Transition of care for women in the puerperal period at hospital discharge

Abstract

Objective

to describe nurses’ activities in transition of care for puerperal women from hospital care to other services in the health care network.

Method

exploratory-descriptive research, developed in the rooming-in of a federal university hospital in southern Brazil. Data were collected remotely, between November and December 2020, through a semi-structured questionnaire via the SurveyMonkey electronic platform with five nurses and four resident nurses. Analysis followed Bardin’s content structure with the support of Qualitative Data Analysis Miner software.

Results

the activities carried out by nurses in transition of care for puerperal women included discharge guidelines and educational actions for puerperal women. Elements such as lack of communication between rooming-in professionals and other services in the Health Care Network and nurses’ workload were considered barriers to transition of care to puerperal women.

Conclusion and implications for practice

although nurses undertake efforts in transition of care to puerperal women through guidance and education for discharge, it is essential to outline management strategies in order to implement a set of systematized actions to ensure continuity of care for puerperal women.

Keywords:
Hospital Discharge; Transitional Care; Nurses; Postpartum Period; Health Services

Resumo

Objetivo

descrever as atividades dos enfermeiros na transição do cuidado à puérpera da atenção hospitalar para os demais serviços da Rede de Atenção à Saúde.

Método

pesquisa exploratório-descritiva, desenvolvida no alojamento conjunto de um hospital universitário federal na região Sul do Brasil. Os dados foram coletados remotamente, entre novembro e dezembro de 2020, por meio de um questionário semiestruturado via plataforma eletrônica SurveyMonkey com cinco enfermeiros e quatro enfermeiros residentes. A análise seguiu a estrutura de conteúdo de Bardin, com apoio do software Qualitativa Data Analysis Miner.

Resultados

as atividades desenvolvidas pelos enfermeiros na transição do cuidado à puérpera incluíram as orientações de alta e ações educativas às puérperas. Elementos como a falta de comunicação entre os profissionais do alojamento conjunto e dos demais serviços da Rede de Atenção à Saúde e a sobrecarga de trabalho dos enfermeiros foram considerados barreiras para a transição do cuidado à puérpera.

Conclusão e implicações para a prática

apesar de os enfermeiros empreenderem esforços na transição do cuidado à puérpera por meio de orientações e educação para a alta, é essencial o delineamento de estratégias gerenciais, a fim de implementar um conjunto de ações sistematizadas para assegurar a continuidade do cuidado à puérpera.

Palavras-chave:
Alta Hospitalar; Cuidado Transicional; Enfermeiros; Período Pós-Parto; Serviços de Saúde

Resumen

Objetivo

describir las actividades de los enfermeros en la transición de la atención hospitalaria a los demás servicios de la Red de Atención a la Salud de la puérpera.

Método

investigación exploratoria-descriptiva, desarrollada en el alojamiento conjunto de un hospital universitario federal en la región sur de Brasil. Los datos se recolectaron de forma remota, entre noviembre y diciembre de 2020, a través de un cuestionario semiestructurado a través de la plataforma electrónica SurveyMonkey con cinco enfermeras y cuatro enfermeras residentes. El análisis siguió la estructura de contenido de Bardin, con el apoyo del software Qualitative Data AnalysisMiner.

Resultados

las actividades realizadas por los enfermeros en la transición del cuidado a la puérpera incluyeron orientaciones de alta y acciones educativas para la puérpera. Elementos como la falta de comunicación entre los profesionales del alojamiento conjunto y otros servicios de la Red de Atención a la Salud y la carga de trabajo de los enfermeros fueron considerados barreras para la transición del cuidado a la puérpera.

Conclusión e implicaciones para la práctica

si bien los enfermeros realizan esfuerzos en la transición del cuidado a la puérpera a través de la orientación y educación para el alta, es fundamental delinear estrategias de gestión para implementar un conjunto de acciones sistematizadas para garantizar la continuidad del cuidado posparto.

Palabras clave:
Alta Hospitalaria; Cuidado de Transición; Enfermeros; Periodo Posparto; Servicios de Salud

INTRODUCTION

The puerperium is a period of intense transformations and adaptations. It begins right after the placental abruption and its end is indeterminate, as it is individual for each woman.The repercussions generated by pregnancy and childbirth can be present in women up to one year postpartum and generate physical, mental, emotional and social transformations, which makes them susceptible to the appearance of complications.¹

Even though most of the alterations that occur in the puerperium are physiological, aggravations to women’s health can occur and, if not identified and treated, can progress, including with maternal death.¹ According to data from the Brazilian Health System Department of Informatics (DATASUS - Departamento de Informática do Sistema Único de Saúde), in 2020, 1,965 maternal deaths were recorded in Brazil, and, of these, 1,180 occurred within 42 days after childbirth.²

In Brazil, most care for puerperal women begins in the hospital and extends to other health services, especially Primary Health Care (PHC). Thus, an adequate transition from care to puerperal women is fundamental. Transition of care is defined as a set of actions aimed at ensuring continuity and coordination of care for patients transferred between different services or between different levels of health care.³

