Home and Community Care Digest

Home and Community Care Digest 7(4) November -0001

Challenges in Shifting Care to the Community: Early Postpartum Discharge Strategies


Community-based programs, such as the Early Postpartum Discharge (EPD) strategy, have been implemented in an effort to curb acute care hospital costs. Using the example of EPD, the authors surveyed the perceptions of public health nurses and assessed the impact of a new primary health care program on the roles of public health nurses. Findings outline benefits and challenges with community care programs when services are transferred from acute care. To facilitate implementation of new community based services, health policy decision-makers need to ensure that well-structured support systems (e.g. clinical training that is program specific, supplying health professionals with proper medical equipment, and increasing access to medical support for public health nurses) are established prior to implementation and that the impact on the role of health professionals assuming the community service is considered.
Background: This study examined the impact of the Early Postpartum Discharge (EPD) strategy on public health nurses (PHN) who provide in-home follow-up to promote the safety and well-being of mothers and newborns. EPD was implemented in Winnipeg in the 1990's to curb inpatient costs, by reducing the length of hospital stay to 48 hours or less for women who had a routine vaginal delivery, and 96 hours or less for uncomplicated cesarean section. While enhanced maternal satisfaction has been associated with EPD, little evidence is available on the perceptions of community nurses who have sustained the practice.

Methods: Semi-structured interviews were conducted in focus groups (n=24) with PHNs from four community health areas in the Winnipeg Regional Health Authority. The community health areas were purposely selected to achieve diversity on geography, demographics (e.g. income, education, cultural diversity), and health indicators (e.g. mortality, rates of chronic and communicable diseases, infant health and maternal health). Interviews from focus groups were audio-taped and transcribed verbatim.

Findings: Three main themes were identified from the interview transcriptions: (1) passion for the PHN role, (2) influence of EPD on practice, and (3) building a PHN future. When asked about what attracted them to their career in public health, PHNs indicated they valued their role in health promotion, disease prevention, working with families, and providing holistic care. In response to questions regarding introduction of EPD, PHNs expressed that EPD led to a shift of focus in their postpartum practice from health promotion to screening and managing acute health problems, such as infant jaundice and weight loss, and maternal hypertension and infection. PHNs expressed that time and resources used in dealing with acute medical needs hampered their ability to develop a long-term relationship with the rest of the community and to engage in health promotion activities. PHNs also mentioned that they often felt inadequate when dealing with acute medical situations and reported lack of confidence in their clinical knowledge. Not having the infrastructure to support their work, and often working with inadequate equipment, many PHNs felt powerless to influence change.

Conclusions: Introduction of EPD has altered the role of public health nurses by shifting priorities in their practice; thereby limiting their capacity to engage in health promotion and disease prevention at the community level. The study points to the need to incorporate active participation of public health nurses, other community health professionals and stakeholders in developing collaborative, cost-effective and evidence-based approaches to community health care. Moreover, the findings demonstrate that when community care programs lack strong supporting infrastructures (e.g. providing clinical trainings that are program-specific, supplying the health professionals with proper medical equipments, and increasing access to medical support for public health nurses), it will create excess burden for community health professionals and have a reversed effect of increasing burden on the health care system. Therefore, as health policy decision makers continue to emphasize the importance of community care in Canada, we need to ensure that wellstructured support systems for community health professionals are established prior to implementing community care programs.


Cusack CL, Hall WA, Scruby LS, Wong ST. Public health nurses' (PHNs) perceptions of their role in early postpartum discharge. Canadian Journal of Public Health. 2008; 99 (3): 206-211.


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