Combined Mother–Infant Nursing Care

research and studies

Combined Mother-Infant Nursing Care NANCY E. WATTERS, RN, MScN

A survey of five Canadian agencies where mother-infant nursing has been implemented found that there is a significant trend toward this concept of care. Agency characteristics, program operational details, the change process, and benefits are examined. Recommendations are made regarding program planning, and the need for more rigorous program evaluation is emphasized.

Over the past decade, significant progress has been made in putting the “family” back into obstetric and neonatal care. Position state- ments, guidelines, and standards related to the development of family-centered maternity and newborn services have been developed in both Canada and the United States.’.’ The initiative of obstetric nurses and their clients has spear- headed many of the recommended changes that have now been achieved. Finally, the “hub of the wheel” of postnatal family-centered nursing care is being put into place-combined care for mother- infant nursing.

Combined care for mother-infant nursing is a method of administering nursing services that en- ables one nurse to care for both the mother and infant. Combined care differs from the traditional arrangement where the nurse is assigned to either one or the other member of this pair, in separate postpartum and nursery units. Mother-infant nursing recognizes

Accepted: May 1984.

the mother-infant dyad as the re- cipient of care. Combined care is based on the assumption that the well being of the mother and the infant is interdependent as they adjust to multiple physical and psychosocial changes during the early postpartal and neonatal days. The assignment of the same nurse to both the mother and her infant increases the continuity and quality of care and enhances job satisfaction for the nurse.

There is a trend* toward this method of administering nursing services that has been described as innovative and successful.3 This system is also referred to as “mother-infant nursing,” “mother- baby n ~ r s i n g , ” ~ “mother-baby primary n ~ r s i n g , ” ~ “combined care,” and “family-centered maternity care (FCMC).”~-~

A recent fact-finding mission to

* According to the survey respondents, many agencies in Canadian cities such as Vancouver, Calgary, Hamilton, and Toronto have already, or are in the process of, converting to mother-infant nursing.

Canadian agencies where combined care for mother-infant nursing has been implemented found that not only is this concept of care effective, but it is also economical and feasible.

BACKGROUND

As one stage of investigating the feasibility of changing from traditional care to mother-infant nursing at a local agency, an informal survey of five agencies that had implemented a similar change over the previous two years was under- taken. An agency questionnaire and interview guide (available from author) was developed and used in conjunction with on-site visits and personal interviews with key people responsible for the change. The questionnaire ad- dressed a) setting, population and related policies; b) operational details of the program; c) the change process; d) outcomes; and e) general.

All of the nurse-managers and consultants interviewed were ex- tremely receptive to the survey.

4 78 Novernber/Decernber 1985 JOGNN

They shared their experiences and views openly and were eager to learn about the experiences of others. Having found little specific help from the literature when planning program changes, the nurse-managers and consultants felt the survey would be an impor- tant contribution to the further development of this concept of care.

AGENCY CHARACTERISTICS

The five agencies were located in three cities in two Canadian provinces. City size ranged from 275,000 to 3,000,000. Three of the agencies stated that they had an average cross-section of clients, while two others described a fairly skewed client population. One of the latter agencies has a high proportion of wealthy clients who go home to nannies, hired to d o most of the child care. The other agency reported that most of their con- sumers are highly motivated, well read, and choose that agency because it is known to meet demands for extensive family-centered options.

The number of postpartum beds ranged from 28 to 72, and the average number of deliveries per month ranged from 250 to 380 (Ta- ble 1). Four agencies had a special antenatal unit and/or high-risk postpartum unit elsewhere in the hospital; only two reported a regular population of antenatal clients on the unit that has the mother- infant nursing program. One of these units also cares for mothers who are recovering during the fourth stage of labor.

The physical layout of the units varied from a small new unit, spe- cifically designed for combined care, to a much older unit where the nurseries are separated from the postpartum unit by a public hallway and elevator bank. The number of nurseries ranged from two to five and, in all but one case, were located centrally with respect to the postpartum beds. In the most ideal setup, the nursery was also visible from the nursing administrative center.

All units were staffed by both R N s and registered nurse assis- tants, but the ratios varied from 1

RNA:0.75 RN to 1 RNA:5.2 RNs. The mean ratio was 1 RNA:2.7 RNs. The two agencies with the highest proportion of R N s on staff reported a gradual phasing out of the RNA position.