Transitional care encompasses a wide range of conditions and services to ensure continuity of care and prevent unintended consequences for vulnerable people who are affected by changes in care or caregivers. For an adequate transition of care, a comprehensive assessment of patients, caregivers, health system and services offered by the community is essential.⁴

To optimize women’s and newborns’ health, postpartum care must become an ongoing process, with services and support tailored to each woman’s individual needs.⁵ Over time, Brazil, through public policies, it has been making efforts to organize a health system that qualifies the assistance to puerperal women, promoting the integration of services, such as the Mother and Child Network, which reinforces the need for multidisciplinary follow-up of women and newborns after the postpartum period, with special attention to risk situations during transition of care.⁶

In addition, it is recommended that, at the time of hospital discharge, the maternity hospital informs the PHC team that women and newborns are returning home. In this way, the health team can organize itself for home visit. The maternity hospital must prepare and send a clear and detailed report on the procedures, medications and possible relevant intercurrences during labor and birth to the PHC team.⁷

It is the responsibility of nurses, obstetric nurses and midwives to provide assistance to women in the postpartum period, carry out educational actions in health, ensure comprehensive care for women through articulation between the points of care, considering the Health Care Network and available community resources, in addition to providing written and verbal, complete and reliable information necessary to monitor the care process.⁸

Scientific evidence points to a lack of guidance for puerperal women at hospital discharge,⁹ low occurrence of puerperal review,¹,¹⁰-¹¹ late home visits to puerperal women, without prioritization, unsystematic and discontinued, discomfort of women in home visits due to care focused only on the baby¹² and fragility in the Stork Network (Rede Cegonha), currently called the Maternal and Child Care Network.¹³

In view of this, the need to deepen knowledge about the transition of care for puerperal women is justified, as they may be susceptible to the emergence of injuries after hospital discharge. In Brazil, in most cases, the beginning of care to puerperal woman is in the hospital environment, where the risks of transition of care are also detected.¹⁴ Follow-up after hospital discharge is essential to mitigate these risks, especially through puerperal consultations, which are one of the tools for preventing illness and maternal death.¹ Nurses occupy a prominent position in transition of care through leadership in discharge management services that aim at continuity of care.¹⁵-¹⁶ Thus, this study aimed to describe the activities of nurses in transition of care for puerperal women from hospital care to other services in the Health Care Network.

METHOD

This is an exploratory-descriptive study with a qualitative approach. The research setting was the rooming-in of the maternity ward of a federal university hospital, located in the state of Santa Catarina, which serves exclusively the Brazilian Health System (SUS - Sistema Único de Saúde) users. The maternity has the Baby Friendly Hospital seal, and is a national reference center in the Kangaroo Method. An average of 220 births are performed per month. In addition to serving low-risk pregnant women, the maternity hospital is a reference for high-risk pregnant women in Santa Catarina. Since 2013, the hospital has offered the Integrated Multidisciplinary Health Residency with an emphasis on women’s and children’s health.

Ten nurses and four nurses residing in women’s and children’s health were invited to participate in the study. Nurses or nursing residents were included in the rooming-in of the maternity ward of the university hospital for a minimum period of three months; this period was considered, as we understand that professionals need to know the routine of the unit to respond to the questionnaire. Professionals who did not send the online questionnaire within the stipulated period of 30 days or were away from their professional activities during data collection were excluded. Six nurses and four nursing residents accepted and sent the questionnaire within the stipulated period. One participant was excluded because he sent the questionnaire unfilled. Through the answers of the nine participants, it was noticed data saturation.

Participant recruitment was facilitated through the support of the head nurse of the rooming-in, who provided nurses’ and nursing residents’ email addresses. Participants were sent via e-mail an invitation to participate in the research and information about the research objectives, maintenance of anonymity, voluntary participation, data collection method, time to respond to the questionnaire and the need to respond to the questionnaire in location that would guarantee the privacy of responses, in order to minimize risks during data collection.

Upon agreeing to participate in the research, participants were directed to the SurveyMonkey platform with the opening of the Informed Consent Form (ICF). After reading and agreeing to this term, participants had access to the research questionnaire. If they did not agree to participate, the SurveyMonkey platform was automatically terminated.

Data collection was carried out remotely in November and December 2020 through a semi-structured questionnaire via the SurveyMonkey electronic platform that included open- and closed-ended questions about transition of care to puerperal women. The time taken to complete the questionnaire took an average of 15 minutes. The main researcher was responsible for sending and receiving the questionnaires and had no previous relationship with the nurses recruited to participate in the research as well as the other researchers.

The methodology adopted for data analysis was Bardin’s content analysis, with the support of Qualitative Data Analysis (QDA) Miner software. Content analysis is a set of communication analysis techniques and comprises three stages: pre-analysis; material exploration; data processing and interpretation.¹⁷

In pre-analysis, data were transported from the SurveyMonkey platform to the QDA Miner, and text skimming was carried out to know the text and obtain the first impressions. In material exploration, registration unit coding and condensation were carried out for constructing the categories. Then, data were processed and interpreted according to the literature on the subject.¹⁷

The research followed the recommendations of Resolution 466/12 of the Brazilian National Health Council, and was approved by the Research Ethics Committee on October 6, 2020, under Opinion 4.332.041. To guarantee participant anonymity, the letter “N” for nurse was used, followed by the cardinal number corresponding to the order in which the questionnaires were received.

