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Acevedo-Hernández BA, Pizarro N, Moriel-Corral BL, González-Carrillo E, Berumen-Burciaga LV. [Nursing educational process to promote self-care of women during the postpartum period]. Rev Enferm Inst Mex Seguro Soc. 2016;24(3):197-204.

Nursing educational process to promote self-care of women during the postpartum period

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

Email: baacevedohdz@hotmail.com

Received: May 19^th 2015

Judged: October 28^th 2015

Accepted: February 18^th 2016

Abstract

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

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Introduction

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.

Methodology

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).

• Transculturality, the social phenomenon that emanates from the cultural heritage of society, influences the way people think, act, and go beyond in their everyday context in which their customs, identity and information are transmitted to others sublimely as part of their behavior and personality. It is the result of the interrelation of nurses and women in the postpartum period. In order to improve the living conditions of puerperium women, education in appropriate health behaviors or care seeks to influence and change behavior. This concept, in turn, is comprised of three subcategories, and examines personal neglect, of hygiene and dietary conditions, and spiritual neglect, a product of disinterest in the physical and emotional aspects, which affects self-esteem, self-perception and the concept we have of life. Transculturality explores myths and beliefs that a puerperal woman has a cultural value, backed by a generations-long family and social history through culture. It also examines family coercion, which is intangible, but exerted on women in the postpartum period through a kind of obligation established as a contribution to the support of the female figure. She is the mother, grandmother, mother-in-law, or sister who accompanies the postpartum mother and gives her advice during this transition. Sometimes, this advice is translated into blind obedience to the personal beliefs of the family member who has more experience with the postpartum period.
• Communication is the verbal and nonverbal exchange between two or more persons, by which feelings, knowledge, emotions, expression of ideas and exchange of views are transmitted in an environment that fosters respect for others. It was evaluated through the examination of communication barriers to identify obstacles to assertive dialogue that arise between sender and receiver (nurse-puerperal woman and vice versa). These were observed without empathizing, by adopting a disinterested attitude through a subtle expression, because in most cases non-verbal communication is perceived by others, which hinders interaction. The third limitation is the repository of information. Commonly, to transfer ideas conveniently, speech can be monotonous, without considering the individual needs and characteristics of women passing through the postpartum period.
• Education is the intentional, direct transformation of consciousness according to the physical, psychological and emotional needs that stimulate the development of knowledge, attitudes, values, practices, behaviors and actions of professional nurses and women in puerperium. To carry out education, assessing the educational needs of the puerperal woman in regards to their situation, whether or not they are conscious of it, is needed. The nurse must choose the right time to intervene for the education of the puerperal woman,  distinguish who they are teaching, and have insight into how they learn, referring to the characteristics in which learning occurs in postpartum women, and the use of methodologies in the educational process by the teacher.

 

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.

Results and discussion

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

Conclusions

• The postpartum period is a unique and transient event in women, from which she is transformed from the social, biophysical, emotional and spiritual points of view. This is reflected in the attitude and actions the woman takes regarding the care of herself and the newborn.
• The effectiveness of the educational process depends on its adaptation to the aforementioned or perceived needs by users and appropriate use of language by the nurse with the postpartum woman, to develop her cognitive skills and practices during self-care, care and adaptation to her new role.
• Even when women do not share certain characteristics such as age, socioeconomic status, number of children, and number of post-natal periods experienced, they have something in common. The common condition is transiting the postpartum period and facing similar situations, such as the need for emotional and educational support. However, as dominion over certain situation is perceived, they do not accept the educational support. Moreover, the fact that they have experienced the postpartum period at another time in their life does not ensure favorable conditions for self-care and newborn care behaviors.
• The support received by the woman during the postpartum period is conditioned by family and cultural structure, socially established by the mother or grandmother, typical of the dynamic that has developed over previous generations. The family demands a tribute to the informal education provided regarding the values, customs, myths and taboos regarding becoming a mother.
• The traditional family structure whose members and roles have been modified is an important aspect to consider, as well as the acquisition of lifestyles influenced by globalization and technological development. Logically, the needs of a puerperal mother can undergo rapid changes, adapting to the demands of everyday life. To meet the requirements of the situation, the nurse must redirect their actions in the field of education.
• Creating awareness and sensitivity in people is essential in any educational process, so that the person distinguishes and decides on behaviors that will favor their health and that of the newborn. Therefore, approaching the process with accurate, simple and clear information, will help the postpartum woman differentiate between the myths and beliefs about:  Why it has always been done that way?; or, Why has it been accepted?
• Transforming the experience to become a critical monitor of their own practices allows the nurse to find areas of opportunity and take into account a broader picture of the phenomenon under study.

Proposal

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.

 

• The care that women in puerperium can provide the newborn is maternal care, defined as the ability to express through love, meeting the physical, emotional and psychological needs of the newborn, which strengthens the mother-child bond.
• Care during the inter-relationship of the nurse with women in puerperium, called therapeutic nursing care, is the professional intervention of the nurse, consistent with a person’s actual or potential needs to maximize the potential to be human and her condition as a postpartum woman in the biological, psychological, social and spiritual dimensions, to be able to adapt to the new environment and living conditions during their evolution.
• The social projection of professional nursing is based on fundamental principles, values, attitudes and skills during care or education. At all times, they should express the moral and ethical commitment to caring, with the profession and society. It also includes personal commitment to their own care and academic training, continuous updating and self-assessment; as well as growth and personal and professional identity, to maintain a positive and empathetic attitude.
• Educational nursing care, defined as the autonomous act derived from actions aimed at solving problems or potential health needs in order to develop skills for self-care and care for others, by implementing appropriate strategies that promote healthy behaviors to the care person. It can be considered the moment when the nurse teaches a postpartum woman how to take care of herself.
• The woman's care for herself during the postpartum period refers to the awareness and internalization, with respect to the acquisition and development of attitudes and skills to make decisions and actions for improving the quality of life according to the new conditions. Postpartum women with awareness of self and of their condition promote in other puerperal women their experiences of self-care and care for life. With the acquisition and practice of healthy behaviors, not only does the risk of complications decrease, there is additionally the balance and the emotional tranquility to enjoy motherhood, other life events, achieving fulfillment as a human being.

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