Staff -patient ratios were calcu- lated on the basis of the number of nursery and postpartum staff on the day shift to the number of postpartum beds. Head nurses, or the equivalent patient care coordinators, were not included as staff. The ratios ranged from 1 nurse:2.8- 4.2 postpartum beds with a mean of 1 nurse:3.5 postpartum beds.

A11 agencies reported a high in- cidence of breastfeeding (75-95%). In each case, a variety of family- centered options, including those in Figure 1 , had been implemented before the change to combined care for mother-infant nursing.

OPERATIONAL DETAILS

All five agencies maintain at least one central nursery, with a core nursery staff for infants who are newly delivered, under pho-

Table 1. Agency Characteristics*

Agency

Characteristic A B C D E Range Mean

Average Number of

Number of Beds on

Deliveries per Month

the Unit

Client Distribution

Ratio of RNAs to RNs on PP/Newborn Unit

Beds on Day shiftt Ratio of Staff to PP

380 350 250 300 330 250-300 322

72 56 33 44 28 28-72 47

+- normal + 7 risk PP - +- normal PP only - - - + + +

A/N recovery A/N room L&D

1:4.6 1:1.5 1 :0.75 1 :5.2 1:1.15 1 tO.75-1~5.2 1 :2.7

1 :3.4 1:3.5 1 :2.8 114.2 1:3.5 1 :2.8-1:4.2 1:3.5

' PP = postpartum. A/N = antenatal. L&D = labour and delivery. t Includes all core nursery and mother-infant staff; does not include head nurses/patient care coordinators.

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Figure 1. The wheel of family-centered postpartum and newborn care.

totherapy, in-care for adoption and, in some cases, “stepping down” from the neonatal intensive care unit. Staff nurses rotate through the core nursery and the mother-infant team. All clients who have had a normal vaginal or cesarean delivery and whose infants are well are eligible and usually involved in the program. An occasional exception occurs when a client does not wish to have her infant stay in her room at all. One program retains the concept of mother-infant nursing even when the infant is in the neonatal intensive care unit. The nurse assigned to the postpartum client is expected to keep informed of the infant’s status, coordinate parent visits with the baby, and respond to the parent concerns.

The nurse introduces the program when she first meets the client by saying that she will be caring for both the mother and infant, at the mother’s bedside. The mother will be assisted to take on the baby’s care, as she is ready, but cesarean clients are usually not expected to do any infant care for the first two days. All agencies reported that the mother-infant pair is usually cared for by the same nurse, on the day shift, for the entire hospital stay. Continuity of patient assignment is a priority.

All agencies are flexible about having the baby returned to the nursery at the mother’s request. If the mother is out of the room, the infant can be left in the nursery, at the nurses station, or in the mother’s room, in view from the open doorway or under the short-term supervision of a willing roommate.

Mother-infant nursing is usually implemented within four to six hours of delivery, after the mother has had her first good rest and the infant has been admitted and ob- served during the early transitional period. This timing can vary. One agency offers mothers the option of keeping their infants with them continuously, from delivery; another reported that cesarean clients do not usually have their infants in the room until the second or third postpartum day.

All five agencies implement combined care for at least eight hours during the day shift. Two centers offer the program during the evening and two others intend to extend their program to 12 or 16 hours a day. Overnight, most infants are returned to the nursery, traditional care prevails, and the number of nursery staff is usually at its peak for the 24-hour period.

All respondents agreed that a ratio of one nurse to four mother- infant pairs is ideal. This is con- gruent with reports in the litera- t ~ r e . ~ . ~ A ratio of one to five, however, is a typical assignment in the programs surveyed. In two cases, a one to six ratio occurs when the unit is very busy. During the evening shift, the patient load can be increased.

Infant care protocols changed significantly as the responsibility for infant care shifted away from the core nursery staff. Infant weights and temperatures are routinely done only once in 24 hours unless they are abnormal. There is no fixed time for infant baths, and they are not always done daily. Most agencies require that infant

assessments be completed once each shift by the assigned nurse, who records data about the infant on a flow sheet clipped to the por- table cot. At least one agency keeps official records for both the infant and mother on the same chart and uses a combined mother-infant card ex.

