THE STANDARDS FOR POSTNATAL CARE BY THE MIDWIFE IN THE HOSPITAL AND THE COMMUNITY

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The tfdtd+bemfy$ eventsare normal physiological processes in the body o f the w orn» and embryotfocmfbaby, Many changes in the internal and external environments cfthefitm Sy take place, simultaneously with these normal processes.These changes lead to the development <f certain tasks and responsibilities that m m be accomplished during the postnatal period.
A description o f the tnidwfó's caring junctions during the post-natal period, in the h o sp M a sw e ttm in the community, is therefore essential This description forms the pórt t f r n arHde that m s published in the previous issue o f Curanonts.Thenrfier fa jfa m tfa tim o f valid standards for postnatal care by the midwife can com m ute t0 quality pa st-m a t care in South Africa.
The aim th is second p a rt o f the study m s to formulate valid general standards fo r postnatal care try the midwife; Coneepfttandards m teform dated with the model o f postnatal care and the stated prerequisites Of sating as conceptual framework.The statistical validity o f all the standards were determined by midwifery experts.

THE NECESSITY OF THE STUDY AND THE IMPORTANCE OF THE RESEARCH PROBLEM
Many changes have taken place in midwifery during the last half of this century.These were described in the first part of this work.
The early postpartum period is, however, not an ideal time for extensive patient teaching, as a result of the mother's priority needs for comfort and rest.A new mother also needs to integrate the experiences of labour with delivery and to fill in the missing pieces in her mind.Women are often critical of their performance during labour and talking about the experience is one of the important psychological tasks of the postpartum penod.
Early discharge precludes extensive patient teaching and deprives the mother of the opportunity to talk to the midwife about her experiences, if good follow-up care for the mother is not provided (Lemmer, 1986: 235;Shehan, 1981:21).
The questions that arise are: • What are the caring activities which the midwife should carry out to assist and facilitate the new family to grow on the health continuum during the postnatal period?
• How can quality care be assured during the postnatal period?
A description of the m idw ife's caring functions during the postnatal period, in the hospital as well as in the community, is therefore essential.Only thereafter can the form ulation of the valid standards for postnatal care by the midwife contribute to the quality of post-natal care in South Africa.

THE AIM OF THE STUDY
The aim of the study was to: • design a model for postnatal care rendered by the midwife to the new family in hospital and, after discharge in the community (done in previous research); • formulate valid general standards for postnatal care by the midwife;

DESIGN AND METHOD OF THE RESEARCH
A descriptive design was used to explore, identify, describe and validate the variables for postnatal care within the context of the Republic of South Africa.
The research technique for the formulation of nursing standards comprises development and quantifying phases (Muller, 1990:19).
The developm ent phase resulted in a description of the phenomenon of caring by the midwife during the child-bearing period.
From such exploration, a model for postnatal care by the midwife was designed (Nolte 1992).
The quantifying phase of the study is the focus of this article in which concept standards were formulated with the model of postnatal care and the stated prerequisites of caring as conceptual framework.The standards, with their underlying principles and criteria, were listed and distributed to a peer group of expats for discussion, cognitive analysis and logical system atisation.
Background information about the research as well as instructions related to preparation for discussion of the standards, were sent to the sample of experts, together with the concept standards.The researcher's telephone number was made available to them and was listed on the instructions in case problems were experienced.
The goal for the discussion was refinement of standards in order to reinforce content validity.Every standard and characteristic were discussed separately.The following was expected of the peer group during their preparation, as well as in the discussion: a) determination as to whether standards and characteristics were: 1 -irrelevant/ not applicable to postnatal care 2 • unclear and non-applicable 3 -applicable but require reformulation 4 -complete, clear, well formulated and highly applicable/realistic to use as a minimum standard in postnatal institutions in order to assure/improve the quality of post-natal care.
b) recommendations for changes in terms of additions and omissions to standards.
The statistical validity of all the standards was determined (Lynn, 1986:383).
After the standards had been refined, the same 4-point ordinal Likert scale was used to evaluate the validity of each standard.
These sets of standards with appropriate background information, were sent to 100 midwives in different areas of expertise for validation.
The population for peer group review and validation of standards.
The target population consisted of: • All the midwives in South Africa who are involved in giving postnatal care in public and p riv a te h o sp itals and in the community, • Midwives who are studying for, or have com pleted their m aster's degree in midwifery; • University lecturers in midwifery; • University lecturers who are experts in the formulation of standards.
Both academic and practical experience was considered to be expertise in midwifery.

