P rinciples and practice

Maternity-Patient Teaching-A Nursing Prioritv

d

BONNIE BROWN, RN, BS

A step-by-step process followed in developing and implementing a comprehensive maternity-patient teaching program is described, An overview of the content of the teaching program also is presented, and the importance of evaluating patient teaching is emphasized.

Meeting new parents’ knowl- edge needs has become an increas- ingly important nursing priority in obstetrics in recent years. The fo- cus on maternity-patient teaching and discharge planning is due to 1) increased acknowledgment and understanding by medical and nursing personnel of skills re- quired of new parents and 2) in- creased public awareness of the importance of health care educa- tion.

Society has changed gradually from an extended family concept to a nuclear family concept, and family size has changed from large to small. During the time when the extended family was predominant, girls learned to care for infants by caring for numerous younger rela- tives. Also, almost all the mothers had their mothers and grand- mothers to assist them with infant care at home. As families gradual- ly have become smaller in size, as a result of economic, social, and cul- tural factors, many women of childbearing age have never cared for a newborn. In addition, be- cause of increased mobility of the family unit in today’s society, many

new parents do not have in-home assistance from their parents in learning infant care skills. Thus, the responsibility of teaching these skills to new parents rests with health care professionals.

The importance of a new moth- er receiving proper care, rest, and nutrition after she returns home from the hosptial has been recog- nized. Expectant mothers no long- er work in fields until the moment of delivery and then return almost immediately to their work, as their grandmothers sometimes did. Health care professionals have be- gun to recognize the importance of adequate postpartal care. Prop er care is important, especially during the first six weeks after delivery, to allow the body to ad- just to changes as it rapidly returns to the nonpregnant state. Al- though having a baby is a natural event, many changes occur in a woman’s physical, psychological, and social being. Time and care must be provided to allow these adjustments to occur in a healthy way.

Having and caring for an infant is no longer considered totally the

woman’s responsibility. Today, ex- pectant fathers are assuming an active role in the childbearing process and care of the newborn. However, they, too, must be helped with their roles. Through- out the birth experience, the fa- ther is taught that he has an im- portant role as a primary support person for the mother. Fathers are encouraged to attend infant care classes and to participate actively in individual instruction sessions.

For many years, patient-teach- ing coordinators at Mount Carmel Medical Center in Columbus, Ohio, functioned as full-time staff nurses with a secondary responsi- bility for patient teaching. The teaching was accomplished only when the patient census was SUB- ciently low enough to allow the nurses time to offer minimal in- structions about infant care and a mother’s postdischarge care. The teaching was given a low priority and, at best, instructions were giv- en only to primiparas.

Planning

In view of the impact of recent social changes on the family, the

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need for more comprehensive ma- ternity-patient teaching to all par- ents, not just primiparas, became more evident. It was recognized that steps needed to be taken to fulfill this professional obligation to parents. The first step in ex- panding the patient-teaching pro- gram was to approach hospital ad- ministration with the idea that educating new parents was impor- tant enough to be done full-time. This required creation of a nurs- ing position-a patient-teaching and discharge-planning coordina- tor, whose primary responsibility would be to develop, implement, and evaluate the effectiveness of a comprehensive patient-teaching program. This coordinator’s sec- ondary reponsibility would be to work with the maternity staff and the Discharge-Planning Depart- ment to ensure proper completion of continuity-of-care referrals, as patients’ needs warranted. Hospi- tal administrative approval for the position was granted.

To help ensure the program’s continuity, two part-time patient- teaching and discharge-planning coordinators were hired and scheduled, so that at least one was available every day on either the day or evening shift. To provide optimum availability to new par- ents, one coordinator would work during the day, four days a week, and the other coordinator would work three evenings a week.

The next step was to develop a comprehensive patient-teaching program that would meet the needs of new parents. Ideally, such a program would use all available methods and media. The coordinators gave physicians an opportunity for input regarding the specific instructions they viewed as important for parents.