Postpartum care schedules also changed as the nurse incorporated both mother and infant into the plan for the day. The biggest change in postpartum care is that the same individual nurse has responsibility for client teaching in all areas-postpartum changes and preventive care, as well as infant care, feeding, and discharge planning. However, all agencies have retained some group, classes on topics such as nutrition, family planning, and breastfeeding. These sessions often include films or slide presentations and are presented by staff nurses or special nurse-teachers. When the nurse is assigned to six mother-infant pairs, the group classes are relied on more heavily for patient teaching.

Visiting policies were not spe- cifically altered as a result of the new programs, but all agencies reported recent changes. Fathers are welcome any time. Siblings and, in four agencies, grandparents may visit with both mother and infant during either open or specified times. Other visitors are either discouraged from coming at all (one agency) or are restricted to specific hours in the late afternoon to early evening. Two agencies al- low other visitors in the room when the infant is present; three do not.

An operational detail that usually had to be adjusted to fit the new program was the organization of staff breaks. The timing of breaks usually changed; on some units, staff now leave in three rather than two shifts. In several places, a “float” nurse has been assigned to

480 November/December 1985 JOCNN

relieve different nurses during this time. This was described as a par- ticularly difficult change for some staff members.

THE CHANGE PROCESS

In all cases, nurse managers were responsible for initiating and supervising the change to mother- infant nursing. In three agencies, these were unit managers; in two, these were nursing directors of the overall obstetric program. Two agencies had additional consultant services from the local university schools of nursing. All respondents mentioned that support from se- nior nursing administration was essential to the success of the change.

Four agencies spent eight to nine months planning before the implementation of the new program. The fifth agency started a pilot project on half of the unit after two weeks of planning-it was another year and one-half before the total program was implemented.

Proposals were developed for approval by one or two levels of hospital administration. The idea was marketed to staff, physicians, and clients via nursing and medical staff meetings, written brochures, community committees, prenatal programs, and visits to similar programs for selected nursing staff. To involve nursing staff in planning the change, most agencies used several mechanisms-committees to develop aspects of staff development, and problem-solving meetings for ventilation of concerns and decision making about program details.

Two agencies reported a successful pilot or trial of the program. In one of these agencies, a large unit is divided into two “ends.” One of these ends, with its asso- ciated nurseries, was set up as a pilot for the new program for an indefinite length of time. The pilot end was initially staffed by the

nurses who were most interested in the concept. This had several benefits:

1) the “bugs” could be worked out of the new program without throwing the entire unit into chaos;

2) the threat of change was re- duced for the most resistant staff nurses as they had time to adjust to the new concept;

3) the unit could still retreat from the new program without the stigma of failure;

4) a cadre of well motivated, ex- perienced staff members was developed who could, then, positively influence their more resistant peers.

The other agency ran a one- month trial period on the entire 28- bed unit once staff development was completed. This trial proved to be a critical stage for working out the details of the new program. For example, it was found that su- perimposing infant care on the usual postpartum schedule did not work; the staff themselves developed a revised schedule for delivering combined care.

Staff development took the greatest proportion of the planning time and was approached quite dif- ferently by each agency. However, there was agreement about the new knowledge and skills required by staff-postpartum assessment and care for the nursery staff, and neonatal assessment and care for the postpartum staff. In one agency, where staff had been rotating through the nursery and postpartum units for many years, no formal staff development program was established.

Rotating staff through the existing traditional roles was an orientation approach used by several agencies before the change. In the agency with the pilot project, staff were rotated through the pilot “end,” where a university faculty consultant did the orientation and

teaching. In another case, several staff committees developed and presented content for an educational day attended by all staff members. Two agencies allotted a specific number of days per staff member for theory and supervised practice. These days were tailored, to some extent, to meet individual learning needs, and the time included some practice with mother- infant nursing. Time alloted for staff development ranged from one to four days per staff member.

The greatest resistance to the change came from the nursing staff, especially those who were working in the nursery. In several cases, this resistance was so intense that certain staff were grandfathered and allowed to continue in their former roles even after program implementation.