RESULTS

Participants in this study were aged between 23 and 52 years, most were female. Data analysis substantiated the construction of two categories, namely: Guidance and education for puerperal woman discharge by the care team; Difficulties faced by nurses in transition of care to puerperal women. This last category included the subcategories: Lack of communication between rooming-in and Primary Health Care professionals; Rooming-in nurses’ workload.

Category 1: Guidance and education for puerperal woman discharge by the care team

Discharge guidelines for puerperal women can be started one day before hospital discharge, from hospital admission, after childbirth, at hospital discharge or when puerperal women have clinical conditions to be discharged. Thus, there is no systematization about the beginning of these guidelines and education for puerperal women, even if the hospitalization time of the patient who had a normal delivery or cesarean section is pre-established by the institution:

Depending on the case, even a day before. (N8).

Since admission, the information provided is aimed at independence and excellence in care. (N9).

36 hours or 48 hours postpartum. (N3).

On discharge day. (N7).

When the puerperal woman evolves well in the postpartum period, without intercurrences and reaches discharge conditions together with newborns. (N5).

Both puerperal women who had a usual risk pregnancy and a high-risk one receive a set of general written guidelines that cover care for women, newborns and bureaucratic issues:

[...] written discharge guidelines are general [...] (N2).

Postpartum guidelines, prescriptions and referrals. (N3).

The guidelines and education for discharge carried out by nurses include care for the breasts, breastfeeding, perineal laceration, observation of lochia, correct use of prescribed medications, contraception, signs of infection and alert for return to obstetric emergency, information about the date for removing the cesarean stitches and guidance on self-care:

Care for women [...] breastfeeding [...] (N2).

General care in the puerperium, physiology of lochia, signs of infection, contraception, breastfeeding [...] return if intercurrences [...] (N4).

[...] post-surgical care in case of cesarean section, breastfeeding, breast care, observation of lochia, [...] guidance on the use of prescribed medications. (N5).

Guidelines on lacerations or post-cesarean suture removal. Use of postpartum iron sulfate [...] breastfeeding, warning signs to return to the obstetric emergency. (N6).

Self-care (breastfeeding, eating, resting) [...] (N8).

[...] use of medications prescribed by the doctor, such as ferrous sulfate [...] (N7).

Before the pandemic, group educational activities were being carried out in the sector with women and their families [...] (N2).

[...] there have already been collective meetings prioritizing breastfeeding. Now it’s guidance on the way out. (N9).

Puerperal women who had a high-risk pregnancy receive verbal guidance according to their clinical conditions, as they have different needs from puerperal women who had a usual risk pregnancy. Moreover, puerperal women who underwent prenatal care at the high-risk pregnancy clinic at the study hospital are instructed to schedule a puerperal consultation at the same service:

[...] puerperal women of a high-risk pregnancy receive specific guidance according to the associated pathology. (N6).

[...] the mothers who had a high-risk management need to be guided according to their case. (N5).

When it comes from the high-risk pregnancy outpatient clinic, they return to the outpatient clinic [...] (N4).

With regard to newborns, puerperal women are taught how to bathe, bandage the umbilical stump, care for sunbathing and breastfeeding. Furthermore, puerperal women are instructed about the vaccines that newborns should receive and the child’s booklet:

[...] newborn care (breastfeeding, umbilical stump, sunbathing, vaccines [...] (N8).

[...] breastfeeding [...] (N6).

[...] reinforcement on breastfeeding. (N7).

Guidance on the child’s booklet. (N7).

To assist in education actions, nurses use educational material:

[...] distribution of folders with guidelines. (N5).

[...] folder with discharge guidelines for puerperal women. (N2).

Some folders. With special attention to breastfeeding. (N9).

Bureaucratic issues include guidance on the need for puerperal women to schedule puerperal and childcare consultations at PHC, registering newborns at the registry office and the services offered by the institution’s social service:

[...] scheduling appointments and follow-up in primary or outpatient care, [...] (N2).

puerperal consultation. [...] (N5).

[...] link to BHU, childcare. [...] (N4).

[...] general guidelines regarding documentation and registration in notary and social service. (N2).

Guidelines regarding the Certificate of Live Birth [...] (N6).

The professionals involved in the guidance and education for discharge are those who make up the multidisciplinary team and are activated depending on each puerperal woman’s biopsychosocial needs:

Nurses, nursing technicians, neonatologists, obstetricians, social workers, speech therapists, psychologists, when necessary. (N2).

Medical professionals and nurses. (N5).

Nurse, nursing technician who takes care of the puerperal woman, breastfeeding team (Breastfeeding Incentive Center), medical team and eventually the social service, psychology and nutrition (when necessary). (N10).

Even with the inclusion of several professionals in the guidelines and education for puerperal women, there is no consensus among participants on the existence of a hospital discharge coordinator. Thus, the nursing and medical staff on duty are responsible for discharges that occur on the day.

