Beatriz Adriana Acevedo-Hernández,1 Norma Pizarro,1 Bernardina Leticia Moriel-Corral,1 Eliazar González-Carrillo,1 Luz Verónica Berumen-Burciaga1
1Universidad Autónoma de Chihuahua, Facultad de Enfermería y Nutriología, Chihuahua, Chihuahua, México
Correspondence: Beatriz Adriana Acevedo-Hernández
Received: May 19th 2015
Judged: October 28th 2015
Accepted: February 18th 2016
Introduction: Research related to nursing care to women during the postpartum period have addressed various topics however, it is identified that education in the care process has not been one of them.
Objective: To explore the development of educational process of professional nursing that promotes self-care of women during the postpartum period.
Methods: Qualitative research was conducted with field notes, depth interviews and participant observation. The analysis was based on the Strauss and Corbin Grounded Theory.
Results: Puerperium is socially a daily event influenced by personal, social and cultural beliefs, it is a socio-cultural legacy situation that does not meet with the generic influenced by family care.
Conclusions: The postpartum period is a unique and temporary event in women; it is reflected in the attitude and the actions taken regarding care for herself and the newborn. Education is an opportunity for professional nursing in relation to communication and education of women in postpartum period.
Keywords: Educational process; Nurses; Postpartum period
Studies were found in Spain, Colombia, Brazil and Mexico referring to the study of nursing care in women during the postpartum period. One of the first studies, which showed the experiential care landscape and education to women in the puerperal period, was conducted by Vinalay and Victoria1 in 2012. In other studies, the approach has been on the care satisfaction of postpartum women,2 knowledge of puerperal women about self-care and newborn care,3 and the influence of culture and family in generic care behaviors that the woman develops for herself4 and for the newborn.5 It was identified in all of these that education on the care process has not been addressed for the professional nursing practice.
However, although studies were conducted in different contexts, they have some common ground, in which the same educational needs of women in the postpartum period prevail. In this sense, Ponce (2005)3 highlights the importance of ensuring education prior to hospital discharge. Also Vinalay and Victoria1 conclude that professional nursing care is focused fully on the biomedical healthcare paradigm, revealing the need to strengthen education and communication with women in postpartum period. So far, there is no evidence on nursing professionals' involvement with an educational focus in the postpartum period in clinical practice.
In this context, grounded theory uses symbolic interaction to allow us to approximate the reality of the object of study; it is an analysis tool that generates, formalizes and builds knowledge of the profession from the findings, contributing to nursing practice (care).6 Castro7 agrees that symbolic interaction identifies the subjectivity and the effects of the interaction between the actors as the central point of the sociological perspective. Questions in studies based on this approach are directed at things with meaning to individuals and how these meanings affect their behavior and interaction with one another.
It should be noted that this type of research helps to generate new knowledge of the educational phenomenon, from observation of nursing professionals during interaction with the care person. Links to guidelines considered important to developing the care concept were established for the present study. Waldow,8 refers to care as going beyond family: it is an approach with love, tenderness, sensitivity and humanity that must transcend through education during the nurse's interaction with the care person.
The aim is to explore the educational process's development of professional nursing that promotes self-care of women during the postpartum period. Through analysis and linking the study to various investigations, it is possible to relate information to help respond to the phenomenon of study, the basis for reaching cardinal concepts that enrich the development of the nurse's educational role in clinical care, and to deepen care as the cornerstone of the profession. In essence, it creates an understanding of the educational process as means to transform consciousness, attitudes, habits and customs towards promoting behaviors of health maintenance.
The methodological approach to qualitative research was conducted through the use of tools such as diary, in-depth interviews, and participant observation, to gather, translate and interpret information from the symbolic interaction in which the nurse-care person link is developed during the educational process to promote self-care in the puerperal woman.
The field of study was the obstetrics department in a public institution of secondary care. To explore the development of the educational process, one condition was collaborating with nurses in the provision of technical, administrative, and managerial care.
In the first group were postpartum women, regardless of the number of experiences of the women. The second group was nurses responsible for the care of these women.
A key is assigned to each of the interviews with nurses (N-1, N-2 ... N-14) and for the group of postpartum women (PPW-1, PPW-2 ... PPW-7). Other codes used for participant observation are PO for participant observation, S for personal story, FN for field note, and NC, note when coding.
