up after discharge from the hospital: Does it make a difference? Applied Nursing Research, 9 (2) , 47-52. Bourgoin, G . L . , Lahaie, N . R. , Rheaume, B . A . , Berger, M . G . , Dovig i , C . V . , Picard, L . M . , & Sahai, V . F . (1997). Factors influencing the duration of breastfeeding in the Sudbury region. Canadian Journal of Public Health, 88 (4) , 238-241. British Columbia Reproductive Care Program (1997). Guidelines for perinatal care. Vancouver, B C : Author. Brooten, D . (1995). Perinatal care across the continuum: Early discharge and nursing home follow-up. Journal of Perinatal and Neonatal Nursing, 9 (1) , 38-44. Brooten D . , Kumar, S . , Brown, L . P . , Butts, P . , Finkler, S. A . , Bakewell-Sachs, S . , Gibbons, A . , & Delivoria-Papdopoulos, M . (1986) . A randomized clinical trial of early hospital discharge and home follow-up of very low birth weight infants. The New England Journal of Medicine, 315 (15), 934-939. Brooten, D . , Naylor, M . , Brown, L . , York. R . , Hollingsworth, A . , Cohen, S . , Roncoli , M . , & Jacobsen, B . (1996). Profile of postdischarge rehospitalizations and acute care visits for seven patient groups. Public Health Nursing, 13 (2) , 128-134. Brown, S. G . , & Johnson, B . T. (1998). Enhancing early discharge with home follow-up: A pilot project. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27 (1) , 33-38. Buhler, L . , & Carty, E . (1997). Healthy Beginnings postpartum program evaluation summary. Vancouver, B C : Vancouver/Richmond Health Board. Burgess, E . (1966). Discussion. In C . Shaw, The Jack Roller (pp. 185-197). Chicago, JJL: University of Chicago Press. Byrd, M . E . (1997). A typology of the potential outcomes of maternal-child home visits: A literature analysis. Public Health Nursing, 14 (1) , 3-11. Cadman, L . (1995). The concerns and coping strategies of new mothers in the early postpartum period. Unpublished master's thesis, University of British Columbia, Vancouver, British Columbia. Canadian Paediatric Society & Society of Obstetricians and Gynaecologists of Canada. (1996, October). Early discharge and length of stay for term birth. (No.22). Ottawa, O N : Author. 191 Chapman, J. J . , Macey, M . J . , Keegan, M . , Borum, P . , & Bennett, S. (1985). Concerns of breast-feeding mothers from birth to four months. Nursing Research, 43 (6) 374-377. Colon, Y . (1996). Telephone support groups. Cancer Practice, 4 (3) , 156-159. Dalby, D . M . , Wil l iams, J. I . , Hodnett, E . , & Rush, J. (1996). Postpartum safety and satisfaction following early discharge. Canadian Journal of Public Health, 87 (2) , 90-94. Davidson, L . (1991) . On call. Nursing Times, 87 (6), 25. Donaldson, N . E . (1988). Effect of telephone postpartum follow-up: A clinical trial. Unpublished doctoral dissertation, University of California, San Francisco. Donaldson, N . E . (1991). A review of nursing intervention research on maternal adaptation in the first 8 weeks postpartum. Journal of Perinatal and Neonatal Nursing, 4 (4) , 1-11. Driscoll , J. W . (1990). Maternal parenthood and the grief process. Journal of Perinatal Nursing, 4 (2) , 1-10. Dwyer, J. J. M . , & Makin , S. (1997). Using a program logic model that focuses on performance measurement to develop a program. Canadian Journal of Public Health, 88 (6) , 421-425. Edmonson, M . B . , Stoddard, J. J . , & Owens, L . M . (1997). Hospital readmission with feeding-related problems after early postpartum discharge of normal newborns. Journal of the American Medical Association, 278 (4) , 299-303. Edwards, N . C. , Mackay, P. G . , & Schweitzer, I. (1992). The provision of public health nursing follow-up services for postnatal clients in Ontario: A cross-sectional survey. Canadian Journal of Public Health, 83 (3) , 200-202. Edwards, N . C . , & Sims-Jones, N . (1997). A randomized controlled trial of alternative approaches to community follow-up for postpartum women. Canadian Journal of Public Health, 88 (2) , 123-128. Elmer, E . , & Maloni , J. A . (1988). Parent support through telephone consultation. Journal of Maternal-Child Nursing, 17 (1), 13-23. Erickson, D . (1992). Postnatal experiences of North Shore women. North Vancouver, B C : North Shore Health. Evans, C. J. (1995). Postpartum home care in the United States. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24 (2) , 180-186. 192 Field, P. A . , & Houston, M . R. (1991). Teaching and support: nursing input in the postpartum period. International Journal of Nursing Studies, 28 (2) , 133-144. Fishbein, E . G . & Burggraf, E . (1998). Early postpartum discharge: How are mothers managing? Journal of Obstetric, Gynecologic, and Neonatal Nursing, 27 (2) , 142-148. Foxman, R . , Moss, P . , Bolland, G . , & Owen, C. (1982). A consumer view of the health visitor at six weeks postpartum. Health Visitor, 55 (6) , 302-308. Gardner, D . L . (1991). Fatigue in postpartum women. Applied Nursing Research, 4 (2) , 57-62. Gilhooly, J. & Hellings, P. (1992). Breast-feeding problems and telephone consultation. Journal of Pediatric Health Care, 6 (6) , 343-348. Gjerdingen, D . K . , & Chaloner, K . (1994). Mothers' experience with household roles and social support during the first postpartum year. Women & Health, 21 (4), 57-74. Gjerdingen, D . K . , & Fontaine, P. (1991). Family-centered postpartum care. Family Medicine. 23 (3) , 189-193. Griepsma, J . , Marcollo, J . , Casey, C . , Cherry, F . , Vary, E . , & Walton, V . (1994). The incidence of postnatal depression in a rural area and the needs of affected women. Australian Journal of Advanced Nursing, 11 (4) , 19-23. Guba, E . G . , & Lincoln, Y . S. (1985). Naturalistic inquiry. Beverly Hi l l s , C A : Sage. Guba, E . G . , & Lincoln, Y . S. (1989). Fourth generation evaluation. Newbury Park, C A : Sage. Gupton, A . , & M c K a y , M . (1995). The Canadian perspective on postpartum home care. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 24 (2) , 173-179. Hagopian, G . A . , & Rubenstein, J. H . (1990). Effects of telephone call interventions on patients' well-being in a radiation therapy department. Cancer Nursing, 13 (6) , 339-344. Hampson, S. J. (1989). Nursing interventions for the first three postpartum months. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 18 (2) , 116-121. Harrison, M . J . , & Hicks, S. A . (1983). Postpartum concerns of mothers and their sources of help. Canadian Journal of Public Health, 74 (5) , 325-328. 193 Jones, L . C . , Maestri, B . O . , & M c C o y , K . (1993). Why parents use the warm line. The American Journal of Maternal Chi ld Nursing, 18 (5) , 258-263. Julian, D . A . , Jones, A . , & Deyo, D . (1995). Open systems evaluation and the logic model: Program planning and evaluation tools. Evaluation and Program Planning, 18 (4) , 333-341. Keeling, A . W . , & Dennison, P. D . (1995). Nurse-initiated telephone follow-up after acute myocardial infarction: A pilot study. Heart & Lung, 24 (1) , 45-49. Krueger, R. A . (1994) . Focus groups. A practical guide for applied research (2 n d ed.). Thousand Oaks, C A : Sage. Lechner, L . , & DeVries, H . (1996). The Dutch cancer information helpline: Experience and impact. Patient Education and Counseling, 28 (2) , 149-157. Lee, K . , & Perlman, M . (1996). The impact of early obstetric discharge on newborn health care. Current Opinion in Pediatrics, 8 (2) , 96-101. Lee, N . (1997). Observations based upon multiple telephone contacts with new breastfeeding mothers. Journal of Human Lactation, 13 (2) , 147-150. Leung. E . (1985). Family support and postnatal adjustment. Bulletin of the Hong Kong Psychological Society. 14, 32-46. L i u , L . L . , Clemens, C . J . , Shay, D . K . , Davis, R. L . , Novack, A . H . , (1997) . The safety of newborn early discharge. The Washington state experience. Journal of the American Medical Association. 