There is no one person who is responsible for this, but everyone acts in the discharge guidelines (medicine, speech therapy, nursing, breastfeeding incentive center). (N2).

Yes, medical team. (N3).

Nurses on duty. (N10).

Category 2. Difficulties faced by nurses in transition of care to puerperal women

This category is made up of two subcategories, namely: Lack of communication between rooming-in and Primary Health Care professionals; Rooming-in nurses’ workload.

Subcategory 1: Lack of communication between rooming-in and Primary Health Care professionals

It appears that the lack of communication between rooming-in nurses and PHC professionals represents a difficulty for transition of care to puerperal women. The lack of formalization of a means of communication between professionals who work in different Health Care Network services makes it impossible to transfer information about women, especially about the risks arising from transition of care, puerperal women’s needs after hospital discharge and scheduling the puerperal consultation. Thus, transfer of information is under patients’ responsibility.

[...] lack of communication and integration between computerized systems and teams for referral and follow-up of puerperal women [...] there is a need for systems capable of producing data on puerperal women and newborns as well as interconnected systems between primary care and reference maternity. (N2).

The lack of contact with primary care to coordinate the care plan. (N6).

I believe that the ideal, as recommended by Rede Cegonha, would be for the patient to already leave the hospital with the appointment scheduled, i.e., already linked to the BHU as well as the baby. (N4).

Subcategory 2: Rooming-in nurses’ workload

The work overload resulting from the shortage of nurses, especially due to the absence of professionals, is an element that makes it difficult to provide guidance and education for the discharge of puerperal women, as they are carried out quickly, broadly and without management by those who have already received them. Furthermore, there is no discharge planning according to each puerperal woman’s individual needs, their previous experiences, beliefs and support network:

Overcrowding in the maternity ward, which means that the final guidelines for discharge are given quickly. (N2).

[...] under sizing and sick leave of nurses in the sector, a factor that increases work overload and reduces the quality of care provided. (N2).

Talk to seven or ten patients or more about all the necessary care. (N9).

Know where you have already been guided or referred. (N8).

DISCUSSION

In this study, transition of care activities developed by nurses with puerperal women included general discharge guidelines and health education for puerperal women and newborns. For an adequate transition of care, the involvement of several activities is essential such as: discharge planning; communication; organization; clarity and availability of information in a timely manner; medication safety; patient education; self-management promotion; social support; advance care planning; coordination of care among members of the health team; monitoring and management of symptoms after discharge; and outpatient follow-up.¹⁸

It is verified, in the study, that there is no preparation of an early discharge planning, individualized and centered on each puerperal woman’s needs, with a view to continuity of care after hospital discharge, since puerperal women receive verbal guidance during hospitalization and written general guidelines at hospital discharge. Discharge planning has been considered a strategy to qualify care and mitigate the risks of complications after hospital discharge. Its early start is recommended, with the participation of the interprofessional team, insertion of patient/family in decisions about care and adoption of a coordinator to articulate resources and transfer information between levels of health care.¹⁹

The discharge guidelines carried out by nurses contemplate the main needs of the puerperium period, and are in line with the literature that points out signs and symptoms of infections, emotional distress, problems with breastfeeding, complications with the breasts, places where the woman can seek assistance when necessary, such as guidelines for puerperal woman discharge,²⁰ except for guidance on emotional problems that may arise in the puerperium.

In addition to nurses, other professional categories also provide guidance according to puerperal women’s needs. In this regard, it is essential that puerperal women be discharged through the elaboration of a Unique Therapeutic Project, considering each woman’s individual needs.²¹

Internationally, it is recommended that obstetric care professionals start planning postpartum care during pregnancy, which needs to be in accordance with each woman’s health needs. Children’s feeding intentions, future pregnancies, preferred contraceptive method, and any chronic illnesses or risk factors that require special care should be addressed. Women and professionals need to identify members of their postpartum care team, including family and friends. Prior to discharge from the maternity ward, it is recommended that the plan be reviewed and women receive written instructions on subsequent visits and who will assume responsibility for the woman’s ongoing care after discharge from hospital.²¹

It appears, in this study, that puerperal women who had a high-risk pregnancy received verbal guidance according to their clinical situation, which is characterized as an important action, as post-cesarean puerperal women and women who have gone through a high-risk pregnancy, with hypertensive disorders during pregnancy, are at greater risk of comorbidities in the postpartum period. Thus, meticulous guidance is recommended for these women in the hospital before hospital discharge and in postpartum care services. Moreover, for puerperal women who had a high-risk pregnancy, it is recommended to schedule an earlier postpartum consultation.²² However, it is noteworthy that the nurses participating in the study guide high-risk puerperal women about the need to schedule a puerperal consultation at the PHC or at the outpatient clinic, but do not perform it for patients, as there is no defined flow for this.

