Postpartum RNs Influence Through Action: Empowering Patients to Identify Perinatal Mood and Anxiety Disorders

Tuesday, 31 October 2017: 9:20 AM

Kathryn M. Giddens, BSN
Maternal Infant Services, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
Ellen K. Fleischman, MSN, MBA
Maternal Infant Services & Support Programs, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA


The aim of this collaborative, evidence-based practice project (EBP) at a large, free-standing women’s hospital was to improve nurses’ knowledge of Perinatal Mood and Anxiety Disorders and to increase patients’ knowledge about these disorders. This project is significant for several reasons. Hospital nurses reported a lack of knowledge and confidence in having a productive discussion with patients regarding the potential of developing Perinatal Mood and Anxiety Disorders. Maternity patients are not always screened for this disorder by providers, and if screened, patients may not seek treatment because of the social stigma associated with these disorders and expectation that new mothers should be happy. The EBP approach was used to change practice and improve patient outcomes.


Women experience an abrupt decrease in reproductive hormones in the immediate postpartum period and along with genetic and environmental factors, Perinatal Mood and Anxiety Disorders can develop. Specifically, these disorders have been described in the literature as the most common complication of childbirth, occurring in 10-20% of cases. Perinatal Mood and Anxiety Disorders are psychiatric conditions occurring during pregnancy and up to a year postpartum, and include depression, bipolar disorder, and anxiety disorders, post- traumatic stress disorder (PTSD), obsessive-compulsive disorder, and psychosis. While postpartum blues can occur commonly in the first week to 12 days after delivery and include symptoms such as crying, anxiety, insomnia, and loss of appetite, symptoms lasting beyond this period may be attributable to Perinatal Mood and Anxiety Disorders. These symptoms may occur at a time when mothers are not seen by a medical provider. Despite the prevalence of these disorders, they are detected and treated in less than half of cases, in part due to social stigma (O’Hara & Wisner, 2014). Untreated perinatal depression and other disorders can lead to a variety of negative outcomes, including impaired infant development and maternal suicide (Gjerdingen & Yawn, 2007; O’Hara & Swain, 1996; O’Hara & Wisner, 2014).


The eight step Evidence Based Practice (EBP) Institute Model, adapted by Brown and Ecoff (2007) from Hayward’s Evidence-based Information Cycle (2007) and Rossmann and Larrabee’s EBP Model for Change (1999) was used to guide this project. The first step in the model is to identify a catalyst for change. Nurses and social workers attending Perinatal Mood and Anxiety Disorder presentations at separate national nursing conferences were inspired to collaborate to improve awareness in postpartum patients about the potential of developing these disorders. The second step in the EBP model is assess (why is this problem important?). A baseline survey of staff demonstrated inconsistencies in discharge education related to Perinatal Mood and Anxiety Disorders, and a need to improve nurse and patient knowledge was identified. Asking or developing a focused question, is the third step. Our PICO question was: Among Maternal Infant Services (MIS) nurses and patients, does providing education related to Perinatal Mood and Anxiety Disorders, as compared to current practice, improve the nurses' knowledge, attitudes, and practice and patients' knowledge about signs, symptoms, and resources for these disorders? The fourth step in the EBP model is to acquire or review available evidence including the literature. A thorough literature search related to Perinatal Mood and Anxiety Disorders, discharge education, and nurse’s knowledge was conducted and then appraised, which is the fifth step in the model. The appraising step includes reviewing the evidence and deciding the applicability to the project. The present EBP project was guided by “Self-Efficacy and Postpartum Depression Teaching Behaviors of Hospital-Based Perinatal Nurses” published in The Journal of Perinatal Education (Logsdon, M.C., Pinto Foltz, M., Scheetz, J., & Myers, J.A., 2010). With permission, the instrument used in that study was used in this EBP project. The sixth step is applying which includes actually applying the evidence to a change in practice. A department-wide educational intervention was developed collaboratively with social work to improve nursing knowledge, attitudes, and practice, as well as patient knowledge using formalized education. Nurses and social workers developed a comprehensive patient education flier, outlining signs, symptoms, and resources related to Perinatal Mood and Anxiety Disorders. Then a department-wide evidence-based nurse educational intervention was implemented, using in-services and educational posters to amplify the education. Clinical nurses (n=30) completed a retrospective pre-post survey measuring their knowledge, attitudes, and practice on Perinatal Mood and Anxiety Disorders and were instructed to educate their patients using the newly-developed education material as part of discharge education. After receiving this education, patients completed a four question survey, measuring their knowledge of Perinatal Mood and Anxiety Disorders. The seventh step of the EBP model includes analyzing the result of the change intervention. In this project, a comparison of pre- and post- change/education results was done. Results from both surveys are discussed in the Results section. The eighth and final step is advancing and adopting which includes sharing results internally and externally to the organization. Although this EBP project started in the postpartum unit, results were shared with other departments in a presentation at the hospital’s Research and Innovations Council and the advanced clinician monthly meeting. An abstract was also submitted to the Association of Women's Health, Obstetric and Neonatal Nurses national conference for external presentation.


