Learning needs of hospitalized women at risk for preterm birth

Learning

Needs of Hospitalized Women at Risk for Preterm Birth Annette Gupton and Maureen Heaman

In this descriptive study, the priority learning needsof hospitalized women at risk of pretermbirth were examined. A conveniencesampleof 34 pregnantwomen completed the Preterm Birth Learning Needs Questionnaire (PBLNQ). Respondentsrated 18 teaching topics on a continuum from “not very important to know” to “very important to know.” The topics rated as most important were the consequencesof prematurity for the baby and problemsof the newborn associatedwith pretermbirth. Responsesto open-endedquestions validated mothers’ overwhelming concerns for the welfare of their unborn children. The emotional crisis precipitated by hospitalization for possible preterm delivery changesthe focus of teaching for those at risk of preterm birth and presentsa particular challenge to those providing patient education. Copyright

0 1994 by W.B. Saunders Company

A

LTHOLJGH preterm deliveries represent only 8% to 10% of all births, they are responsible for over 60% of perinatal morbidity and mortality (American College of Obstetricians and Gynecologists, 1989). Despite recent obstetric and neonatal advances, the incidence of preterm birth has not declined significantly (Morrison, 1990). Although preterm birth is often unanticipated, some women experience complications of pregnancy necessitating antepartum hospitalization. For these women, a premature birth can be anticipated and interventions can be implemented to prepare them for the potential delivery of a premature infant. In an effort to facilitate that preparation, the first step is to determine what hospitalized women at high risk for preterm birth identify as important knowledge to be taught. To date, an assessment of the priority learning needs of women at risk for preterm birth has not been conducted. A research base is needed to guide nurses in selecting the content most apFrom the Faculty of Nursing, Manitoba Nursing Research Institute, University of Manitoba, and St. Boniface General Hospital, Winnipeg, Manitoba, Canada. Annette Gupton, PhD, RN: Associate Professor, Director, Faculty of Nursing, Manitoba Nursing Research Institute; Maureen Heaman, MN, RN: Clinical Nurse Specialist, MaternaNChild Health, St. Boniface General Hospital. Address reprint requests to Annette Gupton, PhD, RN, Associate Professor, Faculty of Nursing, Manitoba Nursing Research Institute, Room 239, Bison Building, University of Manitoba, Winnipeg. Manitoba, Canada, R3T 2N2. Copyright 0 1994 by W.B. Saunders Companv 0897-1897/94/0703-0003$5.00/0

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propriate to women’s needs during their stay on the antepartum unit. The purpose of this descriptive study was to identify the priority learning needs ofhospitalized women at risk of preterm birth. BACKGROUND

Kruger (1991) surveyed 1,230 staff nurses, nurse administrators, and nurse educators regarding their perceptions of the nurses’ role in patient education. All three groups believed that nurses should have a high level of responsibility for patient education. The majority of those participating selected the nurse providing direct patient care as the one having primary responsibility for patient education. Ninety-seven percent of the respondents believed the nurse’s responsibility for patient education would increase in the future. Assessment is the first step of the patient teaching process during which the nurse gathers data or information about what the patient needs to know to adjust to the illness or health-threatening situation. Motivation to learn can be enhanced by determining what the patient wants to learn and teaching this first (Smith, 1987). Redman (1988) suggests that one approach to assessing educational needs is to develop a questionnaire in which the patient indicates the perceived importance of knowing about particular content. Analysis of the responses can then provide a framework for organizing and understanding the totality of information needs of patients. This approach has been used frequently in perinatal nursing. For example, Applied Nursing Research, Vol. 7, No. 3 (August),