Scheduling the puerperal consultation aims to identify postpartum complications, provide guidance on contraceptive methods, care for newborns, support breastfeeding and identify puerperal women’s mental distress.⁷ Despite the importance of the puerperal consultation for both women and newborns, the PesquisaNascer no Brasil (Being Born in Brazil) indicated that 66.5% of women were advised about the need for this consultation at hospital discharge, but only 32.2% of them attended the health services to perform it.²³ Furthermore, women with some comorbidity during the prenatal period had a puerperal return 45% lower than healthy women during pregnancy, which reinforces the deficit of actions aimed at the importance of puerperal consultation or even clarification on the need for the postpartum return in antenatal consultations.¹¹ Furthermore, there was an incipient implementation of transition of care programs for this population.

The highest mortality risk is during the immediate and late postpartum period, with the highest morbidity and mortality rate in the first postpartum week, which makes this a critical moment for women and their child,²⁴ and needs attention from health systems. The American Association of Women’s Health, Obstetric and Neonatal Nurses has released a booklet with a standard list of warning signs to promote puerperal women’s awareness and understanding of postpartum complications. The booklet differentiates when puerperal women should look for a health professional, call an emergency or go directly to the hospital. The objective of this material is to improve the education of puerperal women at hospital discharge and ensure that women, regardless of their risk, are guided about the signs and symptoms associated with maternal morbidity and mortality.²¹

To improve women’s access to puerperal consultations, in the United States, a postpartum education program was developed that included scheduling a puerperal consultation and providing the telephone number of a health professional for postpartum follow-up while still in the maternity ward.²¹ Another strategy carried out in the same country was the implementation of a navigation program for low-income new mothers. Such a program consists of the introduction of a professional who offers support between childbirth and the last postpartum consultation. The navigation program increased the mothers’ adherence to postpartum care, and improved certain indicators, such as the adoption of contraceptive methods, screening for depression and vaccination.²⁵

Other strategies employed to increase the frequency of postpartum consultations and provide continuity of care after puerperal women’s hospital discharge include: discussion about postpartum care during prenatal care consultations; discharge planning to encourage postpartum follow-up; scheduling postpartum appointments during prenatal care or before hospital discharge; use of technologies such as email, text messages and apps to remind women to schedule postpartum follow-up; and a nurse who follows women up in the puerperal period.⁵

In the study hospital, there is no professional responsible for managing the puerperal discharge, one of the essential activities for the proper transition of care. Internationally, one of the most used interventions in the transition of care is the liaison or extension nurse,²⁶ which consists of assigning a nurse to identify patients who need continuity of care after hospital discharge, performing discharge planning with the multidisciplinary team and transferring patient information to the professionals responsible for continuous care after hospital discharge.²⁷

In Brazil, the Complexo Hospital de Clínicas at the Universidade Federal do Paraná implemented the Discharge Management Service centered on liaison nurses’ role. Each nurse manages approximately 100 hospital beds distributed in four groups of related areas, one of which is maternal and child health.¹⁵

A usual risk maternity hospital, belonging to the Complexo Hospital de Clínicas at the Universidade Federal do Paraná, also adopted this strategy. In 2019, of 3791 patients hospitalized/month, 988 were counter-referred liaison nurses. The most prevalent reasons among puerperal women were teenage pregnancy, multiparity, sexually transmitted infections, pregnancy-specific hypertensive syndrome, postpartum bleeding and treatment for infection.¹⁶

Regarding education actions, nurses use educational materials and, before the pandemic, carried out group educational activities, especially on breastfeeding. In this sense, it should be noted that, in rooming-in, educational activities should be carried out for puerperal women, preferably in groups, in order to expand women’s self-care and care for newborns, dispel myths regarding maternity, paternity, breastfeeding, return to sexual life, in addition to providing instructions on health care, nutrition, hygiene, sexual and reproductive health.²⁸

As for the difficulties pointed out by nurses in transition of care to puerperal women, the lack of communication among nurses who work in rooming-in and in PHC is included. A study that explored the transition of care between maternity and other network services showed that one of the challenges was the difficulty in communication between professionals and services as well as transfer of information about patients.²⁸ In the weeks after birth, postpartum care is often fragmented among health professionals, and communication between the hospital and outpatient settings is inconsistent.⁵

Communication between obstetrical nurses and nurses working in PHC was also identified as a barrier in interprofessional collaborative practiceas well as the lack of understanding of the role of each professional and physical distance. Interprofessional collaborative practice is increasingly encouraged in maternal and child health services, due to the growing complexity of patients’ needs and the organization of health services.²⁹

Communication and the availability of information in a timely manner are actions for an appropriate transition of care,¹⁸ and its deficit is associated with delays in care and loss of opportunities for early intervention.²⁹ To improve communication, it is recommended to provide the discharge summary to patients and, if necessary, caregivers, with key information about patients and the care that needs to be provided by community nursing. In addition to this, information about relevant contacts and roles of the community nursing service also needs to be passed on to patients.³⁰

International health systems prove to be strategic for achieving positive results the implementation of a computerized system of care in pregnancy, childbirth, birth and the puerperium, benefiting institutional communication and in a timely manner according to people’s health needs.³¹

Work overload was identified as another difficulty for the transition of care for puerperal women, which is in line with the results of a study on professionals’ and family members’ perspective on the transition from maternity care to other health services. Both professionals and family members recommended appointing a professional to act as a liaison to support transition of care.²⁸ Transitional care involves a series of activities, which demand the professionals’ time, and, therefore, it is necessary to designate a professional for such practice.²⁷ In the literature, it appears that there is an ongoing study on the transfer of care at hospital discharge and the time dedicated by nursing and its effectiveness,¹⁹ which may, in the future, contribute to a better discussion about workload in transition of care.