278 (4) , 293-298. Logsdon, M . C . , Birkimer, J. C . , Barbee, A . P. (1997). Social support providers for postpartum women. Journal of Social Behavior and Personality, 12 (1) , 89-102. Maisels, M . J . , & Kring, E . (1995). Early discharge from the newborn nursery: effect on scheduling of follow-up visits by pediatricians. Pediatric Research, 37, 221 A . Marcus, A . C . , Cella, D . , Sedlacek, S . , Crawford, E . D . , Crane, L . A . , Garrett, K . , Quigel, C . , & Gonin, R. (1993). Psychosocial counseling of cancer patients by telephone: A brief note on patient acceptance of an outcall strategy. Psycho-Oncology, 2, 209-214. May, K . A . , & Mahlmeister, L . R. (1990). Comprehensive maternity nursing (2nd ed.). Philadelphia, P A : J .B. Lippincott. McLean, P. (1998). Telephone advice: Is it safe? The Canadian Nurse, 94 (8) , 53-54. 194 Mil l igan , R. A . , & Pugh, L . C. (1994). Fatigue during the childbearing period. Annual Review of Nursing Research, 12, 33-49. Mis r i , S. (1995). Shouldn't I be happy? Emotional problems of pregnant and postpartum women. New York, N Y : The Free Press. Morsback, G . , & Gordon, R. M . (1984). The relationship between maternity blues and symptoms of puerperal (atypical) depression six to eight weeks after childbirth. Psychologia, A n International Journal of Psychology in the Orient, 27 (3) , 171-175. Morse, J. M . (1998). Validity by committee. Qualitative Health Research, 8 (4) , 443-444. Moyer, A . , Verhousek, H . , & Wilson, V . L . (1997). Facilitating the shift to population-based public health programs: Innovation through the use of framework and logic model tools. Canadian Journal of Public Health, 88 (2) , 95-98. N A A C O G Committee on Practice. (1986). Postpartum follow-up, N A A C O G O G N nursing practice resource. Washington, D C : Author. Norr, K . F . , & Nacion, K . W . , & Abramson, R. (1989). Early discharge with home follow-up: Impacts on low-income mothers and infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 18 (2), 133-141. Oda, D . S. , Fine, J. I. , & Heilbron, D . C. (1986). Impact and cost of public health nurse telephone follow-up of school dental referrals. American Journal of Public Health, 76 (11) , 1348-1349. Olds. S. B . , London, M . L . , & Ladewig, P. W . (1996). Maternal newborn nursing. A family-centered approach (5th ed.). Menlo Park, C A : Addison-Wesley. Patton, M . Q. (1987). How to use qualitative methods in evaluation. Newbury Park, C A : Sage. Patton, M . Q. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park, C A : Sage. Patton, M . Q. (1997). Utilization-focused evaluation (3rd ed.). Thousand Oaks, C A : Sage. Pedersen, C . A . , Stern, R. A . , Pate, J . , Senger, M . A . , Bowes, W . A . , & Mason, G . A . (1993). Thyroid and adrenal measure during late pregnancy and the puerperium in women who have been major depressed or who become dysphoric postpartum. Journal of Affective Disorders, 29 (2+3). 201-211. 195 Polinsky, M . L . , Fred, C . , & Ganz, P. A . (1991). Quantitative and qualitative assessment of a case management program for cancer patients. Health and Social Work, 16 (3), 176-182. Pridham, K . F . , & Chang, A . S. (1992). Transition to being the mother of a new infant in the first 3 months: maternal problem solving and self-appraisals. Journal of Advanced Nursing, 17 (2) , 204-216. Rainey, L . C . (1985). Cancer counseling by telephone helpline: The U C L A psychosocial cancer counseling line. Public Health Reports, 100 (3) , 314-315. Ramos, M . C . (1989). Some ethical implications of qualitative research. Research in Nursing & Health, 12 (1) , 57-63. Rao, J. N . (1994). Fol low up by telephone. British Medical Journal, 309 (6968), 1527-1528. Registered Nurses Association of British Columbia (1999). When nurses give telephone advice: Guidelines for practice. Vancouver, B C : Author. Rhode, M . A . , & Groenjes-Finke, J. M . (1980). Evaluation of nurse-initiated telephone calls to postpartum women. Issues in Health Care of Women, 2 (2), 23-41. Rossi, P. H . , & Freeman, H . E . (1993). Evaluation: A systematic approach (5th ed.). Newbury Park, C A : Sage. Rovers, R . , & Isenor, L . (1988). Mothers' perceptions and use of community health services during the postpartum. Public