The sample
Convenience sampling from the target population was used during both stages of validation of Lhe standards.
Nine midwifery experts and one expert in the formulation of standards in the Witwatersrand -Pretoria area were selected to take part in a peer group discussion of the standards.The midwifery experts were selected to represent institutions where postnatal care is rendered, namely: -Two from private hospitals (both are studying for their master's degree in midwifery); -Three from public hospitals (academic as well as non-academic hospitals), of whom one is a nursing manager, one is studying for her master's degree in midwifery and the other midwife has this qualification; One from the community (who has a master's-degree in community health nursing); -One from a neonatal unit (who is studying for a master's-degree in midwifery); • Two who are engaged in midwifery education at universities (both have master's-degrees in midwifery); • One lecturer in nursing management, who is also an expert in the formulation of standards (she has a doctorate in nursing management -quality assurance).
There are no known guidelines available for the national validation of standards.On the recommendation of a statistics consultant, it was decided to use a minimum of forty experts and a sample of 100 people was drawn to make provision for loss of subjects.The sample consisted of: • The ten experts described above.
• A further contingent of 90 additional experts in midwifery was selected, namely: -Ten midwives of all races in the Western Cape region who practise in the public sector as well as in community clinics; Twelve midwives who are working in community health clinics in the Witwatersrand area.

Content validity
The content validity was confirmed through the literature as well as by the experts and was determined statistically during the quantifying stage by means of a content validity index.
The index was derived from the rating of the content relevance o f the item s on an instrument using a 4-point ordinal rating scale, where 1 connotes an irrelevant item and 4 an extremely relevant item (Muller, 1990:228).An item scoring 3 or 4 was considered valid.
The construct v alidity of the standards was not determined.

Reliability
The researcher tried to control reliability in the following ways (Muller, 1990:229).
-a structured two-phase procedure was used for the validation of the standards.
-clear and structured written instructions were given to the participants during both stages.
-during the discussion of standards, the researcher tried to give each person an equal opportunity to give her opinion about the relevant standard.The group was not dominated by the opinions of one specific person.
-a relatively large group of expert midwives who were not part of the discussion group were selected to validate the standards during the second stage in order to limit the direct influence of the researcher on the participants.
a list of definitions was attached to the standards to explain the meaning of some terminology.
the participants were assured of confidentiality in order to improve objectivity and honesty in their grading of the standards.

Results of the validation of standards
During this phase the statistical validity of all the standards were determined (Lynn, 1986: 383).
After the standards had been refined, the 4 point ordinal Likert scale was used to evaluate the validity of each standard.

THE MIDWIFE Principle
An appropriately qualified midwife, who keeps her knowledge updated, and contributes towards quality midwifery care in the postnatal period.

Standard
The midwife responsible for postnatal care is qualified and keeps her knowledge updated.

Required characteristics
The midwife is registered with the South African Nursing Council as midwife.
It is desirable but not a requirement, that the midwife is also registered as general-and community nurse.
The m idw ife dem onstrates that she is cognisant of changing concepts, trends and scientific advances in postnatal care by p a rtic ip a tio n in sta ff developm ent programmes and by being an active and participating member of the Society for Midwives of Southern Africa.

Principle
Written goals and objectives reflect goal directed postnatal care and are based upon knowledge, skills and judgements reflected in the goals.