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Davis, Brucker, and MacMullen (1988) studied mothers’ postpartum teaching priorities, whereas Martell, Imle, Horwitz, and Wheeler (1989) identified the information priorities of new mothers in a short-stay program. Sullivan (1993) questioned mothers about the information they wanted in standard prenatal classes. A wide variety of topics are considered appropriate for women at risk of preterm birth. Suggested content for educational programs for pregnant women (both high-risk and low-risk for preterm birth) includes an explanation of preterm labor and the potential consequences to the fetus of a preterm birth, the symptoms of preterm labor, how to detect and time uterine contractions, and when to contact health care providers. Women who are at high risk of preterm birth should also be taught the specific factors that place them at risk, suggestions for daily living modification to prevent preterm labor, common problems of preterm infants, and the importance of regular visits to their health care providers (Freda, Damus, Andersen, Brustman, & Merkatz, 1990; Herron, 1988; Herron & Dulock, 1987; Johnson, 1989). However, this content appears to be based on what health care professionals consider important. What is unknown is what women at high risk for preterm birth identify as important. To date, few studies have been published about learning needs of women at risk of preterm birth. Freda, Damus, and Merkatz (1991) conducted a survey of 211 inner-city pregnant women to determine their baseline knowledge concerning preterm birth. Almost one half of the women surveyed did not know how many weeks constituted a normal pregnancy, and one third did not know that babies born preterm could have health problems. These results “support the need to assessthe educational requirements of patients in order to develop the most effective educational interventions” (p. 143). Nurses need to evaluate what their patients know about preterm birth and then develop educational strategies most suitable for their populations. Lynam and Miller (1992) examined mothers’ perceptions of the needs of women experiencing preterm labor. A convenience sample of 14 postpartum mothers of preterm babies were asked to rate the importance of 56 items on a premature labor needs questionnaire. The following needs were identified by mothers as most important: to be asked opinions and preferences regarding type

of delivery; to be informed of how their baby is tolerating the labor process; to have the father of the baby stay during labor; to have questions answered honestly; to be assured of a safe outcome for baby; and to have explanations given in simple terms. Limitations of this study include a small convenience sample, the retrospective collection of data, and the lack of psychometric testing of the questionnaire. Unlike the present study, Lynam and Miller focused on intrapartum needs and explored a variety of needs rather than only learning needs. The nurse has a major role in patient education. The first and most important step in this process is to assess the learner’s needs. Although teaching content for women at risk for preterm birth has been suggested, a comparison between content and the learner’s priorities during the antenatal period has not been performed. This descriptive study examined these priorities. METHOD Sample A convenience sample of 34 pregnant women was recruited for the study. All subjects were hospitalized and considered at risk of either spontaneous or indicated preterm birth. A spontaneous preterm birth is one following either preterm labor or prematurely ruptured membranes, and an indicated preterm birth is one following a medical or obstetrical complication requiring or leading to unavoidable preterm birth (Iams, Johnson, & Creasy, 1988). The majority of subjects were white, married, and high school educated. Gestational age ranged from 26 to 36 weeks with a mean gestational age of 3 1.3 weeks. The most frequent reasons for hospitalization were spontaneous premature rupture of membranes (n = 12, 35%), twin pregnancy with cervical dilation and/or contractions (n = 6, 18%), and antepartum hemorrhage (n = 4, 12%). Additional complications of pregnancy which necessitated hospitalization of these women included incompetent cervix, polyhydramnios, placenta previa, and preeclampsia. Four of the women had experienced a previous preterm birth. Some of the subjects had more than one diagnosis. Procedure The study was conducted on a 1Zbed anteparturn unit in a tertiary care teaching hospital in west-

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em Canadathat has over 4,000 deliveries per year. Women were approachedindividually by the assistant head nurse and were invited to participate. After explaining the study purpose, a self-report questionnairewas given to each voluntary subject. Completed or blank questionnaireswere collected by the assistant head nurses. A completed questionnaire was consideredas consentto participate.

Table 1. Rank Ordering of Means for Importance of Teaching Topics By 34 Women at Risk of Preterm Birth Rank 1.

2. 3.