Health Nursing, 5 (4) , 193-200. Ruchala, P. L . ,& Halstead, L . (1994). The postpartum experience of low-risk women: A time of adjustment and change. Maternal-Child Nursing, 22 (3) , 83-89. Rush, B . , & Ogborne, A . (1991). Program logic models: Expanding their role and structure for program planning and evaluation. The Canadian Journal of Program Evaluation, 6 (2) , 95-106. Rush, J. P . , & Ki tch , T. L . (1991). A randomized, controlled trial to measure the frequency of use of a hospital telephone line for new parents. Birth, 18 (4) , 193-197. Rush, J. P . , & Valaitis, R. K . (1992). Postpartum care: Home or hospital? Canadian Nurse, 88 (5) . 29-31. Sandelowski, M . (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8 (3) , 27-37. 196 Sandelowski, M . , Davis, D . H . , & Harris, B . G . (1989). Artful design: Writ ing the proposal for research in the naturalist paradigm. Research in Nursing & Health, 12 (2) , 77-84. Siegel, S. (1992). Telephone follow-up programs as creative nursing interventions. Pediatric Nursing, 18 (1) , 86-89. Simpson, K . R . , & Creehan, P. A . (1996). Perinatal nursing. Philadelphia, P A : J .B. Lippincott. Tobert, S. R. (1986). Concerns of mothers in the first month postpartum. Unpublished master's thesis, University of British Columbia, Vancouver, B C . Tulman, L . , Fawcett, J. , Groblewski, L . , & Silverman, L . (1990). Changes in functional status after childbirth. Nursing Research, 39 (2), 70-75. Valaitis, R. , Tuff, K . , & Swanson, L . (1996). Meeting parents' postpartal needs with a telephone information line. The American Journal of Maternal Chi ld Nursing, 21 (2) , 90-95. Vancouver Health Department, B . C . Women's Hospital, & St. Paul's Hospital. (1995). Healthy Beginnings community postpartum service expansion. Vancouver, B C : Author. Wasson, J . , Gaudette. C . , Whaley, F . , Sauvigne, A . , Baribeau, P . , & Welch, G . (1992). Telephone care as a substitute for routine clinic follow-up. Journal of the American Medical Association, 267 (13), 1788-1793. Weinberg, S. H . (1994). A n alternative to meet the needs of early discharge: The Tender Beginnings postpartum visit. The American Journal of Maternal Ch i ld Nursing, 19 (6) , 339-342. Wen, S. W . , L i u , S . , & Fowler, D . (1998). Trends and variations in neonatal length of in-hospital stay in Canada. Canadian Journal of Public Health, 89 (2) , 115-119. White, E . (1992). Early maternity discharge program guidelines. Victoria, B C : Ministry of Health. Wilkerson, N . N . (1996). Appraisal of early postpartum discharge programs. The Journal of Perinatal Education, 5 (2) , 1-5. Wilkins , V . C . (1993). Pediatric hotline. Journal of Nursing Administration, 23 (3) , 26-28. Wil l iams, L . R . , & Cooper, M . K . (1996). A new paradigm for postpartum care. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25 (9) , 745-749. 197 Woollett, A . , & Parr, M . (1997). Psychological tasks for women and men in the postpartum. Journal of Reproductive and Infant Psychology, 15 (2) , 159-183. 198 Appendix A : C H N Telephone Intervention at Six Weeks Postpartum Many new parents have asked to be called again at 6-8 weeks: -How are things going with you and your baby? (1) -Are you breast or bottle-feeding? (2) -If bottle-feeding, did you start out this way? (3) -If breast-feeding are you aware that this is a growth spurt time for your baby? (4) Anticipatory Guidance re: growth and development of babe. -Have you made an appointment for your baby's first immunization? (5) -Would you like me to book you into a baby clinic? (6) Some moms feel a bit lonely when they are home with a newborn, especially i f there is no family support around. -Has this been true for you? (7) We have some great support groups that provide information and networking with other new parents. Many long lasting friendships have developed. -Are you aware of our support groups at Kiwassa and North Health Unit? (8) -Would you like me to mail you some information about the groups? (9) Some Women experience postpartum blues. -Has this been happening to you? (10) If Multiparous: -How is your child reacting to the new baby? (11) -Do you have any questions I can help you with at this time? (12) -Has this call been helpful? (13) North Health Unit, Vancouver Health Department (1996). Questions re: 6-week call. Vancouver, B C : Author. 