An in-depth interview guide was designed specifically for both groups.
Nurses were encouraged to comment on how they educate puerperal women. During the interview, if it was necessary to guide the nurse on the subject during the interview, two support questions were considered: "What should be taken into account to educate women during the postpartum period?"; and, "According to your experience, can you explain the aspects nurses should consider in teaching women passing through the postpartum period?" To close the interview, the nurse was asked to address the issues they think should be included in the postpartum woman teaching process from their point of view.
Interviews with postpartum women were held in a cordial dialogue. They were asked, "What is this time in your life that you are in?, based on their experiences. "How do you feel it is easier to learn when the nurse gives you care?" (a guiding question), and support questions: "Tell me about this stage. How do you feel being a mother? Tell me about any doubts you may have in any postpartum situations."
And to end the interview, "What do you think you in particular need to learn for your care?"
At the beginning of the interviews, the project objective was explained to participants. They gave informed consent to participate and to be recorded in the interview. At the end, they were thanked for their participation. Then we proceeded to transcribe the data, as well as the description of pauses, expressions, attitudes, gestures and glances. During data collection, we took notes of their stories, to develop some assumptions and possible explanations of the phenomenon, and triangulated the information with field diary notes. The data analysis was conducted based on Strauss and Corbin’s grounded theory.9
The line-by-line analysis yielded the "living codes" that were grouped according to meaning in the text to form categories and subcategories, as axis of this study (Figure 1).
Figure 1. Categories and subcategories from living codes
Data analysis and participant observation facilitated the abstraction of the essence of the findings and the conceptual framework for the educator role of the nurse (Figure 2). Nursing care for puerperal women is provided based on the biomedical approach, providing information on basic issues of uterine involution, bleeding patterns, breastfeeding and contraceptive methods. Such information is provided on admission, during the stay, and reinforced at hospital discharge with support material. However, as there is an educational program in the postpartum area, the identification of needs comes from the informal dialogue, and this is how the decision is made about what to inform the woman. In addition, this process is influenced by the nurse’s knowledge. She has the skills to function in the role of teacher and communicate with postpartum women.
Figure 2. Role of nurse educator in practice
The postpartum women were between 16 and 29 years old. Only one woman was a minor, and in most women, their first postpartum experience occurred in adolescence. The group of nurses was composed of men and women, and not all female nurses had experienced the postpartum period, and not all male nurses had been with a partner during this event.
In the analysis of the transculturality, women participants expressed the following references to personal neglect, myths and family coercion: "But the postpartum woman does not do care actions," N-8. "Postpartum women have strange myths and ideas about care and lactation," N-3. "My mother will help me, she knows everything," PPW-2. "My sisters had children and they told me how to do it, what they knew, they taught me." PPW-5.
In related studies on generic care to restore balance during the postpartum period6 and self-care practices in postpartum adolescents,5 care is structured based on the beliefs of thermal imbalance and restoration thereof. Socially, puerperium denotes a world of practices rooted in cultural constructions of each particular society, handed down from generation to generation.
The social and family environment of women in the postpartum period implies a path by which we must move cautiously, as along the way there are challenges and risks to be avoided. In everyday practice, the nurse has faced situations where puerperium women have lifestyles derived from beliefs, myths and rituals from their culture and family regarding personal and hygienic care. This can lead to doing generic care practices that do not always favor the best hygiene and dietary measures, creating perspectives on the postpartum period which affect the willingness to accept the actions suggested by the nurse. During the postpartum period, women receive guidance and support from other women in the family, who provide the meanings of the corporal care practice and collaborate on housework, and interpretation at the household level. It is a rigid period where the beliefs of the more experienced relatives are beliefs that have been learned and adapted and sometimes lack scientific knowledge.10-12
Vargas et al.,13 explained that it is difficult for new knowledge to replace beliefs and customs coming from the family environment, where women learn what the postpartum period and motherhood are informally, through imitation of patterns. In this way, acquired behaviors influence the development of further action.
During the interaction with the woman in puerperium, nurses expressed some limitations related to the communication. First, those relating to the cultural influence, and secondly, those that have been identified in other colleagues in the nurse - postpartum relationship, such as: the use of technicalities in explanations, the nurse's disinterest in women in the postpartum period, and finally, the attitude of being a repository of information that is replicated and reproduced.