Instrument

The instrument to explore the learning needsof hospitalized women at risk for preterm birth was developed by the authors as no suitable tool was found in the literature. The PretermBirth Learning Needs Questionnaire (PBLNQ) included a rating scale and several open-ended questions. The PBLNQ was pilot tested with three women, and the items were reviewed by two additional perinatal nurse experts for content validity. The questionnaire consisted of 18 topics commonly included in educational programs for women at risk for pretenn birth (Herron, 1988; Herron & Dulock, 1987; Johnson, 1989). The instructions stated, “The following list contains items which are often taught to those at risk for preterm birth. In your opinion which ones are important to be taught?” Respondentswere askedto rate eachtopic on a continuum, from (1) “not very important to know” to (20) “very important to know” using a 20-point visual analog scale. A visual analog scale was used owing to its ease of administration and its suitability for use in clinical settings (Waltz, Strickland, & Lenz, 1991). The 18 topics are listed in Table 1. The questionnaire also included four openended questions: 1. What is the most important information for a mother who is at risk for preterm birth to know? 2. What concernsdo you have about being considered at risk for pretetm birth? 3. Are there things that mothers at risk for preterm birth do not need to know or should not be taught? 4. What would you tell someone (a friend or relative) to help them cope with being at risk for preterm birth? Data Analysis

The topics were rank ordered from most important to least important. Content analysis was used to analyze the responsesto the open-endedques-

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4. 5. 6. 7. a. 9. 10. 11. 12. 13. 14. 15. 16. 17.

18.

Tooic

The consequences of prematurity for the baby Problems of the newborn associated with preterm birth How premature babies are cared for at home How premature infants grow and develop The signs and symptoms of preterm labor How premature infants are cared for in hospital Treatments for preterm labor Nutrition and prevention of preterm birth How to get rest and relaxation to prevent preterm birth What a neonatal intensive care unit looks like How to change your lifestyle to reduce risk (e.g., quit smoking) A description of those who are at risk for preterm birth How to feel for contractions How to tell when you are having contractions How to reduce stress The consequences of prematurity for the mother Experiences and feelings of other women who have had preterm labor/birth A definition of preterm labor

Mean

SD

19.38

1.65

19.29

1.66

19.21

1.82

18.71

3.40

18.53

2.60

18.09 17.91

2.81 3.13

17.35

3.83

16.74

4.47

16.29

5.22

16.18

4.47

16.09 15.97

4.00 5.86

15.94 15.91

6.14 4.87

15.88

4.88

14.68 14.5

5.78 5.13

tions. Themes and recurring regularities were determined, and data were categorized and coded. The quantitative data was comparedwith the qualitative to discern commonality or divergence of conceptual themes. RESULTS

Table 1 presentsthe pregnant women’s ranking of teaching content items from most to least important. In general, all items were rated toward the “important to be taught” end of the continuum with the mean rating for the items ranging from 14.50 to 19.38 out of a possible 20. The 2 items of teachingcontent rated asmost important were ‘ ‘the consequences of prematurity for the baby” and “problems of the newborn associated with preterm birth. ’ ’ The items “how premature babies are

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cared for at home” and “how premature babies grow and develop” also were rated as highly im-

portant. Of the 18 items, “a definition of preterm labor” was rated last or least important to know. Although the women in this study were worried and concerned, they considered “experiences and feelings of other women who have had preterm labor/birth’ ’ relatively unimportant. It was rated as

