A nurse is providing discharge teaching to a client who is postpartum. for which of the following

Postpartum discharge instructions are a crucial part of a mother’s birth experience. Finding the method to provide those discharge instructions in a manner that increases the mother’s satisfaction with her hospital experience is important. This quasi-experimental study examined the relationship between new mothers’ interaction with nurses providing postpartum instructions by the traditional and class methods and their satisfaction with discharge teaching. The results indicated new mothers were satisfied with both methods of discharge teaching; however, they were more likely to report stronger agreement with overall satisfaction with the traditional method of discharge teaching than with attending the discharge class.

Keywords: discharge class, discharge teaching methods, patient satisfaction, postpartum teaching, traditional discharge teaching

Education classes are available to expectant parents prenatally in many countries throughout the world, and parents attend anticipating they will learn to better manage the process of childbirth and how to care for their newborn (Ahldén, Ahlehagen, Dahlgren, & Josefsson, 2012). Such classes have been shown to increase the knowledge and skills of the parents prior to their birth experience, which can lead to their feelings of self-efficacy (Svensson, Barclay, & Cooke, 2009). Although many pregnant women take advantage of these classes, their focus may be on the actual labor and delivery experience and not necessarily on the infant care and parenting skills discussed. For these mothers, this can lead to feelings of being unprepared to leave the hospital and questioning whether they are ready to care for the newborn and themselves at home, unless the nurses caring for them in the hospital can provide the education they need.

Postpartum teaching is an essential aspect of nursing care during the hospital stay following childbirth. Assessment for the stability of the physical status of both the mother and newborn is crucial after birth, but once established, the focus should turn to assisting the mother learn to care for herself and her newborn once she is discharged from the hospital. Rodrigues et al. (2014) found mothers not only required physical care following the birth of their babies but also those who felt they did not receive adequate guidance in how to care for themselves and their newborn after they birthed were dissatisfied with the care provided. Therefore, it is incumbent on nurses to provide instructions to these women throughout their hospital stay as well as prior to discharge to equip them to be confident and competent in their self and infant care skills as well as satisfied with the care received.

Ensuring patient satisfaction is also important for nurses as they implement the education so vital to new mothers before they are discharged home for financial reasons. Not only do nurses want to provide patients with a sense of satisfaction with the physical care and education provided but now hospital reimbursement is also tied to provider performance and patient outcomes (National Council of State Boards of Nursing, 2014). Positive outcomes can lead to reimbursement for services rendered; one of these outcomes is satisfaction with care (Schuelke, Young, Folkerts, & Hawkins, 2014).

Satisfaction is a leading indicator of the quality of nursing care (Camacho et al., 2012). Because of the involvement with patients during a hospital stay, nursing care directly affects patients’ perceptions of satisfaction with the entire experience (Coban & Kasikci, 2010). Thus, it is incumbent on nurses to strive to use interventions that will provide new mothers with the care that leads to the highest satisfaction.

One of the key attributes of satisfaction with nursing care is the provision of adequate patient education (Wagner & Bear, 2009). Giving sufficient and suitable information to postpartum women to meet their needs of learning to care for themselves and their newborn may contribute to a positive experience for new mothers. This information can lead to higher satisfaction with the postpartum stay (Chan, Wong, Lam, Wong, & Kwok, 2013).

One of the key attributes of satisfaction with nursing care is the provision of adequate patient education.

Postpartum discharge planning begins from the moment a laboring woman is admitted to the hospital to birth her baby, as nurses assess her knowledge and identify areas of teaching appropriate for her. It culminates in the review of general discharge instructions recommended by national organization guidelines, the patients’ obstetrical and pediatric health-care providers and postpartum and neonatal nurses (Smith, Hwang, Dukhovny, Young, & Pursley, 2013; Weiss & Lokken, 2009). Because hospital stays are relatively short, the amount of time nurses have to educate women to care for themselves and their newborns is restricted. Thus, nurses need to find an appropriate method to communicate this vital information to new mothers to ensure their questions are answered and they feel confident in their care-taking skills.

Teaching methods nurses use to instruct childbearing women vary and can potentially impact the quality of the instructions and the mothers’ level of satisfaction. Strategies employed include one-to-one instruction, video recordings, written materials, and group/class instruction. Individualized instructions given by the nurse caring for the new mother is one method used on many postpartum nursing units to provide self and infant care education to new mothers prior to discharge (Wagner, Bear, & Davidson, 2011). In fact, mothers who receive individual discharge instructions by the primary nurse have shown satisfaction with overall nursing care (Wagner et al., 2011; Wan, Hu, Thobaben, Hou, & Yin, 2011).

Martin (2005) studied perceptions of the quality and quantity of postpartum teaching when new mothers were given an instructional video recording to watch prior to individual instructions from a nurse before leaving the hospital after childbirth. She found many patients did not consider the video recording discharge instructions and concluded they preferred postpartum teaching in person.