"Indigenous women... it is difficult to communicate, with them usually, Tarahumara women absorb silently," N-1; "You speak very nicely but they do not understand," N-7; "The nurse lacks empathy for women in postpartum period," N-5; ".. little empathy is reflected in her," N-7; "They come and say, practically recite it, the content ... what they already know by heart, regardless of whether it is understood or not" N-12; "Nurses only transmit information," N-14.
Vinalay and Victoria,2 Odinino and Brito,3 and Diaz,14 identified nursing professionals' strengths and weaknesses, highlighting communication and human aspects, which are thought to go beyond their technical capacity, stressing their role as educators.
For Ausubel,15 language is an important facilitator of learning by reception, including the manipulation of concepts and suggestions through properties of representation that have the words, refining sub-verbal abilities that arise in meaningful learning, and generate more precise language and transferable ideas. Patricia Benner16 in her beginner to expert theory, specifies professional competencies of the nurse for the teaching role, and defines that:
"The nurse provides a coherent, consistent, concise, clear explanation in a language that can be comprehended and understood by the person of care."
Fernandez17 expresses the need to guarantee education to women in the postpartum period and includes the father of the newborn. She believes that education is a tool that positively impacts maternal and child health, but that the more effective educational approach is still unknown. In turn, Ponce4 refers to the need to improve human relations, including a change of attitude in nursing professionals, the preamble of adaptation of postpartum women.
In the context of everyday nursing practice, there are perceived and unperceived educational needs, both for the nurse and women in postpartum period. These needs consist of education, circumscribed conditions, and characteristics in which the educational process develops, including educational needs, who learns how to teach; so participants expressed below: "One learns instinctively," PPW-4. "I get questions aimed at the baby," PPW-5. "One is not born knowing how to be a mom." PPW-7 "What are they learning?" N-8. "I noticed chatting between them, it is easier to learn by watching other patients, only if I explain ... they should take information in so that they don't get re-admitted," N-1; ..."through educational materials, brochures" N-2; "It is so easy to convince a woman after her first birth but the other one, so-so, she has a history and believes that all children are the same," (N-2, referring to the woman who has had multiple pregnancies). "I do not need to learn anything, I've lived it all, I have experience." PPW -4; "I feel able, because I have two babies and do well with them." PPW -8. "The woman with her second child says she does not need to learn anything, however, during the observation it was found that when breastfeeding, she doesn't hold the breast, leaving it for the child to suckle on." NC-21, PO (PPW-6). The 16 year-old woman (MP-9), expressed no need to learn. "No, because I have my mom," PPW-9. In this situation, the support that the mother had previously reiterated to her was perceived. She was seen as a great moral support, the ideal person to help her at this time. NC-32, S, PO.
In this sense, Vargas et al.13 report that regardless of age, women turn to family members who have experience in the postpartum period. In another study of resonance and dissonance in the process of post-partum care,2 discrepancies between the practices they perform and the needs felt were found in women in puerperium regarding communication, care, expression of feelings and education.
Bandura18 mentioned: "I could not imagine how in a culture, a whole repertoire of behaviors could be transmitted by only direct experience, so it was then that I began to develop the idea that –much learning occurs through only observation- i.e. people learn in a social context recognizing cognitive influence on behavior and from this, there are behaviors that are learned through observation."
From the cultural-family legacy, women during the postpartum period have physical, emotional, and educational needs that demand the intervention of nurses. In the present study, multiple factors hampering education, including those originating from the nurse herself and those that are part of the idiosyncrasies of women, were identified during the development of the nurse-postpartum relationship.
In Mexico and Spain in 2003 and 2009, respectively, researchers agreed on the need to improve and adapt maternal education programs and implement new strategies.19,20 Despite the time between the studies, areas of opportunity in the educational process of women in postpartum period are similar. Other developments related to women's education after childbirth, contraceptive use, pelvic exercises and urinary incontinence, assert that only education can favorably influence the rehabilitation of women during postpartum.21,22
The next step is the conceptual proposal of care and types of care generated in the nurse-postpartum woman interaction, in which the improvement and renewal of the practice are essential elements of daily life in the clinical setting.