Although different professionals carry out activities in the transition of care, nurses are important protagonists of care, occupying a prominent position in promoting safe transition of cares.³² These professionals conduct and lead most interventions. However, successful models of transition of care point out that it is fundamental for nurses to have a deep knowledge of the health system, of the social assistance service, interpersonal skills and also clinical knowledge so that the results are satisfactory.²⁶

In traditional health systems, nurses’ relationship with patients ends with hospital discharge, however, due to the need for continuity of patient care, it is essential that transition of care actions be developed that involve the health system, nurses and caregivers.⁴

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

Transition of care activities aimed at puerperal women are still incipient, which demonstrates the need for investments by the hospital institution so that it can ensure continuity of care for puerperal women.

In this regard, the very difficulties faced by nurses in the transition of care, such as the lack of communication between rooming-in and PHC professionals and the shortage of nursing professionals, point to elements that can be transformed to qualify transition of care. The systematization of communication between rooming-in and PHC professionals, with the use of technology and the appointment of a professional to manage hospital discharge, is an essential element that can contribute to the transition in puerperal care.

It is believed that this study will help nurses and nursing managers to assess their practices in relation to transition of care in postpartum hospital discharge and to be able to implement actions that involve and empower puerperal women in their care, through guidance and education according to the needs, fears and uncertainties of these women and, furthermore, develop actions to strengthen the link between the services of different levels of health care so that puerperal women have adequate follow-up after hospital discharge.

In the research field, the need for investments in intervention research on transition of care actions that can contribute to continuity of care in the Health Care Network is highlighted. As limitations of this study, there is the qualitative approach, which does not allow the generalization of results, and also the collection of online data, due to the COVID-19 pandemic, which prevented the establishment of a physical place for meeting with participants.