Standard
The midwife formulates postnatal care goals and objectives and ensures that they are met

Required characteristics
There is evidence of written long and short term goals and objectives in the appropriate postnatal service.
The goals are in harmony with those of the nursing service, organisation, nursing profession and the postnatal care philosophy.
The goals and objectives are stated in measurable, behavioural terms, allowing for a realistic evaluation of results/outcomes.
The midwife is the facilitator for the achievement of postnatal care goals that include the following aspects: -ensurance of an optimum level of physical health for every member of the family (Reformulate/reject).
-the experience gives meaning and value for the new family (Reformulate).
-parents have a realistic perception and concept of themselves, -their bodies and their abilities as parents (Reformulate/reject).
-the identification and expression of feelings and the formation of healthy relations among the different family members (Reformulate).
-family members take the responsibility, individually and as a unit, to promote, maintain and restore their own health, as well as the health of their baby.They make use of their rights and responsibilities to participate actively in decisions about their health and health care (Reformulate).

Principle
Policies and procedures define the boundaries of the midwifery practice within the health care setting.

Standard
There is a set of policy statements and procedures in every postnatal service.

Required characteristics
The relevant South African Nursing Council regulations and other health care acts are available; Policies for postnatal care service include: • parameters and methods for assessing the postnatal status of the family.
• parameters and methods for assessing the well being of the newborn.
• medications used during the postnatal period.
• parameters for deviations from normal and appropriate interventions.
• parameters for referral to other disciplines in the health care team.
• parameters for diagnostic and treatment procedures.
The content validity is confirmed through the literature as well as by the experts.It was determined statistically during the quantifying stage by means of a content validity index.This was derived from rating the content relevance of items on an instrument using a 4-point ordinal rating scale, where 1 connotes an irrelevant item and 4 an extremely relevant item (Muller, 1990:228).
An average content validity index of 3,5 was used in this study as the minimum to accept a standard/criterion (Muller, 1990).A standard deviation within the 0,05 level of significance was taken to indicate consensus between the respondents.Items with standard deviations o u tsid e th is ran g e require reformulation/validation depending on the type of grading done by the respondents.
The results of the assessment of the validity of standards/criteria are presented as follows: the standard/criterion is stated and the need for reformulation or rejection is indicated in brackets.
The standards/criteria which were accepted have no brackets.

PHILOSOPHY Principle
A philosophy states those values and beliefs that influence the practice of the midwife.It serves as a guide for and an explanation of action.

Standard
There is a written philosophy for postnatal care (Reformulate)

Required characteristics
There is evidence of a written postnatal philosophy in the appropriate health service (Reformulate); The philosophy flows from and is congruent with the philosophies of the health institution and the nursing profession (Reformulate).
There is proof of continuous revision of the philosophy to include the latest scientific knowledge/advances (Reformulate).
The components of the philosophy include belief statements regarding: -the family during the postnatal period (Reformulate) the practice of the midwife;

SCIENTIFIC METHOD OF NURSING Principle
The utilisation of a scientific method of nursing contributes towards individualised, goal directed nursing.

Standard
The scientific method of nursing is utilised by means of a nursing documentation system in accordance with the scope of practice for midwives (South African Nursing Council R2598 as amended).

Required characteristics
T he p rin c ip le s o f sc ie n tific nursing (assessment, planning, implementation and evaluation of postnatal care) are utilised and documented for each childbearing family from admission/acceptance through to the end of the postnatal period.

Assessment
Each family's nursing needs are assessed by a midwife at the time of admission/acceptance and continously during the postnatal period (in hospital and in the community) (Reformulate).
Continuous assessment includes the following aspects: • physical aspects of both the mother and the baby • psychological aspects of the new family, which include the family relations and the self concept of the parents (Reformulate) • motherhood skills in baby care activities • educational needs of the family members • social aspects which include general living conditions, forms of social support, the roles of extended family members and the influence of cultural beliefs and uses (Reformulate).