Written materials are frequently used as an adjunct to individualized teaching and can enhance the quality of the postpartum instructions (Buchko, Gutshall, & Jordan, 2012). Not only do handouts and booklets provide visual learners with their preferred method of instruction but it also gives the mothers something to reference once they go home.

Some nurses provide teaching to expecting or new mothers through group classes. In the outpatient setting, studies have shown women are satisfied with education provided in antenatal classes (Serçekuş & Mete, 2010; Teate, Leap, Rising, & Homer, 2009) and group prenatal care (Klima, Norr, Vonderheid, & Handler, 2009; Lathrop, 2013). These classes allow those in the group to learn the same information simultaneously, share personal experiences and ideas, network, and ask questions benefitting all in attendance (Schlittenhart, Smart, Miller, & Severtson, 2011; Teate et al., 2009). Smith and Waller-Wise (2011) found scores on Press Ganey patient satisfaction surveys increased when a nurse from the childbirth education department conducted postpartum discharge classes in the inpatient setting.

Various methods and tools to deliver postpartum discharge instructions have enhanced the quality of instructions and been shown to increase patient satisfaction. However, at a time when the cost of nursing care is being explored to determine allocation of resources (Jenkins & Welton, 2014), it would be beneficial for nurses to demonstrate their contribution to the outcome of satisfaction through the extensive teaching they dispense to new mothers. Because the provision of discharge instructions is typically the last thing nurses give to patients before they leave the hospital, it is of interest to measure patient satisfaction with this vital area of care. Therefore, the aim of this study was to determine the relationship between the method used by nurses to provide postpartum discharge instructions to new mothers and patient satisfaction during the hospital stay following childbirth. In addition, the relationship between the mother’s unique characteristics and their level of satisfaction was explored.

The purpose of this study was to determine the relationship between new mothers’ interaction with nurses using different methods to provide postpartum teaching and their satisfaction with nursing care. The two methods used by the nurses were (a) the traditional method (defined as one-to-one teaching between the nurse and new mother) and (b) a group discharge class (three or more new mothers taught by an experienced mother–baby nurse). The relationship between new mothers’ background variables and the level of their satisfaction with nurses’ teaching methods was also explored.

Cox’s (1982, 2003) interaction model of client health behavior (IMCHB) provided the framework for this study and guided its design. Cox’s IMCHB is a middle range theory that examines the unique characteristics of the patient, the relationship between the patient and nurse (operationalized as the interaction between the nurse and patient during discharge teaching), and the influence these elements have on one of five health outcomes. Satisfaction with care was the health outcome measured in this study. It is postulated that as the nurse tailors care to meet the unique needs of the patient, the outcomes are more likely to be positive.

This study used a quasi-experimental, posttest-only survey design. It was conducted on a postpartum unit with approximately 100 births per month in a hospital in Northeast Florida. Permission to conduct this study was granted by the institutional review board of the hospital prior to its commencement.

A convenience sample of postpartum women who gave birth on the obstetrical unit and met the inclusion criteria was recruited for this study. Inclusion criteria encompassed patients 18 years of age or older who birthed a baby in this hospital, had an uncomplicated vaginal birth or cesarean surgery and a healthy baby who was rooming in, expected to be discharged that day, and able to speak, read, and understand English. To detect a medium effect with a power of 0.80, the sample size for comparing two independent groups was determined a priori to be 51 participants per group.

The instrument used in this study was a modified version of the Client Satisfaction Tool (CST; Bear & Bowers, 1998) developed to measure patient satisfaction with nursing care based on the Cox IMCHB. Although the CST measured patient satisfaction with nurse practitioner care in a senior center, the modified CST was revised to measure patient satisfaction with postpartum teaching methods used by nurses. Content validity for the modified CST was established by three university professors who were experts in obstetrical nursing and familiar with the Cox model. Internal consistency reliability was established for the modified CST with Cronbach’s alpha (α = .983).

This questionnaire consists of nine items, two which represent each element of the patient–provider interaction (affective support, health information, decisional control, and professional/technical competencies) contained within Cox’s IMCHB (1982, 2003) theorized to influence the health outcome and satisfaction with care (Bears & Bowers, 1998). The ninth item measured the overall satisfaction with care. Each of the nine items included a 5-item Likert scale, ranging from strongly agree (5) to strongly disagree (1). In addition, a demographic questionnaire was used to collect information about the unique characteristics of the participants identified within the Cox model.