Where staff resistance was the greatest, attempts to sabotage the new system did occur. Infants were left with mothers who were then given little help with the infant care; there were also some cases of “trading” mothers for infants. Several factors usually worked to reduce the resistance to change: opportunity for the nurses to ven- tilate their concerns; a staff development program that resulted in security of the caregivers with their new dual role; and the passage of time.

Resistance from physicians was usually minimal, once the program was established and its benefits were apparent. Several agencies reported a lingering lack of coop- eration from some pediatricians who prefer the convenience of performing infant examinations in the nursery with the help of nursing staff. This seems to be best handled by a firm stand by the nursing staff in their belief that the program is a reorganization of nursing service and, a s such, within the domain of nursing. Por- table examining trays have been provided and accompanied by

November/December 1985 JOGNN 48 1

written posters and verbal instruc- tions that suggest the infant can be examined in the mother’s room, with her assistance, as in a regular office visit. This arrangement re- lieves the nursing staff of unnec- essary errand time. Furthermore, parents appreciate being present during this procedure in order to express concerns and receive re- assurance about the infant’s progress.

Initial problems with the new program usually related to difficulty in monitoring the infant’s status and care. A system of accountability had to be worked out between the core nursery and mother-infant team who now shared responsibility in this area. One agency stated they were even prepared to see a temporary de- cline in the quality of care while these problems were being re- solved.

OUTCOMES

Four programs were reported to be working well within one to several months after implementation. One program required a year to run smoothly.

In three agencies, the main financial costs of the new programs were incurred for staff development during the planning phases. These costs were not always budgeted for but generally ranged from the equivalent of one to four paid days per staff member. Meeting time for planning was incorporated into existing schedules; some staff development occurred, cost-free, on days when patient census was low or student help was available.

Four agencies required no additional staff to implement the new program, and one agency budgeted for one new staff position. (The latter agency still has the lowest staff:patient ratio.) Physical plant or equipment costs were minimal (e.g., a set of extra scales). One unit reported a $31,000 budget savings

over the one and one-half years that their pilot program was in op- eration; financial costs of the total program were not available.

There were two benefits of mother-infant nursing reported by all agencies: increased client satisfaction and increased job satisfaction for the nurse. Four agencies also felt that quality of care was improved because the nurse knew both mother and infant and could be more sensitive to the needs of each. Mothers went home more secure and competent with infant care. Additional benefits mentioned included increased staff flexibility, range of competence, and accountability, especially in the nursery.

There were no common disadvantages reported; however, each agency mentioned at least one. These included 1) increased demands on the nurse because broader expertise is required; 2) the need for strong administrative support to handle resistance to the change; 3) the lack of suitability for wealthy clients who d o not expect to personally handle their own infant care at home; 4) the difficulty in fitting the infants into the hospital classification system to get a daily census; and 5 ) extra staff re- quirements. Each of these disadvantages was mentioned only once.

None of the agencies developed a formal plan for program evaluation before implementation. Most agencies routinely gather infor- mation about client satisfaction via questionnaires that relate to the total obstetric service. In some cases, there is an item specific to mother-infant nursing. In only two of the five agencies were these questionnaires used before a s well a s following the change.

Impressions about increased job satisfaction for staff were gathered informally via staff meetings, interviews, and day-to-day observa- tions by the nursing administra- tors. In only one agency was there

a structured plan for a before-and- after measurement of staff percep- tions: a questionnaire was used to measure staff opinion about the concept of mother--infant nursing. These results were not available at the time of the survey.

Attempts to ascertain the impact of the new programs on quality of care were limited to two agencies that listed the nursing audit as part of program evaluation. One of these was a hospital-wide audit in use for some time; the other was a unit-specific audit, which was still being developed. N o final results were available.

All agencies were committed to their new path, and, even without empirical data, the respondents were convinced of the benefits of mother-infant nursing.

CONCLUSIONS

This survey of five Canadian agencies suggests that combined care for mother-infant nursing is a feasible, cost-effective, satisfying, and beneficial method of delivering obsetric and newborn services. Each agency has a unique set of variables that will determine the operationalization of a mother-infant nursing program. These variables include physical plant, client population, administrative struc- ture and number, and educational level and skills of the nursing staff. Nurse managers responsible for the postpartum and nursery units will be the initiators and prime movers behind the change. Some resistance can be expected from nursing staff, who may be threat- ened by an expanded role. This is best met by a careful planning period of at least eight months, which incorporates principles of change theoryg*’’ to involve nursing per- sonnel and which includes a sound plan for staff development (see Appendix).