Planning
The data obtained from the assessment provides a basis for nursing diagnosis and contributes to the formulation of care plan; Midwives are responsible for the planning of the care; The care planning is in accordance with: • the scope of practice for midwives (South A frican N ursing C ouncil R2598 as amended) • written goals and objectives, policies, procedures and standards of the specific postnatal service • the medical therapy prescribed by the medical practitioner • the actions of the other health team members (Reformulate).
Care is planned according to the needs and health problems of the individual/family.
The plan of care is well documented in the patient's records.

IMPLEMENTATION
The implementation of the nursing care plan is supervised by a midwife.
documentation of nursing care is appropriate, precise and reflects family status (Reformulate).
the care is facilitative and supportive.

Evaluation
Evaluation of goal achievements is performed and documented; Evaluation of goal achievement is evaluated by a midwife continuously and at the end of the postnatal period in hospital and at home.

Documentation
D o cum entation com plies w ith legal requirements.
The document is a complete reflection of the family's health care condition (Reformulate).
The document is an effective record of reality (Reformulate).

Principle
Postnatal care is facilitative and supportive activity to promote, maintain and restore the health of the family, depending on the status of the family on the health continuum.The care is based on scientific knowledge and the available technology.

Standard
The stated objectives and goals for the family to prom ote progression on the health continuum will be met through quality postnatal care.

Standard
The prerequisites of care must be met before quality care can take place.

Required characteristics
Members of the family verbalise that: • the midwife demonstrates unconditional acceptance of them as persons and of their values and beliefs; • she treats the individual/family as dignified person/s with a potential for success.
• she accepts and respects their individual uniqueness; • she accepts and promotes their rights and responsibilities to participate actively in decisions about their own health and health care during the postnatal period; • they have confidence and faith in the midwife's expertise; • they perceive the midwife as sincere and willing to care for them; • the m idw ife u tilise s effe c tiv e communication skills.
• she listens and hears the most important cognitive messages and identifies the underlying affective messages in the family's communication; • she perceives the family's non-verbal messages; • she responds in a verbal and non-verbal way that indicates understanding and facilitates the conversation and progression of the relationship; • she accepts and promotes the expression of positive and negative feelings; • she responds in verbal as well as non-verbal ways that indicate empathy;

Standard
The facilitating and supportive activities of the m id w ife, c o n sist o f g u id an ce, accompaniment, support, crises intervention and the provision of an environment that p ro m o tes p ro g ressio n on the health continuum.These activities are carried out collectively or individually depending on the individual/family's bio-psycho-social needs.

Guidance
The midwife assists the family in directing them to an unknown area of which they have a lack of knowledge and/or experience; The guidance is appropriate to the needs of the individual/family whether in the form of suggestions, instructions, direction or supervision;

Support
The midwife supports the individual/family by: • sustaining them in effort and helping them with the tasks thereby preventing them from failing or avoiding an unpleasant situation or decision (Reformulate): • mobilizing their psycological resources; • her availability in respect of time, strength, emotion and information; The midwife's supportive actions include physical, em otional, inform ational and spiritual support The midwife enhances the capacity of the natural social support system; The midwife encourage the use and/or formation of self-help groups to provide this support