REFERÊNCIAS

• ¹
  Pinto IR, Martins VE, Oliveira JF, Oliveira KF, Paschoini MC, Ruiz MT. Adherence to puerperal consultation: facilitators and barriers. Esc Anna Nery. 2021 nov;25(2):e20200249. http://dx.doi.org/10.1590/2177-9465-ean-2020-0249
  » http://dx.doi.org/10.1590/2177-9465-ean-2020-0249
• ²
  Ministério da Saúde (BR). Datasus [Internet]. Brasília: Ministério da Saúde; 2020 [citado 2023 mar 16]. Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/mat10uf.def
  » http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/mat10uf.def
• ³
  Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003 abr;51(4):556-7. http://dx.doi.org/10.1046/j.1532-5415.2003.51186.x PMid:12657079.
  » http://dx.doi.org/10.1046/j.1532-5415.2003.51186.x
• ⁴
  Shahsavari H, Zarei M, Mamaghani JA. Transitional care: concept analysis using Rodgers’ evolutionary approach. Int J Nurs Stud. 2019 nov;99:103387. http://dx.doi.org/10.1016/j.ijnurstu.2019.103387 PMid:31442782.
  » http://dx.doi.org/10.1016/j.ijnurstu.2019.103387
• ⁵
  ACOG Committee Opinion. Optimizing postpartum care. Am Coll Obstet Gynecol [Internet]. 2018 mai; [citado 2022 set 20];131(5):e140-50. Disponível em: https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2018/05/optimizing-postpartum-care.pdf
  » https://www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2018/05/optimizing-postpartum-care.pdf
• ⁶
  Portaria nº 715, de 4 de abril de 2022 (BR). Altera a Portaria de Consolidação GM/MS nº 3, de 28 de setembro de 2017, para instituir a Rede de Atenção Materna e Infantil (Rami). Diário Oficial da União [periódico na internet], Brasília (DF), 6 abr 2022 [citado 2023 mai 31]. Disponível em: https://in.gov.br/web/dou/-/portaria-gm/ms-n-715-de-4-de-abril-de-2022-391070559
  » https://in.gov.br/web/dou/-/portaria-gm/ms-n-715-de-4-de-abril-de-2022-391070559
• ⁷
  Ministério da Saúde (BR). Atenção ao pré-natal de baixo risco. Brasília: Ministério da Saúde; 2012.
• ⁸
  Resolução nº 516, de 23 de junho de 2016 (BR). Normatiza a atuação e a responsabilidade do Enfermeiro, Enfermeiro Obstetra e Obstetriz na assistência às gestantes, parturientes, puérperas e recém-nascidos nos Serviços de Obstetrícia, Centros de Parto Normal e/ou Casas de Parto e demais locais onde ocorra essa assistência e estabelecer critérios para registro de títulos de Enfermeiro Obstetra e Obstetriz no âmbito do Sistema Cofen/Conselhos Regionais de Enfermagem. Diário Oficial da União [periódico na internet], Brasília (DF), 27 jun 2016 [citado 2023 mai 31]. Disponível em: http://www.cofen.gov.br/resolucao-cofen-no-05162016_41989.html
  » http://www.cofen.gov.br/resolucao-cofen-no-05162016_41989.html
• ⁹
  Silva EC, Pereira ES, Santos WN, Silva RAR, Lopes NC, Figueiredo TAM et al. Puerperium and nursing assistance: women’s perception. Rev Enferm UFPE On Line. 2017 jul;11(Supl 7):2826-33. http://dx.doi.org/10.5205/reuol.11007-98133-3-SM.1107sup201702
  » http://dx.doi.org/10.5205/reuol.11007-98133-3-SM.1107sup201702
• ¹⁰
  Assis TR, Chagas VO, Goes RM, Schafauser NS, Caitano KG, Marquez RA. Implementação da Rede Cegonha em uma regional de saúde do estado de Goiás: o que os indicadores de saúde mostram sobre atenção materno-infantil. Rev Electron Comun Inf Inov Saude. 2019 dez;13(4):843-53. http://dx.doi.org/10.29397/reciis.v13i4.1595
  » http://dx.doi.org/10.29397/reciis.v13i4.1595
• ¹¹
  Gonçalves CS, Cesar JA, Marmitt LP, Gonçalves CV. Frequency and associated factors with failure to perform the puerperal consultation in a cohort study. Rev Bras Saúde Mater Infant. 2019 jan/mar;19(1):63-70. http://dx.doi.org/10.1590/1806-93042019000100004
  » http://dx.doi.org/10.1590/1806-93042019000100004
• ¹²
  Corrêa MSM, Feliciano KVO, Pedrosa EM, Souza AI. Acolhimento no cuidado à saúde da mulher no puerpério. Cad Saude Publica. 2017 abr;33(3):e00136215. http://dx.doi.org/10.1590/0102-311x00136215 PMid:28380144.
  » http://dx.doi.org/10.1590/0102-311x00136215
• ¹³
  Gonçalves RL, Penna CMM. Everyday scenes of care: the stork network under construction. Rev Min Enferm. 2019 jan;23:e-1237. http://dx.doi.org/10.5935/1415-2762.20190085
  » http://dx.doi.org/10.5935/1415-2762.20190085
• ¹⁴
  Martins SN, Julião e Silva JF, Rodrigues DP, Fialho AVM. Ações de enfermagem no período puerperal na atenção primária à saúde. Rev Tendên Enferm Profis [Internet]. 2012 [citado 2022 set 20];4(4):833-8. Disponível em: http://www.coren-ce.org.br/wp-content/uploads/2019/01/A%C3%A7%C3%B5es-de-Enfermagem-no-Per%C3%ADodo-Puerperal-na-Aten%C3%A7%C3%A3o-Prim%C3%A1ria-%C3%A0-Sa%C3%BAde.pdf
  » http://www.coren-ce.org.br/wp-content/uploads/2019/01/A%C3%A7%C3%B5es-de-Enfermagem-no-Per%C3%ADodo-Puerperal-na-Aten%C3%A7%C3%A3o-Prim%C3%A1ria-%C3%A0-Sa%C3%BAde.pdf
• ¹⁵
  Bernardino E, Silva OBM, Gallo VCL, Vilarinho JOV, Silva OLS, Selleti JDN. Enfermeiras de ligação na gestão de altas do complexo hospital de clínicas. Enferm Foco. 2021;12(7, Supl 1):72-6. http://dx.doi.org/10.21675/2357-707X.2021.v12.n7.SUPL.1.5164
  » http://dx.doi.org/10.21675/2357-707X.2021.v12.n7.SUPL.1.5164
• ¹⁶
