Effectiveness of Clinical Pathway for Postnatal Mothers with Vaginal Delivery upon the Knowledge and Practice of Nurses and Maternal Outcome

Ms. K. M. Sathya Devi,¹* Dr. Latha Venkatesan², Mrs. Prof. Lizy Sonia³

¹M.Sc Nursing IInd Year, ²Principal, ³Professor, Obstetrical and Gynaecological Nursing,

Apollo College of Nursing, Chennai, Tamil Nadu

E-mail: marimuthu_sathya@yahoo.com

INTRODUCTION:

Pregnancy is a period of expectant waiting and one that all of us aspire to experience at least once in our lifetime. Widespread concerns are being voiced in the western world about rising rates of childbirth interventions and the postnatal care. A clinical pathway is the integrated care map framed with the necessary and time bound care by the multi-disciplinary team to reduce the length of hospitalization say, cost-effectiveness, improves the level of satisfaction and patient outcome. In this study, researcher devised the clinical pathway to support postnatal period by necessary interventions with set of timely framed care to improve the level of satisfaction and to evaluate of maternal outcome.

NEED FOR THE STUDY:

In present healthcare scenario, majority of the clients depend on the insurance or their health care benefits from the certified organizations. Many of the hospitals in the Tamilnadu have collaboration with the insurance agencies and providing care through the insurance mode. Need of procedure and timings are the evidences to the insurance agencies to prevent malpractice. Clinical Pathway helps in reducing the variations, improves quality care and protects the clinicians and institutions against malpractice litigation. So the researcher interested in reducing the length of stay by providing care as appropriate to time after delivery, improves the level of satisfaction and maternal outcome by framing Clinical pathway. Here the researcher developed a common clinical pathway for vaginal delivery for cost-effectiveness when they are depends on the insurance mode of paying for their health care.

STATEMENT OF THE PROBLEM:

A Quasi- Experimental Study to Assess the Effectiveness of Clinical Pathway for Postnatal Mothers with Vaginal Delivery upon the Knowledge and Practice of Nurses and Maternal Outcome at Apollo First Med Hospitals, Chennai.

OBJECTIVES OF THE STUDY:

1. To assess the pre and post-test level of knowledge and practice of nurses regarding clinical pathway for postnatal mothers with vaginal delivery.

2. To evaluate the effectiveness of clinical pathway for postnatal mothers upon the knowledge and practice of nurses.

3. To assess and compare the maternal outcome in control and experimental group regarding clinical pathway for postnatal mothers with vaginal delivery.

4. To determine the level of satisfaction upon nursing care in the control and experimental groups of postnatal mothers with vaginal delivery.

5. To determine the association between the selected demographic variables of nurses with their pre and post-test level of knowledge regarding clinical pathway for postnatal mothers with vaginal delivery.

6. To determine the association between the selected demographic variables with maternal outcome and level of satisfaction in control and experimental groups of postnatal mothers with vaginal delivery.

7. To determine the association between the selected obstetric variables with maternal outcome and level of satisfaction in control and experimental groups of postnatal mothers with vaginal delivery.

ASSUMPTIONS:

Ø The critical pathways are used to minimize the steps of unnecessary interventions to carry out the work with a time set.

Conceptual Framework based on Jean Ball Deck Chair Theory (1987)

Ø Integrated care pathway will be framed by the team of health care personnel’s to provide care for hospitalized clients.

Ø Nurses are the only personnel who always care and interact most of the time with the hospitalized clients.

Ø Clinical pathway provides satisfied care, reduces length of stay and has better client’s outcome.

Conceptual Framework

The researcher adopted Jean Ball Deck Chair Theory for this study.

The baseof the chair is formed by the maternity services resting on the views of the society regarding families.

Ø The side-strut of the chair is woman’s personality, life experiences and so on. The central strut her family and support system.

The seat of the chair is the woman’s maternal well-being.

Research Methodology

Research Approach

An Evaluative research approach is used in this study to determine the extent of primary objective is meets the desired the results.

Research design

The research designs are represented diagrammatically as follows:

For Nurses

O₁ X O₂

O₁ --- Pre-test to assess the knowledge of nurses regarding clinical pathway on postnatal mothers with vaginal delivery.

X --- Structured teaching on clinical pathway for postnatal mothers with vaginal delivery.

O₂ --- Post-test to assess the gained knowledge of nurses regarding clinical pathway on postnatal mothers with vaginal delivery.

