Promoting Couplet Caring Within a Maternal-Newborn Unit

Saturday, 28 October 2017

Jennifer L. Aguilar, MSN
Administration, Wellspan Health, York, PA, USA
Barbara L. Buchko, DNP
Department of Nursing, WellSpan Health, York, PA, USA
M. Sharon Harris, MSN
Maternal Child Health Leadership Academy, Memphis, TN, USA

Title: Promoting Couplet Caring within a Maternal-Newborn Unit


Aguilar, Jennifer; Buchko, Barbara; Harris, M. Sharon

Author Details:

Jennifer Aguilar MSN, RN,; Barbara Buchko, DNP, RNC-MNN; M. Sharon Harris, MSN, RN, NEA-BC


This project was created for the Maternal-Child Health Nurse Leadership Academy (MCHNLA) through the Sigma Theta Tau International, sponsored by Johnson and Johnson.


As the healthcare delivery system transitions to value-based care and perinatal core measures are tied to reimbursement, it invites reexamination of nursing practices in the Maternal-Newborn Unit. Improving adherence to Joint Commission Perinatal Care Measure 05 requires public awareness of breastfeeding benefits, identification of healthcare team biases, and implementation of supportive practices.

The Pennsylvania Department of Health introduced the Keystone 10 (K10) Initiative to facilitate the improvement of exclusive breastfeeding rates. A component of K10 is promoting mother/baby togetherness 23 of 24 hours per day during their hospital stay. Separating mothers and babies after birth has been a customary practice for decades in many hospitals. This practice suits the need of the hospital staff or mother request, not the needs of the newborn. Research shows that separating mother and newborn impairs bonding and reduces opportunities to breastfeed at the first cues of hunger, which can negatively impact the success of breastfeeding.


Performance on Perinatal Core Measure 05, exclusive breastmilk feeding, continues to fall below the benchmark at a large community hospital in South Central Pennsylvania, with more than 3,200 births annually. The intent of this project was to increase the time mothers and newborns spend together during their hospital stay, thereby increasing opportunities to breastfeed and bond.


A study team of 11 direct care nurses representing day and night shift nurses with varying opinions about promoting mother-baby togetherness 23 of 24 hours per day was convened. Current research about mother-baby togetherness was reviewed by the team. Research indicated that establishing a strong mother- baby bond is essential for the newborn to thrive. This attachment cannot occur if the newborn is not co-located with the mother. Studies show that newborns who stay with their mothers continually in the first days of life cry less, sleep more soundly, nurse longer, and gain weight better than those who are separated from their mothers. Following the literature review, goals were set by the team to increase mother-baby togetherness on the unit.

Team members serve as “Mother- Baby Togetherness” champions on the unit. As champions these nurses model the way, inspire a shared vison, challenge the naysayers, and foster collaboration on their unit. Research evidence and goals were shared with service line team members, management, RNs, nursing assistants, nurse practitioners, pediatricians, midwives, and obstetricians, and ultimately the patients.

A random sampling tool was developed and baseline data were collected identifying date, time, reason for baby being in nursery, and newborn nursery census for each shift. The team identified barriers to mother-baby togetherness such as equipment placement and availability. Additional barriers were identified as public knowledge and outpatient messaging.

The team recognized that though the term mother-baby togetherness meant something to them, it did not adequately translate the goal to the nursing team. The term “couplet caring” was used in the research literature. Couplet caring means that the mother-baby dyad is cared for by the same nurse, which promotes the newborn staying in the mother’s room as much as possible. This practice allows for greater continuity of care and greater opportunity for patient-nurse relationship building. Couplet caring was established as a standard of practice for the Maternal-Newborn unit and a policy was developed. Childbirth education, OB office education, and system website messaging were evaluated to ensure that all information supports mother and baby togetherness 23 of 24 hours. Conflicting messages were modified to support the team goal, prepare mothers for the change in practice, and set expectations. Similar changes were made to the prepared childbirth series and prenatal education. Rack cards, bulletin boards, and educational posters were developed to increase public awareness of the importance of keeping the mother and newborn together during the postpartum hospital stay.


Data analysis is not complete; however, nurses report that the number of newborns brought to the nursery for unacceptable reasons such as mother showering or resting has decreased over time with completion of staff education and role modeling by the couplet caring champions. The amount of time newborns spend in the nursery also decreased over time, regardless of acceptable or unacceptable reasons. Staff are more mindful of the amount of time a baby spends in the nursery for appropriate reasons, delivering the newborn back to mother’s room more promptly. In addition, physicians and advanced practice clinicians no longer suggest mothers send baby to the nursery so they can rest. The staff’s changes in practice seem to reflect their agreement the goal of couplet caring.

Meaningful changes were observed by the team. Nurses are saving time and steps by not having to move babies back and forth to the nursery. The team estimated that it took about 8/10 of a mile in a 12-hour shift to move babies back and forth from the mothers’ room to the nursery. The unit is quieter because of the reduced number of bassinets rolling in the hallways. The newborn nursery nurse can leave the nursery and assist coworkers with newborns in their rooms. Because of the decreased nursery census, the hospital can consider using the current large newborn nursery for a continuing care nursery, which affords a solution to increasing NICU population needs.

Due to the lag in Press Ganey data, we are unable to determine if patient satisfaction was influenced by the implementation of couplet caring. It has been noted by those who perform purposeful rounding that patients and families are highly satisfied with having their newborn with them at all times. Similarly, because of the approximate 3-month reporting gap, the data is not yet available to validate an increase in exclusive breastfeeding rates directly correlated to couplet caring. By keeping mothers and newborns together and offering mothers increased time to bond with their newborns, we believe that we will see an increase in exclusive breastfeeding rates.


The immediate post-implementation findings suggest that couplet caring has taken hold in the Maternal-Newborn Unit. Continued modeling of behavior as a standard of nursing practice and continued tracking will ensure the sustainability of this work and move the unit close to meeting the Joint Commission Perinatal Care standards.