On the morning of a patient’s planned discharge, if three or more women were scheduled to leave the hospital that day, she was given the choice of receiving her discharge teaching by attending a postpartum class. The postpartum discharge teaching class was held in a designated educational room on the nursing unit. Each weekday, Monday through Friday, the lactation consultant, who is a registered nurse with postpartum and newborn nursery experience, conducted the discharge teaching class. She reviewed maternal and newborn care and discussed standardized discharge instructions furnished by the obstetrical and pediatric providers. As she explained each topic, she initialed the discharge sheet indicating the topic was reviewed with the mothers and placed the form in the mother’s chart.

On weekends, another lactation consultant, who is a registered nurse with postpartum and newborn nursery experience and worked every Saturday and Sunday, conducted the discharge teaching class, presenting the same information provided during the week. She also initialed the instruction sheet as she went over the discharge information and placed this form in the patient’s chart. If either of these nurses were not at work, one of the postpartum nurses filled in for her in conducting the discharge class, using the same material for the new mothers.

If the patient chose not to attend the class or less than three mothers were scheduled for discharge, she received the traditional discharge teaching. The traditional discharge teaching included the same information provided in the discharge teaching class but was delivered one-to-one by the nurse who cared for her that day. As the primary nurse provided the maternal and newborn instructions, she initialed the topics on the discharge form and placed it in the patient’s chart.

At the conclusion of discharge teaching, each mother attending the class received a cover letter explaining the study in detail, a demographic questionnaire, a modified CST survey, and a plain envelope. The survey instruments were printed on blue paper to indicate the mother received her discharge instructions through the class method. If she agreed to participate in the study, she filled out the forms when she returned to her room, placed them in the envelope and sealed it. If she did not agree to participate, she placed the blank forms in the envelope and sealed it.

The mothers who had discharge instructions presented by the traditional method received the cover letter explaining the study in detail, a demographic questionnaire, a modified CST survey, and a plain envelope. These survey instruments were printed on white paper. Using a different color of paper for each of the teaching methods enabled the researcher to identify which method of teaching the mother received: the class or traditional method. After the nurse left a patient’s room, if the patient agreed to participate in the study, she completed the questionnaire and the survey and placed them in the plain envelope and sealed it. If she did not agree to participate, she placed the blank forms in the plain envelope and sealed it.

As the patient was leaving the hospital, she placed the sealed envelope containing the questionnaire and survey into a locked box located at the nurses’ station, near the mother–baby unit exit door. The box was emptied once per week by the principal investigator who had the only key to the box. Data collection continued until at least 51 usable surveys were collected for each group. Because of the number of participants in the final discharge class, 53 usable surveys were collected for that group.

Once the data were transcribed, the surveys were stored in a locked filing cabinet in the nurse manager’s office to preserve data integrity and security. At the end of 3 years, they will be destroyed.

Statistical analysis was performed with SPSS Version 19 and JMP9, a SAS product. Demographic data collected for the study included variables identified in the Cox IMCHB: age, race, marital status, education, income, mode of birth, parity, method of payment for hospitalization, and previous experience with hospitalization. Descriptive statistical analysis for the traditional teaching method groups (Table 1) showed the women were generally White (78.4%), married (60.8%), and multiparous (56.9%); had an average age of 27.8 years; more than a high school education (62.8%); and an annual family income of less than $50,000 (62.8%). She birthed her baby vaginally (70.6%), experienced a previous hospital experience that was positive (60.8%), and had some form of insurance (94.1%), either private or government provided (Medicaid/Medicare).

Comparative Demographic Characteristics of the Sample and Teaching Methods

Mothers in the discharge class group (see Table 1) were mostly married (62.3%), White (69.8%), multiparous (56.6%), educated higher than the high school level (60.4%), with an average age of 26.9 years, and an annual family income of less than $50,000 (64.1%). Her baby birthed vaginally (75.5%), she had a hospital experience that was positive (67.9%), and had some form of insurance (94.3%), either private or government provided (Medicaid/Medicare).

The data collected on the modified CST showed most mothers in both groups responded to each of the nine items with an agree (4) or strongly agree (5). None of the mothers answered strongly disagree (1) on any of the surveys. In addition, although some mothers answered “disagree” or “not sure” for some of the items on the modified CST, there were less than five of those responses for any of the items for either group. Therefore, responses less than “strongly agree” were grouped together and compared to the “strongly agree” responses.

The mean satisfaction score for the participants receiving the traditional method of discharge teaching was 4.92 (SD = .22), whereas the average mean for those attending the discharge class was 4.79 (SD = .37). Kruskal-Wallis and chi-square tests showed there was no relationship between the background characteristics age, marital status, education, income, mode of delivery, and parity and the mean satisfaction scores on the modified CST for both the mothers who received the discharge teaching by the traditional or the class methods.