secondfrom last. The literature has suggestedthat teaching a mother how to detect early contractions can be beneficial in the diagnosis of preterm labor and instrumental in the prevention of preterm birth (Herron, 1988; Herron & Dulock, 1987; Johnson, 1989). However, “how to tell when you are having contractions” was rated 14th in importance. The first open-endedquestion askedrespondents to describe information consideredmost important for those at risk to know. The majority of responsescenteredaround their concern for the welfare of the unborn baby. Most women indicated a needto know the possible risks or complications to the baby and the baby’s chance of survival if premature birth should become a reality (n = 22, 67%). A needfor reassurancewas the secondmost frequent response(n = 11,32%). Women showed a need to be told that “the baby will be OK” and wanted assistance in coping. For instance, one subject believed that it was most important to know “how to prepareoneself psychologically and physically to face the stress, fear, etc.” Another stated, “For the staff to be supportive of the mother. ’ ’ Nine mothers (27%) believed it was most important to know how prematurebirth might be prevented, and six (18%) wanted ongoing information on the condition of the baby as their pregnancies progressed. Only three respondents wanted information on how to care for a premature baby. The theme of “concern for the baby’s wellbeing’ ’ continued to be shown in responses to Question 2: “What concerns do you have about be.ingat risk for preterm birth?” Thirty-one mothers (91%) expressedconcern about the chancesof survival for the baby, had worries over possible complications or permanentdisabilities associated with prematurity, and were concerned about the development of the fetus, particularly lung maturity. Additional concerns involved future care of the baby, how long the baby might be in hospital, and whether it would be possible to breastfeeda premature baby. Concerns were also generatedby

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the uncertainty of the situation. One mother stated, “so many unknowns, so many ‘ifs’ cause fear.” The possibility of cesareanbirth and not knowing when labor would begin were uncertainties that also generateddistress. All those responding to the question regarding information that should not be taught expresseda desire to be told “everything.” Typical responses included, “I like to know exactly what is going on and get all the facts straight, so I can prepare myself both physically and psychologically,” “The more knowledge I have the more positive I feel. Not knowing the possibilities is frightening,” and “ . . . if you are prepared for the worst and it doesn’t happen, it feels great. If it does, I think that being totally unprepared could cause serious problems-both personally and in your family. ” Additionally, three women expressedthe need for complete honesty. One woman said, “Up front honesty is the best way to go. This is enough of a surprise; you don’t need more surprises because you weren’t told something,” whereas another stated, “I prefer to know as much as possible and appreciate honesty in my doctors, coupled with human compassion.’ ’ Several women included advice for those involved in teaching women at risk: Give information gradually so mother has time to absorb and accept at her own pace. Don’t tell them something they may have done or not done has increased the risk. It adds to the guilt. The use of alarming-sounding medical terms that when defined aren’t life-threatening [is frightening]-not talking down to a mother but make sure she’s familiar with the phrases and terminology you’re using-don’t assume someone else has already explained-don’t get overly technical-quoting statistics doesn’t reassure-you want to know how your baby is doing.

When describing advice they would give to others at risk for preterm birth, the most frequent recommendation was to tell other women in similar circumstances to rest and relax (n = 6, 18%). Trusting in the health care system was also mentioned by six women (18%): I would try to remind them how advanced medicine is and the chances for survival are high. Reassure them that absolute care is taken when handling preterm labor-competent doctors and nurses, modem technology. Make sure you know what is happening at all times. Listen closely to what you are told and obey the medical staff.

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Keeping informed was seen as important (n = 4, 12%): Inform yourself-talk to others who have gone through it. To seek professional help and information and not to listen to those who know little or nothing. Ask as many questions as they can regarding effects of preterm labor on baby and mother and read articles/books on preterm births.

Maintaining a positive attitude was also offered as advice to others: Don’t go on a guilt trip. Keep an optimistic and positive attitude no matter what. Hope for the best, prepare for the worst. Positive imagery and relaxation help.

DISCUSSION

Concern for the infant’s welfare was apparent in both the qualitative and quantitative data. The priority learning needs selected by these women were the consequences of prematurity for the baby and problems of the newborn associated with preterm birth. These priorities were validated by the qualitative data with the majority of women responding that it would be most important to know the possible risks or complications to the baby and the baby’s chances of survival if born prematurely. The major implication of the study is that nurses need to address patients’ concerns before introducing content less related to fetal well-being. The data from the study show that women’s top two learning priorities are consequences of prematurity for the baby and problems of the newborn associated with preterm birth. These priorities and the qualitative data reflect women’s major concern regarding welfare of the unborn baby. Anxiety regarding the outcome for the baby may interfere with the woman’s ability to learn other content. Teaching content assessed as important by the nurse may not be assimilated until the patient’s anxiety is reduced. Smith (1987) supports this contention in stating, “Learning readiness will be enhanced if the patient’s concerns are attended to before teaching” (p. 66). Preparation has been described as one method of decreasing stress and anxiety. A 1983 review of studies evaluating patient teaching suggests that “anxiety is alleviated by reducing the area of unknown experiences, fears, and fantasies” (WilsonBarnett & Osborne, 1983, p. 37).