199 Appendix B : Participant Information Sheet Participant's Code Number Participant's First Name/Phone Number Infant's Birthdate Date of Hospital Discharge Date of Initial Family Contact Date and type (phone/visit) of follow-up contacts to family: : Date of Six Week Telephone Cal l Were all six-week questions covered during the call? Yes/No If no, List by numbers those not addressed: Date Letter Sent: Date Consent Received: C H N offering telephone call (code) Demographic Information Age Marital Status Primiparous/Multiparous Ethnic Background First Language Type of Birth: Vaginal/ Cesarean Childbirth Education: Yes/No Age of other children Education level: Grade 12 Some post-secondary__ University Degree 201 I understand that my participation in the study is voluntary and that I may withdraw from the study at any time without jeopardizing any future health care. I acknowledge receiving a copy of the letter and the consent form for my records. I consent to participate in this study: Participant Signature Date Please print your name Telephone Number 203 I understand that my participation in the study is voluntary and that I may withdraw at any time without jeopardizing my position. I have received a copy of the letter and the consent form for my records and I consent to participate in this study. Participant Date Please print your name Telephone Number 204 Appendix E : Interview Guide (Postpartum Women) 1) Introduce researcher 2) Clarify participant's questions about the intent of the study or interview process 3) Discuss the interview focus: to understand, postpartum women's views about the usefulness of the telephone intervention, the concerns women discussed with the C H N , the impact of the intervention for women and their families, and to gain their suggestions for changes to the telephone intervention A ) The content and process of the six week telephone call with the C H N : (Areas to probe) Please tell me about your conversation with the C H N at six weeks postpartum What were your concerns and challenges at the time of the call? What would you have done about those concerns i f the C H N had not called? How comfortable did you feel in discussing your concerns with the C H N ? - What helped you feel comfortable in discussing your concerns? - What would have helped you feel more at ease in talking about your concerns? D i d you have sufficient time during the call to discuss your concerns? If not, why? - Were your concerns explored to your satisfaction during the call? - Were there any concerns that remained after the call? If so, - What did you do about them? - What did you like about the telephone contact? - Was there anything you did not like about the call? B) The helpfulness of the telephone intervention: How helpful was the telephone contact for you or your family? - How do you feel about the use of the telephone to provide postpartum care? C) The changes resulting for women and their families following the call: - What has changed for you, your infant, or your family as a result of receiving the call? - Were there concerns that you discovered during the call that you have acted on since? - Are there issues you are addressing now? - What resources or supports are you using for these? 