The two groups’ responses were placed into one of two categories: those who “strongly agreed” or those who “did not strongly agree.” Chi-square analysis showed some significant associations between the methods of discharge teaching and some of the elements of the patient–provider interaction surveyed on the modified CST. As reported in Table 2, mothers who received discharge instructions by the traditional method were more likely to indicate they strongly agreed to decisional control and health information items than mothers who attended the discharge class. These items were “I was included in decision making about my discharge teaching,” χ2(1) = 5.3601, p < .05, and “the discharge information I received in the hospital will help me take care of myself and my infant at home,” χ2(1) = 4.0315, p < .05. In addition, mothers receiving their discharge instructions by the traditional method were more likely to mark strongly agree to the statement: “Overall, I was satisfied with my discharge teaching,” χ2(1) = 5.1714, p < .05 than mothers who attended the discharge class.

Responses on the Modified Client Satisfaction Tool

Because childbirth is typically a positive and happy time for new mothers, it is not surprising that the mean scores on the modified CST for mothers receiving their discharge instructions by both the traditional and class methods indicated satisfaction. This is consistent with the findings of a similar study measuring patient satisfaction with nurses using both the traditional and demonstration/return demonstration methods of providing postpartum discharge instructions (Wagner et al., 2011). Although there were no significant differences in the results for that study, the mothers receiving discharge instructions with both methods used by nurses showed satisfaction with care.

New mothers who received discharge instructions by the traditional method were more likely to “strongly agree” they had decisional control (included in decision making about their discharge teaching) and health information (information received will help them care for themselves and their newborn infants) than mothers who received their discharge instructions by the class method. It may be that nurses using the traditional method were able to provide the information more quickly because they knew which items of information were already covered with the new mother throughout the day instead of a more formalized presentation of the information in a class. Because more new mothers were multiparous, it may be their knowledge or comfort level with some areas of self or infant care was higher than first time mothers and therefore felt some of the information in the class was not needed. Because each class had various mothers with different learning needs, those attending could not ask the nurse to skip over topics they didn’t need or want reviewed, thereby negating the opportunity to have the instructions personalized to her need. In addition, because the nurse giving the discharge class may not have been the same nurse assigned to care for each patient in the class that day, the instructions given might not be exactly the same as those given by the primary nurse, causing some confusion.

New mothers who received discharge instructions by the traditional method were more likely to “strongly agree” they had decisional control and health information than mothers who received their discharge instructions by the class method.

Mothers who received the discharge instructions from nurses using the traditional method of teaching were more likely to strongly agree to overall satisfaction with the discharge teaching than those attending the class. The traditional method of providing discharge instructions allows for implementation at a flexible, convenient time for the new mother rather than the scheduled time for the class. Mothers who had a cesarean surgery may feel discomfort sitting in the classroom chairs during the teaching session instead of having the benefit of remaining in their bed while receiving the discharge instructions. Certainly, there may be modesty issues in attending the class with other new mothers (and their family members) while dressed in a patient gown and robe, leading some mothers to feel uncomfortable.

This study’s limitations included a small sample size from one setting and lack of diversity, which prevents generalizability of the results to the population. The small sample failed to detect significant differences in most of the items on the modified CST for mothers in both groups, so replication with a larger sample size would increase the chance of detecting larger effects for the method of teaching. A more diverse population from other settings could also provide greater insight into the satisfaction of new mothers with other demographics, such as younger patients or primiparas, demonstrate with postpartum teaching methods used by nurses.

Nurses should strive to deliver high quality care to obtain the best outcomes for patients, including satisfaction. Identification of nursing interventions resulting in the greatest satisfaction with care provided is therefore of value to the discipline. While determining which method of postpartum discharge teaching leads to higher patient satisfaction is of significance to nursing practice in the hospital setting, it could also shed insight into patient satisfaction with education in the outpatient setting.

Even though preparation for childbirth education is traditionally provided in a group setting using the class method, it may be helpful to consider the findings learned in this study when developing or revising those classes. For instance, allowing mothers and their coaches to assist in choosing the topics to be covered in each session instead of maintaining a specific predetermined agenda could help to increase interest and satisfaction.

Of note, the standardized survey used to measure patients’ perspectives of the care they receive while hospitalized is the U.S. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, n.d.). Hospital payments are linked to these HCAHPS performance ratings based on the quality measures obtained through the surveys. Among the items included on these surveys are “Communication with Nurses” and “Discharge Instructions.” Because patient education is correlated with higher satisfaction rates, hospitals are now putting an emphasis on improving education (Patient Ed, 2011). In fact, patient education has been shown to increase the HCAHPS ratings (Schuelke et al., 2014).

Not only is patient education tied to reimbursement but also reports of greater satisfaction may establish positive relationships and future use of hospital services (Cleary, Horsfall, & Hunt, 2003; Laschinger, Hall, Pedersen, & Almost, 2005). Therefore, it is important for postpartum nurses caring for new mothers to provide excellent patient education, for both the health and well-being of the mother and her infant and the financial health and well-being of the hospital.

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