Health education of the family
Health education of the family takes place in the hospital during the postnatal period (Reformulate/reject).
Health education is continued when the patient is discharged from hospital by means of handouts, postnatal classes self-help groups and the community midwife; There is evidence of communication between the midwife in the hospital and the community regarding unattained educational objectives (Reformulate).
Health Education is based on the problem solving process; Health education is based on an assessment of the following aspects of the family; -readiness and motivation to learn (Reformulate); there unique learning needs; -their background, lifestyle, habits of daily living, their modes of thinking and perceiving and other sources of learning.
Objectives for health education are stated; The content is determined and includes physical, psychological as well as spiritual aspects depending on the family's needs; The health education methods and techniques are determined by the learning needs of the family; Evaluation of the achievement of learning objectives is performed (Reformulate); The formal written programme for postnatal patient education, is available, consisting of all the aspects th at should be taught (Reformulate); The -realistic expectations on the part of the mother of her own body and physical abilities (Reformulate); The fam ily verb alises/d em o n strates knowledge about self care responsibilities based on effective preparation for discharge from the hospital in the following areas: -personal physical care (Reformulate); -physical care for the baby (Reformulate); -parenting skills; -sibling rivalry (Reformulate); sexual activity and contraception (Reformulate); signs of possible complications and the acctions that will be necessary (Reformulate); -scheduled appointments for postnatal examinations of mother and baby; -information on social support systems (Reformulate); information on community postnatal services (Reformulate); Provision of an environment that promotes progression on the health continuum P o stn atal care is provided in a safe environment where the midwife; • assesses the practice setting for reasonable freedom from environmental hazards; • promotes adequate staffing in the postnatal ward (Reformulate); • knows the location and use of emergency equipment; • she abides by infection control procedures; • demonstrates accessibility to an emergency transport system appropriate for the practice setting where applicable; • she assesses the environment for safety, availability and adequacy of equipment and supplies (Reformulate); • m aintains a healthy interpersonal relationship with other members of the health team.
Postnatal care is provided in an environment which is as homelike as possible where: -the family members feel comfortable and secure (Reformulate); -rest and graded activity are promoted; -an adequate diet is provided; -physical well-being is promoted; -visiting hours improve family relationships; flexibility in the rooming-in system makes provision for individual needs; -provision is made for the privacy of the family (Reformulate).
The mental and psychological environment is as comfortable as possible in a relationship of acceptance and trust (Reformulate).
new stimuli are introduced slowly so that the family gets time to get to know them; -the attachment between the family and the new baby is enhanced; -where a healthy integration of the labour experience takes place, and -where the promotion of a better self-concept and self esteem for all the family members takes place (Reformulate).

Accompaniment
Through accompaniment the family can be led to independance and the finding of meaning and a worthy existence (Reformulate); supportive action; A ccom panim ent does not take place continuously but only when the family cannot act independently and needs help.
The midwife does crisis intervention when the family have a crisis; Crisis intervention is based on an assessment of the following aspects of the family: -the abilities of the family members; -their readiness and motivation to learn; -their unique needs; -their background, lifestyle, habits of daily living, their modes of thinking and perceiving.
Crisis intervention is based on the problem solving process; The midwife uses her verbal and non-verbal com m unication skills to facilitate the following: airing of the family member's feelings; working through their feelings; Til ere is evidence of communication between the midwife the hospital and the community regarding unattained objectives for crises intervention.
C ontinuation of postnatal care by the midwife There is evidence of formal communication between the hospital based midwife and the community health midwife (Reformulate).
There is evidence of continuation of quality postnatal care by the community midwife after the mother's discharge from the hospital.

CONCLUSIONS
In these conclusions each group of standards will be discussed separately.

The midwife
The standard, as well as the characteristics from this group was accepted and remained unchanged except for the characteristic about the midwife's registration as general-and community health nurse which must be reformulated.The fact that only 38% of the sample were registered as community health nurses could account for this result The philosophy The standard, as well as all but one of the c rite ria fo r th is standard, m ust be reformulated.The result, however, does not reflect whether the respondents think that this standard is not practical, whether it is unnecessary to have a philosophy or whether it was badly formulated.

Goals and objectives
The standard as well as the characteristics indicating the necessity o f goals and objectives was accepted.The specific objectives for postnatal care show the following results: The characteristic "assurance of an optimum level of physical health for every member of the family" was rejected.Comments on this item by different respondents indicate that they have a problem with "every" member of the family.
Another rejected characteristic was that which stated the parents must have a realistic perception and concept of themselves and their bodies.However, the literature indicates this as an essential objective in postnatal care by the midwife.This item therefore should be reform ulated and m idwives should be educated about the necessity of this objective.This recommendation also applies to the other objectives which require reformulation.
The rejection of some of the above-mentioned items on the objectives of care also has an important effect on the acceptance of the model of care by the midwife.