The teaching program’s objec- tives, lesson plans, and printed materials were presented to the physicians. The medical director of the nurseries, who had assisted

the coordinators in developing the program, made the presentation and endorsed the proposal. Al- most all physicians were familiar with fragmented portions of the program and responded positively to the integrated approach. They supported its implementation and continue to encourage participa- tion. Hospital patient-education committees provided assistance in developing an acceptable frame- work for the program. Audiovisu- al services personnel were consult- ed in selecting appropriate films for use on closed-circuit television.

Before implementation of the program, the third step was to reeducate health care personnel to the concept that skills required by new parents in caring for a new- born are learned skills, and not instinctive. Educational programs for obstetrical nursing services were conducted. The program in- formed the staff about the objec- tives of the teaching program and what their responsibilities would be during the implementation and evaluation of the program. Cur- rent obstetrical trends, such as childbirth education, family-cen- tered maternity care, bonding and psychological adaptation to par- enting, were discussed to empha- size the effect childbearing has on the family unit. Open discussion allowed the staff to express feel- ings regarding the teaching pro- gram and current trends and to ask questions. Discussion questions clarified their specific teaching re- sponsibilities and the role of the patient-teaching coordinator. The staff responded positively to this presentation and actively assumed their roles in the program’s imple- mentation.

Implementation

After obtaining input from the relevant health care professionals, objectives and lesson plans for the teaching program were formulat-

ed. An organized method of pro- viding comprehensive instructions to all mothers as a standard part of postpartum care was developed. The teaching program included individualized nurse-patient in- structions about the infant and self-care, group demonstrations, and audiovisual presentations. A manual was written designed to serve not only as an orientation guide to the hospital for prospec- tive maternity patients but also as a teaching tool. It contains informa- tion about the hospital and the maternity department, sugges- tions about preparation for hospi- talization, medical terminology, in- fant care, mother’s hospital and home care, and what parents can expect at home. This manual is given to expectant parents in the physician’s office and the hospital’s prenatal clinic during the last tri- mester of pregnancy. Mothers are instructed to bring the manual with them when they are admitted to the hospital.

Nurses in the maternity depart- ment conduct tours to orient ex- pectant parents to the hospital’s physical setting. During the tour, departmental policies and proce- dures are explained. The tours are designed to decrease the prenatal anxiety and apprehension experi- enced by almost all expectant cou- ples. Expectant grandparents are encouraged to attend the tours so that they feel included in the birth- ing process.

When expectant parents are ad- mitted to the hospital, breathing and relaxation techniques are taught or reinforced to assist the mother during labor and delivery. Questions from parents are en- couraged and answers are given.

After the infant is born, the new parents are invited to spend as much time with the infant as the infant’s and mother’s conditions allow. This bonding experience continues from the delivery room to the special-care recovery unit.

12 JanuaryIFebruary 1982 JOGN Nursing

Infant care demonstrations are given daily, allowing new parents to attend if they wish and when the mother feels well enough to do so. Statistics have proved this to be accepted enthusiastically by the new parents. During the two years since its implementation, 70% of the women delivering at the hos- pital attended the infant care dem- onstrations.

The nursing staff, working closely with the infant care physi- cians, instruct mothers on how to meet the infant’s nutritional needs. During infant feedings, as- sistance is offered to mothers re- garding initiation of breast- feeding, formula preparation, position for feedings, and burping techniques.

Programs on infant care are of- fered daily on closed-circuit televi- sion, with step-by-step techniques regarding breastfeeding, formula preparation, and infant bathing; program guides are provided. The programs are revised periodically as new techniques on infant care become available.

Nursing personnel discuss inte- gration of the infant into the fam- ily unit with mothers who have other children. To promote fur- ther the family-centered maternity care concept, sibling visitation is offered, which allows children at home to see and visit their mother while she is in the hospital. Also, sibling visitation gives children an early introduction to the newborn.