For Postnatal mothers

- O₁

X O₁

X --- Implementation of clinical pathway for the postnatal mothers with vaginal delivery.

O₁ --- Observation of level of satisfaction and the maternal outcome for the postnatal mothers with vaginal delivery.

Tools Used in the Study

The instruments used in this study were demographic variable proforma, obstetrical variable proforma, knowledge assessment questionnaire, clinical pathway practice checklist, complication assessment rating scale and satisfaction rating scale (Developed by the researcher).

Data collection procedure

The researcher got permission from Medical superintendent at Apollo First Med Hospitals to conduct the study in their institution after the ethical committee clearance. The researcher collected the data by participatory observation technique, records and from the staff nurses. The daily observation time schedule was 12 hours of nursing practice from 7am-7pm. The data collection period was from June 17^th to July 17^th 2011. The postnatal mothers were assessed from 1 hour to 48 hours of following delivery. The researcher approached nurses in all the postnatal wards like A, D, E, H & I and selected 40 nurses by purposive sampling technique and obtained verbal consent for the study. Maintained rapport and explained about the aims of research to the nurses which are going to be conducted for the postnatal mothers with vaginal delivery. Assessed pre-test knowledge for the nurses regarding the clinical pathway for postnatal mothers with vaginal delivery through structured questionnaire. Thirty postnatal mothers with vaginal delivery were selected by using purposive sampling and observed the existing nursing practice. The researcher collected the data by daily 12 hours of nursing practice from 7am-7pm and the following nursing activities were collected from the night shift staff and the records of the mother. Checked the maternal outcome and their level of satisfaction with the existing nursing practice through the rating scale. The nurses were taught about the clinical pathway and list of cares for postnatal mothers with vaginal delivery through the structured teaching programme and implemented the clinical pathway for the practice. The researcher selected 30 postnatal mothers by purposive sampling. After 7 days of clinical pathway implementation and teaching, the researcher administered the post-test questionnaire to the same nurses and assessed their knowledge. Observed the nursing practice & checked the maternal outcome and their level of satisfaction with the rating scale. The compliance, partially compliance and non-compliance activities were monitored with the clinical pathway practice checklist.

Plan for Data analysis

Descriptive and Inferential statistical are used in this study.

Major Findings of the Study

Percentage Distribution of Pre and Post-test Level of Knowledge of Nurses in Clinical Pathway

Comparison of Mean and Standard Deviation of Level of Satisfaction in Control and Experimental Group of Postnatal Mothers with Vaginal Delivery

Level of satisfaction	Mean	SD	‘t’ value
Control group (n=30)	67.5	10.73	3.069***
Experimental group (n=30)	74.46	6.27

Comparison of Mean and Standard Deviation of Maternal Outcome in Control and Experimental Group of Postnatal Mothers with Vaginal Delivery

Maternal outcome	Mean	SD	‘t’ value
Control group (n=30)	3.26	3.55	3.336***
Experimental group (n=30)	0.93	1.43

Implications

Clinical pathway is the framed guidelines which improves the quality of care provided to the patients. It can widely use in the Education, Practice, Research and Administration. It also helps to formulate the new model in future development.

Nursing Practice

Clinical Pathways are structured, multi-disciplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management, clinical audit and also financial management. They provide detailed guidance for each stage in the management of a patient treatments & interventions with a specific condition over a given time period, and include progress and outcomes details. Clinical Pathways aim to improve, in particular, the continuity and co-ordination of care across different disciplines and sectors.

Nursing Education

The nursing care plan is a commonly used teaching tool in nursing education. By developing individualized nursing care plans for specific clients, students practice use of nursing process and making clinical judgments and decisions. However, the system of managed care has impacted current clinical practice, and many health care agencies have shifted their emphasis from requiring the traditional columnar nursing care plans to use of clinical pathways and standards of care. As result of this trend, nursing educators are faced with the problem of preparing students to cope with today's reality in clinical practice.