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With this principle in mind and given that study findings reported and described worries and anxieties about the welfare of the unborn baby, various strategies have been suggested. Anticipatory support programs to help women prepare for a potential preterm birth might incorporate a visit from a neonatal nurse consultant, provision of pamphlets and books describing premature infants, and a tour of the neonatal intensive care unit (NICU) (Johnson & Murphy, 1986; Montgomery, 1989; Neumann, Lowe, Millea, & Kozel, 1989). Chappel (1988) found that a predelivery orientation to the NICU decreased maternal state anxiety at the mother’s first visit to her infant postdelivery. The learning priorities identified by this sample differ from the priority content of preterm birth prevention programs. Preterm birth prevention programs tend to emphasize a definition of preterm labor, what the risk factors are, signs and symptoms, and how to palpate for contractions. These women rated a definition of preterm labor as least important to know and rated how to tell when one is having contractions as 14th in importance (out of 18 items). Being hospitalized with a complication of pregnancy most likely increases the patient’s feeling that preterm birth is something that will happen rather than something that might happen. The focus of concerns change, and the needs of hospitalized women may differ from the needs of those remaining in the community. The appropriateness of the teaching provided by preterm birth prevention programs needs to be validated by the women participating in those programs. The results of this study support the finding of Lynam and Miller (1992) that “several mothers were forthright in their comments related to the need to have their questions answered honestly” (p. 130). Study subjects commented that they wanted to be told everything and that complete honesty was important. Concern for the infant’s welfare appears to predominate in both the antepartum and intrapartum periods as Lynam and Miller (1992) reported that mothers were focused on their fetuses throughout labor and wanted to be assured of a safe outcome. When outcomes are likely to be negative, honesty must be coupled with support and reassurance. Women identified several concerns, many of which were generated by the uncertainty of the situation. Feelings of helplessness and loss of con-

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troll have been identified as predominant stressors by women experiencing antepartumhospitalization (Loos & Julius, 1989; Waldron & Asayama, 1985). Nurses need to enhancethe mother’s sense of (controlover the situation by providing her with appropriate information and teaching basedon her choices first. Steele (1987) has suggestedthat reduction of parental anxiety is one way to assist them to adaptto the crisis of a prematurebirth. She states that parents “will experience less anxiety and a greater senseof control if they understand the physical and psychological implications of their infant’s illness” (p. 18). Results of learning needs assessmentssuch as this can assistnursesto identify the priority teaching needsof their patients and provide information that meets those needs. Respondentsto Kruger’s (1991) survey recommendedthe development of educational tools, checklists, and media to assist nursesin meeting patient educationneeds.The priority learning needs identified by the women in this study could form the basis for developmentof those types of resources.

CONCLUSION

One of the nurse’s most important roles is that of health educator. Although it is critical for the nurse to understand and know the teaching content for various patients, an equally important areaof nursing knowledge is how to present content in a way that can be most readily understood and used. Findings from this study have shown that addressing an antenatal patient’s anxieties and concerns abouther unborn child may be the best initial starting point in patient education. Fear for the unborn baby was reflected in what the women said was important to learn and further describedin the qualitative data. Respectfor learning priorities as the patient sees them needs to be acknowledged with appropriate teaching follow-through. Once that is accomplished, the learner is likely to be more open to what the professional views as important to be learned. ACKNOWLEDGMENT The authors would like to acknowledge the assistance of Cristina Pallone, RN, with data collection.