205 Prior to the telephone call, what were your impressions of the care C H N s offered to you after you had your baby? - Have your views about C H N s changed as a result of receiving the telephone call? How? How would you feel about receiving or initiating further contact with the C H N ? D) Suggestions to improve the telephone intervention: What changes would you suggest to improve the telephone intervention? Eg . Content of call , timing or frequency of the call? - Would you prefer nurse-initiated or participant initiated telephone contact or personal contact from a C H N after having your baby? - When would you have wanted the C H N to contact you? - Would you suggest the telephone contact be offered to all women? Why? - Would you want to receive the telephone contact again at six weeks postpartum i f you were to have another baby? The demographic information on the participant information sheet w i l l be completed at the end of the telephone interview. Women wi l l be asked whether the researcher may contact them again to clarify the information obtained. 206 Appendix F: Focus Group Guide (CHN) 1) Introduction of researcher 2) Clarification of questions regarding the intention of the study or focus group 3) Discuss the focus group purpose, to obtain C H N ' s views about the intervention's benefits, shortcomings, and areas for improvement 4) Discuss process of focus group session 5) Introduction of participants and sharing of experiences (brief) in providing the telephone intervention to women and their families A ) Benefits of the telephone intervention for women and their families: - What are your impressions of the benefits for women and their families from the telephone call? (infant feeding/health, maternal transition, family adjustment, resource use) In your experience, what changes have occurred for women and families following the telephone call? - What changes for women and families do you anticipate w i l l occur as a result of the telephone contact? B) The benefits of offering the telephone intervention for the C H N role: - What are the benefits for the C H N role of providing the telephone intervention? - What has changed for you as a C H N , as a result of implementing the telephone call? C) The challenges of offering the telephone intervention at six weeks postpartum: - What difficulties have you encountered when giving the call to women and their families? (infant feeding/health, maternal adjustment, family adjustment, community resources) How does the telephone intervention affect the postpartum services you provide to women, infants, and families? D) Improvements for the Telephone Intervention: How would you suggest the telephone intervention be improved? Eg . Content of the call, frequency and timing of the call, and the recipients (families) of the call? The study's purpose is to gain an understanding of your perspectives on the telephone intervention. Have I missed anything you would like to share now? 207 The key points of the focus group discussion w i l l be summarized and participants w i l l be asked i f this is an adequate summary, i f not, to add their comments. Participants w i l l be asked i f the researcher may contact them again to clarify information obtained. 208 Appendix G : Community Health Nurses Information Sheet Do you currently provide H B program care? Yes/No When did you begin offering the telephone intervention? Is your involvement in the telephone program, with English speaking families Both English and non-English speaking families Only non-English speaking families Average number of telephone contacts you make per month Age: Education Level: R N B S N M S N Master's Student Other Number of years practicing as a R N Number of years working in community health nursing, Prevention: Home Care C D C Other C H N Code Number 209 Appendix H : Telephone Cal l Documentation Sheet Healthy Beginnings Six Week Follow-up Client Name: Phone: Baby Name: Birthdate: Pul l Chart Yes N o Multiparous Yes N o (circle one) (circle one) Notes: C H N : Date: North Health Unit, Vancouver Health Department (1996). Healthy Beginnings six week follow-up. Vancouver, B C : Author.
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
For non-commercial purposes only, such as research, private study and education. Additional conditions apply, see Terms of Use https://open.library.ubc.ca/terms_of_use.
Graduate
Evaluation of a telephone intervention in community health nursing postpartum care
Text