Clinical Pathway Practice for Postnatal Mother with Vaginal Delivery

S no	1-4 hours	4-24 hours	24-48 hours
1.	Immediate assessment Ø Assess and record the involution of uterus Ø Monitor and record the flow and status of Lochia Ø Assess and record the general condition of the mother Ø Assess and record vital signs	Immediate assessment Ø Assess and record the involution of uterus Ø Monitor and record for flow of Lochia rubra Ø Assess and record the general condition of the mother Ø Assess and record REEDA score in episiotomy wound is 0 Ø Assess for perineal hematoma(if any) Ø Inform to the doctors if haematoma presence Ø Monitor pad saturation	Immediate assessment Ø Assess and record the involution of uterus Ø Monitor and record the status of Lochia rubra Ø Assess and record the general condition of the mother. Ø Assess and record REEDA score in episiotomy is 0
2.	Oxygenation Ø Assess and record the oxygen need of the mother. Ø Provide and maintain proper ventilation Ø Suction the newborn Ø If need provide oxyhood for the newborn	Oxygenation Ø Provide and maintain adequate ventilation Ø Teach and demonstrate about the deep breathing exercises	Oxygenation Ø Provide and maintain adequate ventilation
3.	Nutrition Ø Keep NBM as per condition of the mother Ø Assess and provide bland diet/ normal diet Ø Assess the fluid status and encourage adequate fluid intake	Nutrition Ø Encourage and provide balanced diet Ø Encourage fluid intake Ø Administer nutritional supplements as prescribed	Nutrition Ø Explain about the nutritional requirements of the mother during lactation. Ø Encourage to take adequate fluid intake Ø Administer nutritional supplements
4.	Elimination Ø Assess for voiding pattern of the mother Ø Assess and provide care for Haemorrhoid if present	Elimination Ø Maintain and record I/O of the mother Ø Assess and prevent the complication of constipation	Elimination Ø Assess and maintain I/O of the mother Ø Assess and record the regular bowel pattern
5.	Position Ø Provide comfortable position Ø Teach about the different positions for breast feeding	Position Ø Provide comfortable position	Position Ø Provide comfortable position
6.	Rest Ø Promote and provide adequate rest immediately after delivery Ø Encourage adequate sleep hours Ø Explain and restrict the visitors	Rest Ø Promote and provide adequate rest and sleep.	Rest Ø Promote and provide rest and sleep
7.	Comfort Ø Encourage to have body cleanliness Ø Assess for pain at perineum Ø Provide sitz bath as prescribed. Ø Administer pain medications as prescribed	Comfort Ø Encourage overall cleanliness Ø Assess and record Afterpain Ø Assess and provide comfort measures Ø Administer pain medications as prescribed	Comfort Ø Encourage overall cleanliness Ø Administer pain medications as prescribed
8.	Regulatory functions Ø Assess and record vital signs -Temperature -Pulse -Respirations -Blood pressure Ø Assess and record the signs and symptoms of complications	Regulatory functions Ø Assess and record vital signs -Temperature -Pulse -Respirations -Blood pressure	Regulatory functions Ø Assess and record vital signs -Temperature -Pulse -Respirations -Blood pressure
9.	Personal hygiene Ø Teach and demonstrate the breast care Ø Explain and encourage about breast care Ø Teach and demonstrate about the perineal care	Personal hygiene Ø Explain and encourage to take bath daily Ø Explain and encourage about breast care Ø Encourage to have perineal hygiene	Personal hygiene Ø Explain and encourage to take bath daily Ø Explain and encourage about breast care Ø Encourage to have perineal care
10.	Safety Mother Ø Provide non-slippery floors Ø Orient and arrange the articles nearby table Ø Assess and record the signs and symptoms of early complications Ø Administer medications as prescribed Ø Administer RhoGAM immunoglobulin if the mother is Rh incompatibility. Newborn Ø Promote breast feeding at the earlier. Ø Explain and promote Rooming-in Ø Teach and demonstrate about the kangaroo care Ø Teach and demonstrate the mummification of the newborn Ø Restrict the visitors Ø Explain to avoid frequent handling of the newborn	Safety Mother Ø Assist with the mother while doing activity Ø Involve family members to prevent injury/fall Ø Administer medications as prescribed Ø Administer RhoGAM if not administered. Ø Assess and record the status of the rubella Ø Get consent for the rubella vaccines if present Newborn Ø Administer Vit. K as per order Ø Administer OPV to the newborn Ø Administer BCG vaccine within 24 hours	Safety Ø Encourage to take precautions while doing activity Ø Administer antibiotic as prescribed
11.	Communication Ø Maintain good rapport while caring mother Ø Explain adequately before doing procedures Ø Communicate all activities performed to mother and the newborn	Communication Ø Explain and involve family members during the care of mother and the newborn Ø Maintain good rapport Ø Be gentle while doing care to the mother and newborn	Communication Ø Explain all activities adequately with good rapport
12.	Spiritual Ø Provide spiritual orientation to the mother and her family members Ø Meet the spiritual need of the mother	Spiritual Ø Meet the spiritual need of the mother	Spiritual Ø Meet the spiritual need of the mother
13.	Activity Ø Encourage early ambulation Ø Assist the mother when out of bed for the first time	Activity Ø Encourage ambulation Ø Teach and demonstrate about the postnatal exercises Ø Deep breathing exercises Ø Leg and arm exercises Ø Coughing exercises Ø Kegel’s exercises Ø Back exercises Ø Assess the Homan’s sign by dorsi-flexion of the ankle of the foot and it causes pain at the calf muscles.	Activity Ø Encourage postnatal exercises
14.	Diversional needs Ø Provide psychological support Ø Provide diversional support	Diversional needs Ø Encourage the family members to involve in the mother and baby care.	Diversional needs Ø Encourage the mother to involve in baby care
15.	Health teaching Self care Ø Teach and demonstrate about self-massage of fundus Ø Explain about perineal care and sitz bath Ø Encourage to wear tight braissere Baby care Ø Assist in feeding the newborn.	Health teaching Ø Assist and encourage Coping with family routine Baby care Ø Explain and demonstrate about o Newborn suctioning o Positioning o Feeding o Diaper change o Cord care. Ø Teach and demonstrate about the baby bath Ø Provide knowledge regarding temporary /permanent family planning methods	Health teaching Ø Teach about discharge follow-up Ø Teach and provide immunisation schedule Ø Motivate the mother for temporary/ permanent family planning methods.
16.	Discharge plan ---	Discharge plan Ø Assess and record the general condition of the mother and the newborn Ø Prepare for discharge summary	Discharge plan Ø Teach and prepare for discharge