REFERENCES ,4merican College of Obstetricians and Gynecologists. (1989). Preferm labor (ACOG Technical Bulletin No. 133). Washington, DC: Author. Chappel, I. ( 1988). Anreparcum orientation of high-risk mothers to neonatal infensive care unit: Effect on maternal anxiety following premature birth. Unpublished master’s thesis, University of Florida. Davis, J.. Brucker, M., & MacMullen, N. (1988). A study of mothers’ postpartum teaching priorities. Maternal-Child Nursing Journal, 17(l), 41-50. Freda, M., Damus, K., &Merkatz, I. (1991). Whatdopregnant women know about preventing preterm birth? Journal of Obstetric. Gynecologic, and Neonatal Nursing, 20, 140. 145.

Freda. M.. Damus, K., Andersen, H., Brustman, L., & Merkatz, I. (1990). A “PROPP” for the Bronx: Preterm birth prevention education in the inner city. Obstetrics and Gynecology, 76. 93%96s. Herron, M. (1988). One approach to preventing preterm birth. Journal of Perinatal and Neonatal Nursing, 2, 33-41, Herron, M., & Dulock, H. (1987). Preterm Labor (2d ed.). Series 2, Prenatal Care, Module 5. White Plains, NY: March of Dimes Birth Defects Foundation. Iams, J., Johnson, F., & Creasy, R. (1988). Prevention of preterm birth. Clinical Obstetrics and Gynecology, 31. 599615.

Johnson, F. (1989). Assessment and education to prevent

preterm labor. American Journal of MaternallChild

Nursing,

14, 157-160.

Johnson, T., & Murphy, J. (1986). Psychosocial implications of high risk pregnancy. In R. Knuppel & J. Drukker (Eds.), High-risk pregnancy: A team approach (pp. 173-186). Philadelphia, PA: Saunders. Kruger, S. (1991). The patient educator role in nursing. Applied Nursing Research, 4, 19-24. Loos, C., & Julius, L. (1989). The client’s view of hospitalization during pregnancy. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 18, 52-56. Lynam, L., & Miller, M. (1992). Mothers’ and nurses’ perceptions of the needs of women experiencing preterm labor. Journal qf Obstetric, Gynecologic, and Neonatal Nursing, 21, 126-136. Martell, L., Imle, M., Horwitz, S., & Wheeler, L. (1989). Information priorities of new mothers in a short-stay program. Western Journal of Nursing Research, 11, 320-327 Montgomery, L. (1989). An anticipatory support program for high-risk parents: Follow-up results. Neonatal Network, 8(3), 31-35.

Morrison, J. (1990). Preterm birth: A puzzle worth solving. Obstetrics and Gynecology, 76, 5S-12s. Neumann, M., Lowe, M., Millea, D., & Kozel, M. (1989). Nebraska hospital establishes program for high-risk obstetric patients. NAACOG Newsletfer, 16(l). 1, 4-7. Redman, B. (1988). The process of patient education (6th ed.). St. Louis, MO: Mosby.

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Smith, C. (1987). Patient education: Nurses in partnership with other health professionals. Philadelphia. PA: Saunders. Steele, K. (1987). Caring for parents of critically ill neonates during hospitalization: Strategies for health care professionals. Maternal-Child Nursing Journal, 16(l), 13-27. Sullivan, P. (1993). Felt learning needs of pregnant women. The Canadian Nurse, 89(l), 42-45. Waldron, J., & Asayama, V. (1985). Stress, adaptation and

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coping in a maternal-fetal intensive care unit. Social Work in Health Care, 10(3), 75-89. Waltz, C.F., Strickland, O.L., & Lenz, E.R. (1991). Measurement in Nursing Research (2d ed.). Philadelphia, PA: Davis. Wilson-Bamett, J., &Osborne, J. (1983). Studies evaluating patient education: Implications for practice. International Journal of Nursing Studies, 20. 33-44.