Approximately two weeks after discharge, nurses call each mother to answer her questions and to determine the effectiveness of the teaching program. When nursing personnel identify a mother who will need assistance in the home, a public-health referral is initiated. Although home visits by hospital nurses to all mothers postdis- charge would be ideal, such visits are not possible within the frame- work of the hospital’s policies and organizational structure.

I)ocumentation of Patient Teaching

Instruction to new parents is im- portant, as is documentation that the teaching was completed. Docu- mentation fulfills requirements set by the Joint Commission for Ac- creditation of Hospitals and indi- vidual states’ hospital standards. It is a communication tool for co- workers and provides assurance to hospital management of teaching performance. The documentation tool should be designed so that it shows what was taught and when, and the learner’s response; there should be a place for the instruc- tor’s signature. Evaluation of the effectiveness of the teaching can be achieved through a variety of methods: return demonstrations, patient questions, patient respons- es, and nurses’ observation of non- verbal communication during the teaching sessions.

To fulfill the documentation requirements, the Postpartum- Teaching and Discharge-Planning Form (available from the author) was designed. This form is com- pleted for every mother who deliv- ers at the hospital, and remains as a legal record.

Staff educational programs were conducted to introduce the form, emphasize its importance, and en- sure that it be completed properly for each maternity patient. Staff members questioned the need for extensive documentation, saying it would be time-consuming and an extra load on their already busy schedules. Staff resistance to change was evident; however, resistance diminished as the form’s value as a communication tool was recognized.

The patient-teaching and dis- charge-planning coordinator sum- marizes the documentation on each form and works closely with nurses to ensure consistent docu- mentation quality. Patients are vis- ited the day of discharge to fur-

ther confirm that the teaching was completed. This visit serves to evaluate how accurately the pa- tient learned the instructions pre- sented.

Summary

The overall positive response of the parent participants has validat- ed the utility of the program. Fu- ture program expansion and revi- sion will be based on social and technological change. Participant responses to the program will be monitored continually to deter- mine whether their needs are be- ing met. The program clarified the role nursing personnel have in teaching maternity patients. It serves to increase the new parents’ self-confidence in being able to adjust to their new roles.

One possible future expansion of the program might be post- discharge group discussion ses- sions, supervised by nursing per- sonnel. During those sessions, mothers could discuss feelings that they are experiencing, any dif€i- culties they may have adapting to their new roles, and other topics they feel are relevant. Nurses would attend these sessions to serve as resource persons and group facilitators.

The need for patient teaching in obstetrics is being recognized in- creasingly as a priority by health care professionals in the field of maternakhild health. A concise and accurate means of documen- tation is necessary to ensure that consistent, comprehensive instruc- tions are given to all new parents.

Acknowledgment

The author wishes to acknowl- edge the assistance of Nancy A. Brunner, RN, MS. Bibliography Kelly LY. Dimensions of professional

nursing. New York: MacMiUan Pub- lishing, 1975:119-35; 156-64.

Marriner A. The nursing process: a scientific approach to nursing care.

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St. Louis: CV Mosby, 1979: 133-47. Pohl ML. The teaching function of the

nursing practitioner. Dubuque: Wm C Brown, 1978.

Schaefer MJ. Toward a full profession of nursing: the challenge of the edu- cator’s role. J Nurs Educ 1972; 1 1 ~39-45.

Whitehouse R. Forms that facilitate patient teaching. Am J Nurs 1979;79: 1227-9. Bonnie Brown is a maternity-patient teach-

ing and discharge-planning coordinator at Mount Carmel Medical Center in Columbus, Ohio, Ms. Brown, who has served as a staff nurse at Ohio State University Hospitals, earned her BS from Ohio State Universty.

Address for correspondence: Bonnie Brown, RN, 86 Determine Lane, Pa- taskala, OH 43062.

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14 JanuaryIFebruary 1982 JOGN Nursing