A pilot project or trial period has proven to be useful in some set-

482 November/December 1985 JOGNh

tings. Nursery staff must be prepared to revise their thinking about what constitutes safe and essential care for the newborn, and all staff must be ready to revise other schedules and routines.

As the teaching role for the nurse comes into greater focus, time should be spent in assisting staff to increase their skill and comfort with health promotion and patient education. Workshops on these topics could be part of staff development for the change. A bedside teaching manual could be developed as a working tool for the nurse and client. The manual might include guidelines for self and infant care, anticipatory guidance regarding homegoing, and other areas of usual concern. This would encourage clients to assume more responsibility for their own learning, reinforce the teaching provided by the nurse, and increase the chance that teaching would be consistent among nursing staff.

Patient charts should include some record of patient education and parent-infant attachment a s well as a record of the physical status of mother and infant. A joint mother-infant cardex is a logical communication tool for this type of program.

In most cases, combined care for mother-infant nursing costs no more than traditional care. Theo- retically, it should be more costef- fective, as many repetitive nursery tasks are eliminated. Some funds for staff development will be required during the planning stages, but these costs and savings have not yet been well budgeted out.

The benefits of the program have not been accurately measured.

While the positive results of the change seen to be immediately apparent to those involved, a careful evaluation procedure would guar- antee program stability and increase the chance of securing support for further expansion.

Combined care for mother-infant nursing is the core component of a postpartal and neonatal program that allows nurses to deliver comprehensive, satisfying care to mothers and their infants. A grow- ing trend toward this type of obstetric nursing practice indicates that it is here to stay.

REFERENCES

1. Canadian Institute of Child Health. Family centred maternity and newborn care: a resource and self- evaluation guide. Ottawa, 1980.

2. lnterprofessional Task Force on Health Care of Women and Chil- dren. Joint position statement: The development of family-centred maternity/newborn care in hospi- tals. JOGN Nurs 1978;5:55-8.

3. McKenzie CA. Forward: sympo- sium on maternal and newborn nursing. Nurs CIin North Am 1982; 17( 1): 1.

4. Harvey K. Mother-baby nursing. Nursing Management July 1982;7:

5. Vestal K. A proposal: primary nursing for the mother-baby dyad. Nurs Clin North Am 1982;17(1): 3-9.

6. Mizer H, Barraro A. Change-for nursing service and education. Nurs Clin North Am 1979;14(2): 337-47.

7. Paukert S. One hospital’s experi- ence with implementing family- centered maternity care. JOGN Nurs 1979;6:351-8.

8. Candy M. Birth of a comprehensive family-centered maternity program. JOGN Nurs 1979;2:80-4.

22-3.

9. Olson E. Strategies and techniques for the nurse change agent. Nurs Clin North Am 1979;14(2):323-36.

10. Welch L. Planned change in nursing: the theory. Nurs Clin North Am 1979; 14(2):307-2 1.

Address for correspondence: Nancy E. Watters, R N , 150 Glen Avenue, Ottawa, Ontario. CANADA K1S 3A2.

Nancy Watters is director of a research project which is designed to implement and evaluate combined care for mother-infant nursing and supported by the University of Ottawa and the Ottawa General Hospital.

Appendix: Mother-Infant Nursing- Preplanning Considerations

1. What are the advantages and disadvantages?

2. Do you have enough support for long- term commitment to the change?

3. What is the necessary staff:client ratio? Do you have this, or can you obtain this?

4. What knowledge and skills are required to care competently for the mother- infant pair? What, of this, would have to be supplemented for existing staff? How can this be achieved?

5. How will staff be included in planning the change?

6. What will be the length of the planning period?

7. Will the program be implemented for all clients or only selected mother-infant pairs?4

or trial p e r i ~ d ? ~ What would be gained?

9. What other policies will have to be changed or developed?

10. What are the costs of the change? 11. How will the new program be

12. How will the new program be

8 . What is the feasibility of a pilot project

marketed?

evaluated?

Novernber/Decernber 1985 JOGNN 483

Documents

Combined Mother–Infant Nursing Care