The nurses’ survey instrument included seven demographic questions and four, five-level Likert scale questions. The mean scores from the retrospective pre-, post- 1, and 30 day post- surveys were compared. There were significant differences (p=.000) in the following areas: (1) knowledge of Perinatal Mood and Anxiety Disorders (M = 2.83 pre; M = 3.64 post), (2) current teaching practices(M = 3.34 pre; M = 4.12 post), (3) comfort in teaching (M = 3.66 pre; M = 4.20 post), and (4) attitudes that Perinatal Mood and Anxiety Disorders education should be provided to all postpartum patients (M = 4.71 pre; M = 4.89 post). The patients’ surveyincluded 4 questions related to the education received and their knowledge of Perinatal Mood and Anxiety Disorders. On a 5 point Likert scale, patients rated their knowledge of Perinatal Mood and Anxiety Disorders at a mean of 4.27 (SD=.60 with a range 1=low, 5=high) after receiving discharge education. Nearly all patients (29/30) answered “yes” that they had more knowledge than before the nurse reviewed the information in the discharge education.

Implications for practice

Clinical nurses play a critical role in empowering patients with information about Perinatal Mood and Anxiety Disorders. Enhancing nurses’ knowledge, teaching competencies, and creating nursing interventions around these disorders within the discharge education are strategies to enhance a mothers’ recognition of the symptoms and resources. By empowering patients with knowledge about the signs, symptoms, and resources available for Perinatal Mood and Anxiety Disorders, patients will be better prepared to identify these disorders and seek treatment if indicated. Although the initial EBP project included only 30 nurses, the information was disseminated to a larger group of nurses within the hospital. A professional development workshop focused on Perinatal Mood and Anxiety Disorders was held, and registration was open to all nurses at the hospital. A Psychiatrist who works at an outpatient clinic with Perinatal Mood and Anxiety Disorder patients and a panel of former patients gave a captivating presentation to over 65 nurses. To further educate staff, an annual nursing competency focusing on Perinatal Mood and Anxiety Disorders and other psychiatric disorders seen in perinatal patients was developed. This education will be implemented hospital-wide in the spring of 2017.


Because clinical nurses play an important role in patient education, it is recommended all nurses working with maternity patients receive education on Perinatal Mood and Anxiety Disorders. Providing perinatal patients with an awareness of these disorders is critical, since symptoms may appear up to a year postpartum when the mother is in a period when they are not typically seen by a medical professional. Nurses can empower these women and their family members with information and engage them in recognizing signs and symptoms and then need to seek treatment if necessary. It is also recommended that a collaborative, inter-professional approach be used for Perinatal Mood and Anxiety Disorders education, using resources such as social workers and psychiatrists. Improving perinatal providers’ awareness of the importance of screening pregnant and postpartum patients in the office is vital for the timely identification and treatment of women with these disorders.