Nursing Administration

Clinical pathways (integrated care pathways) can be seen as an application of process management thinking to the improvement of patient healthcare. An aim is to re-centre the focus on the patient's overall journey, rather than the contribution of each specialty or caring function independently. Instead, all are emphasised to be working together, in the same way as a cross-functional team.

Nursing Research

Clinical pathway is using as an audit tool identify the characteristics of care well organized processes. The different research has been conducted on clinical pathway with various clinical conditions to identify the effectiveness on the patients care. The literature also suggests that clinical pathways must be developed, implemented, and evaluated utilizing validated methods including the use of best practice standards and can facilitate learning and change by employing a multitude of competencies while maintaining a sphere of influence over patient and families, nurses, and the system.

Nursing Theory

The researcher used the conceptual frame work based on Jean Ball Deck Chair (1987) in this study. This conceptual frame work helps to provide safe and secure maternity services for the population. It also stimulates to develop new models and theories for the identification of maternity needs and apply to reduce the high risks of reproductive women in future.

CONCLUSION:

This study shows that effectiveness of the clinical pathway on postnatal mothers with vaginal delivery. The researcher found that there is increase in knowledge after post-test among the nurses with practice of clinical pathway checklist. Among the postnatal mothers in the control and experimental group, the level of satisfaction and maternal outcome differs with slight significant differences. Finally the researcher reveals that the clinical pathway is very essential for practicing the nursing care activities among all groups of clients with varying clinical conditions.

REFERENCES:

1. Anderson, K. L. et al. (1994). Mosby’s Medical and Allied Health dictionary (4^thed). Missouri: Mosby

2. Blegen, M.A., Reiter, R. C., Goode, C.J., & Murphy, R. R. (2008). Outcomes of hospital based managed care:a multivariate analysis of cost and quality. Journal of Obstetrics and Gynaecology, 86(5). 809-814

3. Carol, M., & Ratiff, C. (1997). The Development and Implementation of an Integrated Multidisciplinary Clinical Pathway. Journal of WOCN, 24(2). 66-71

4. Dhaher, E. et al. ( 2008). Factors associated with lack of postnatal care among Palestinian women: A cross-sectional study of three clinics in the West Bank.Journal of BMC Pregnancy and Childbirth, 8(26). 96-99

5. DeLuc, K. et al. (2000). “Are different models of care pathways being developed?” International Journal of Health care Quality Assurance, 13(2).80-86.

Received on 13.07.2012 Modified on 25.08.2012

Accepted on 29.08.2012 © A&V Publication all right reserved

Asian J. Nur. Edu. and Research 2(3): July-Sept. 2012; Page 165-170