Policies and procedures
The standard, as well as its characteristics on policies and procedures was accepted and remained unchanged.
Scientific method of nursing Although it is not indicated as such, it was mainly the midwives from the private hospitals who had problems with these items.
The standard was accepted.None of the characteristics were rejected but a few needed reformulation.
The respondents indicated a problem with assessing the "family's" needs and the question arises whether "family-centred care" is really practical.
Care by the midwife The standard was accepted and can stay unchanged.
Prerequisites for care The standard as well as all the characteristics were accepted and can stay unchanged.This also serves as acceptance for this part of the model of care by the midwife.
The constituents of care The standard was accepted and can stay unchanged.

Guidance
All the criteria under guidance were accepted and can stay unchanged.

Support
Under the heading "support", all the criteria were accepted and stayed unchanged, except for one which must be reformulated.This item must be reformulated because of its length, which makes it difficult to follow and understand.
Health education of the family Most of the criteria under this heading were accepted with a few exceptions.The items which were rejected were those on: Health education of the "family" in the hospital.The respondents again indicated problems with educating the whole family.This criterion was rejected.
-Communication between hospital and community midwives must be reformulated.Although a few respondents indicated that this criterion should be reformulated, it is not clear whether the criterion was not clearly stated or whether they think that this is not a very practical criterion.
The criteria regarding the contents of education were rejected, namely, the physical environment and sibling rivalry.
Of the 32 criteria on health education 16 (50%) must be reformulated.The remarks made by some of the respondents next to these criteria, again indicate that these should rather be criteria for an ideal situation.The researcher got the impression that the respondents marked 3 on the Likert scale not because the criteria are unclear to them, but rather because they consider the criteria as impractical.
The establishment of an environment A few criteria under this heading also need reformulation.

Accompaniment
All the criteria under accompaniment were accepted and stay unchanged except for the first one which was classified as not clear by the respondents.This criterium must therefore be reformulated.

Crisis intervention
All the criteria under this heading were accepted by the respondents.

Continuation of postnatal care
The one criterion on continuation of care was accepted w hile the o ther one on com m unication betw een hospital and community midwives needs reformulation.

RECOMMENDATIONS
The following reccommendations may be made from this study:

Future research
The following research should flow from this research project: -Qualitative studies to determine the experience of postnatal caring by the new family as well as the midwife and to compare it with these standards.

Quality assurance in postnatal care
The following steps should be followed: The reformulation of the relevant standards and criteria; The use of these standards in hospitals and maternity clinics based on the model for care by the midwife, as optimum standards for postnatal care by the midwife in South Africa; -The development and standardization of an evaluation instrument which is based on these standards and criteria; -The development of continuing education as well as in-service programmes to improve the knowledge of midwives on postnatal care, and to keep them up-to-date with the latest developments in this area.

CONCLUSION
It is clear that continuous research is essential to describe the unique role of the midwife during the child-bearing period.Thereafter the formulation of valid standards based on these descriptions, can only contribute to the quality of care provided by midwives in Southern Africa.

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Five midwives of all races in the Eastern Cape region who practise in the public sector, Pive midwives of all races in the Natal region who practise in the public sector, -Five midwives of all races in the Orange Free State region who practise in the public sector, -Twenty mid wives of all races in the Transvaal region who practise in the public sector, -Ten midwives of all races in the Transvaal region who practise in the private sector, -Six university lecturers in midwifery; -Three university lecturers in community health nursing; Four lecturers at nursing colleges; -Ten members of the Central Board of the Midwives Society of Southern Africa; fam ily v erb alizes/d em o n strates knowledge about the following aspects of diagnostic/treatment procedures: the reason and nature for the procedure (Reformulate); -possible effects/results of the treatment (Reformulate) T he fam ily v e rb a lise s/d e m o n stra tes knowledge about the following aspects: -Their physical environment during hospitalisation; (Reformulate/reject);