Evaluating Postpartum Home Visits By Student Nurses
Jennifer Burns-Vandenberg, BSN, RN
This research study evaluated: (1) whether problems identified by student nurses during postpartum home visits were consistent with those described in the postpartum literature and (2) whether interventions utilized by student nurses during postpartum home visits were consistent with interventions recommended in the postpartum literature. The sample for the secondary data analysis consisted of eleven Omaha assessment databases for families with a mother who was no more than 6 months postpartum. Nursing students identified all of the fifteen problems identified in the postpartum literature, plus additional problems not found in the postpartum literature. Nursing students interventions far exceeded those found in the literature. Results strongly support the value of theory-based assessments and the importance of evaluation research regarding postpartum interventions.
Description of the Problem: Postpartum home visits have traditionally focused on the physical recovery of mothers and infants using a medical model systems approach to assessment (Beger & Cook, 1998). Nursing students are schooled in theory-based assessments such as the Omaha tool (Martin & Scheet, 1992), with far more comprehensive assessments than traditional medical models. The purpose of this study was to evaluate the postpartum nursing problems identified and interventions derived by nursing students from the Omaha assessment tool in terms of their correspondence to postpartum nursing problems and interventions described in the postpartum literature.
Recent changes in health care delivery, with an emphasis on cost containment, have drastically shortened the postpartum hospital stay for new mothers and their infants. While the shortened hospital stay may represent significant cost savings for third party payers, it does not decrease the amount of patient education and support that must be provided to assure the health and safety of both mother and infant in the early postpartum months (Scott, DiSaia, Hammond, & Spellacy, 1994). Home visits are considered an effective way to facilitate positive outcomes for mother-baby dyads in the postpartum periods during the months following birth. The postpartum period is commonly defined as the period from delivery of the placenta to the return of the uterus to its non-pregnant state at about 6 to 8 weeks after delivery. However, new mothers may not achieve full functional status until 3 to 6 months after childbirth (Tulman, Fawcett, Groblewski, & Silverman, 1990).
The Betty Neuman Health Care Systems Model (1989) provided the framework for this study. Neumans model incorporates a total person approach to patient problems and conceptualizes health on a continuum dependent upon equilibrium of the state of the system (Alligood & Marriner-Tomey, 1997). Neuman (1989) defined stressors as environmental factors that can potentially or actually disrupt the equilibrium of the system and can lead to either positive or negative outcomes. According to Neuman (1989), the main goal of nursing is to facilitate optimal wellness for the client. Nursing actions are designed to retain, attain and maintain optimal client wellness using primary, secondary and tertiary interventions (Neuman, 1989). The interventions are defined as levels of prevention that can begin at any point after a stressor is either suspected or identified. The Omaha assessment tool provided nursing students with a comprehensive database for problem identification, and for determining interventions based on the Neuman Systems Model of primary, secondary or tertiary prevention. The four domains addressed in the Omaha assessment tool were environmental, psychosocial, physiological, and health related behaviors.
The review of the postpartum literature was organized according to the four domains of the Omaha assessment tool: environment, psychosocial, physiological and health related behaviors. Environmental concerns in the postpartum period referred to the physical surroundings, safety concerns, and financial problems that might hamper newborn development or maternal progress toward optimal health (Peterson & Saldana, 1996). Postpartum psychosocial concerns included depression (Gruen, 1990, Whiffon & Gotlib, 1989) and role changes (Pridham & Chang, 1992). The literature about postpartum physiological concerns focused on early physiological adaptations to childbirth, especially breast-feeding problems (Polit & OBeirne, 1997) and body image concerns. Health related behaviors related to the postpartum periods included nutrition, sleep and rest patterns (Quillin, 1997). The nursing and medical literature was rich with information regarding women during the early day and weeks of the postpartum period. Very few literature sources focused on nursing interventions for the identified postpartum problems or concerns or evaluation of the effectiveness of suggested interventions (Fishbein & Burggraf, 1998).
The research questions were: (1) What postpartum problems did student nurses identify for mothers during postpartum home visits? (2) Did the problems identified by the student nurses reflect the postpartum problems in the literature? (3) What interventions did student nurses utilize during postpartum home visits? (4) Were the interventions utilized by student nurses consistent with the interventions described in the postpartum literature?
The descriptive study used secondary data selected from the Maternal, Child and Family Health Project evaluation database (Jones, 1998). Eleven assessments met inclusion criteria for families with a new mother no more than six months postpartum. Approval for the protection of human subjects was obtained from the project coordinator and the College of Nursing Human Subjects Committee. The research questions were answered by comparing the problems identified and interventions used by nursing students during postpartum home visits, with lists of postpartum problems and interventions derived from the postpartum literature. The problems and interventions derived from the literature were organized according to the Omaha domains for purposes of the study comparisons.
The student nurses identified problems in all four areas of the environmental domain: income, sanitation, residence, and neighborhood/workplace safety. All eleven student nurses listed inadequate income as a problem for their clients. Many families evidenced problems with their residence such as inadequate safety devices, sanitation problems with insects or rodents and concerns about neighborhood safety. The literature reflected possible problems in terms of safety of the home and neighborhood, but did not address the environmental problems related to inadequate income or sanitation.
Most of the psychosocial postpartum problems identified by the student nurses were consistent with those found in the literature (e.g., depression, role changes, and care-taking skills). The problems identified which did not correlate with the literature included difficulties with interpersonal relationships (other than mother-baby), grief, abused child (e.g. consistent negative messages to the children), growth and development (of other children), and human sexuality.
Student nurses identified nine problems in the physiological domain. Several of these were unrelated to physiological concerns specific to the postpartum period (e.g., vision problems, dental problems and skin rashes). Problems in the four domains are often interrelated (e.g., a mother may not have glasses because of inadequate income).
The problems identified in the domain of health-related behaviors were generally consistent with those found in the postpartum literature (e.g., nutrition, physical activity, and family planning topics). In fact, the majority of the nursing students identified nutrition as a postpartum problem. A minority of students also found problems that were not reflected in the postpartum literature, including problems with health care supervision, personal hygiene and technical procedures (e.g. insulin injections).
The student nurses interventions far exceeded the interventions recommended in the sparse literature on this subject. The students interventions were most often: (1) health guidance, teaching and counseling; (2) surveillance; and (3) case management.
Understanding the concerns, educational deficits and problems experienced by mother-baby dyads allows for implementation of primary, secondary, and tertiary prevention interventions within the Omaha domains of environment, psychosocial, physiological and health related behaviors. This study demonstrated the diversity of problems that may occur during the first six postpartum months and the lack of literature to support the nursing interventions. It is imperative for nurses and student nurses to anticipate problems beyond the scope of current postpartum literature. Study results also support research to evaluate postpartum nursing interventions. The lack of research verifying effective postpartum interventions for diverse postpartum problems makes it difficult for nurses to engage in research-based practice or to develop theory-based models of practice.
1. Faculty support for student work: Terry Badger, PhD, RN and Gale Manke, MS, RN
2. Funding: This study utilized data from the "Maternal, Child, and Family Project" conducted in collaboration with Salud Para Todos, Inc. (Dr. Brenda Evens, Executive Director), and funded by the Pima County Health Department, State of Arizona.
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