  Silva OB, Bernardino E, Silva OL, Rorato C, Rocha DJ, Lima LS. Enfermeiro de ligação de uma maternidade de risco habitual: dados de contrarreferências. Enferm Foco. 2021;12(1):79-85. http://dx.doi.org/10.21675/2357-707X.2021.v12.n1.4048
  » http://dx.doi.org/10.21675/2357-707X.2021.v12.n1.4048
• ¹⁷
  Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011.
• ¹⁸
  Burke RE, Kripalani S, Vasilevskis EE, Schnipper J. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013 fev;8(2):102-9. http://dx.doi.org/10.1002/jhm.1990 PMid:23184714.
  » http://dx.doi.org/10.1002/jhm.1990
• ¹⁹
  Zanetoni TC, Cucolo DF, Perroca MG. Alta hospitalar responsável: validação de conteúdo de atividades do enfermeiro. Rev Gaúcha Enferm. 2022 mai;43:e20210044. http://dx.doi.org/10.1590/1983-1447.2022.20210044.en PMid:35613237.
  » http://dx.doi.org/10.1590/1983-1447.2022.20210044.en
• ²⁰
  Portaria n. 2.068, de 21 de outubro de 2016 (BR). Institui diretrizes para a organização da atenção integral e humanizada à mulher e ao recém-nascido no Alojamento Conjunto. Diário Oficial da União [periódico na internet], Brasília (DF), 24 out 2016 [citado 2023 mai 31]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2016/prt2068_21_10_2016.html
  » https://bvsms.saude.gov.br/bvs/saudelegis/gm/2016/prt2068_21_10_2016.html
• ²¹
  Kleppel L, Suplee PD, Stuebe AM, Bingham D. National Initiatives to improve systems for postpartum care. Matern Child Health J. 2016 nov;20(Supl 1):66-70. http://dx.doi.org/10.1007/s10995-016-2171-1 PMid:27531012.
  » http://dx.doi.org/10.1007/s10995-016-2171-1
• ²²
  Weissmann-Brenner A, Heusler I, Manteka R, Dulitzky M, Baum M. Postpartum visits in the gynecological emergency room: how can we improve? BMC Pregnancy Childbirth. 2020 mai;20(1):278. http://dx.doi.org/10.1186/s12884-020-02927-7 PMid:32381028.
  » http://dx.doi.org/10.1186/s12884-020-02927-7
• ²³
  Bittencourt SDA, Cunha EM, Domingues RMSM, Dias BAS, Dias MAB, Torres JA et al. Nascer no Brasil continuity of care during pregnancy and postpartum period for women and newborns. Rev Saude Publica. 2020 nov;54:100. http://dx.doi.org/10.11606/s1518-8787.2020054002021 PMid:33146323.
  » http://dx.doi.org/10.11606/s1518-8787.2020054002021
• ²⁴
  Baratieri T, Natal S. Postpartum program actions in primary health care: an integrative review. Cien Saude Colet. 2019 out;24(11):4227-38. http://dx.doi.org/10.1590/1413-812320182411.28112017 PMid:31664395.
  » http://dx.doi.org/10.1590/1413-812320182411.28112017
• ²⁵
  Yee LM, Martinez NG, Nguyen AT, Hajjar N, Chen MJ, Simon MA. Using a patient navigator to improve postpartum care in an urban women’s health clinic. Obstet Gynecol. 2017 mai;129(5):925-33. http://dx.doi.org/10.1097/AOG.0000000000001977 PMid:28383374.
  » http://dx.doi.org/10.1097/AOG.0000000000001977
• ²⁶
  Coffey A, Mulcahy H, Savage E, Fitzgerald S, Bradley C, Benefield L et al. Transitional care interventions: relevance for nursing in the community. Public Health Nurs. 2017 set;34(5):454-60. http://dx.doi.org/10.1111/phn.12324 PMid:28374544.
  » http://dx.doi.org/10.1111/phn.12324
• ²⁷
  Aued GK, Bernardino E, Lapierre J, Dallaire C. Liaison nurse activities at hospital discharge: a strategy for continuity of care. Rev Lat Am Enfermagem. 2019 ago;27:e3162. http://dx.doi.org/10.1590/1518-8345.3069.3162 PMid:31432917.
  » http://dx.doi.org/10.1590/1518-8345.3069.3162
• ²⁸
  Psaila K, Kruske S, Fowler C, Homer C, Schmied V. Smoothing out the transition of care between maternity and child and family health services: perspectives of child and family health nurses and midwives’. BMC Pregnancy Childbirth. 2014 abr;14(1):151. http://dx.doi.org/10.1186/1471-2393-14-151 PMid:24766674.
  » http://dx.doi.org/10.1186/1471-2393-14-151
• ²⁹
  Aquino MRJV, Olander EK, Needle JJ, Bryar RM. Midwives’ and health visitors’ collaborative relationships: a systematic review of qualitative and quantitative studies. Int J Nurs Stud. 2016 out;62:193-206. http://dx.doi.org/10.1016/j.ijnurstu.2016.08.002 PMid:27522239.
  » http://dx.doi.org/10.1016/j.ijnurstu.2016.08.002
• ³⁰
  Pellett C. Discharge planning: best practice in transitions of care. Br J Community Nurs. 2016 nov;21(11):542-8. http://dx.doi.org/10.12968/bjcn.2016.21.11.542 PMid:27809581.
  » http://dx.doi.org/10.12968/bjcn.2016.21.11.542
• ³¹
  Silva LBRAA, Angulo-Tuesta A, Massari MTR, Augusto LCR, Gonçalves LLM, Silva CKRT et al. Evaluation of the Rede Cegonha: feedback of results for Brazilian maternity hospitals. Cien Saude Colet. 2021 mar;26(3):931-40. http://dx.doi.org/10.1590/1413-81232021263.25782020 PMid:33729348.
  » http://dx.doi.org/10.1590/1413-81232021263.25782020
• ³²
  Lima MADS, Magalhães AMM, Oelke ND, Marques GK, Lorenzini E, Weber LAF et al. Care transition strategies in Latin American countries: an integrative review. Rev Gaúcha Enferm. 2018 nov;39(0):e20180119. http://dx.doi.org/10.1590/1983-1447.2018.20180119 PMid:30517436.
  » http://dx.doi.org/10.1590/1983-1447.2018.20180119

Edited by

ASSOCIATED EDITOR

Stela Maris de Melo Padoin https://orcid.org/0000-0003-3272-054X

SCIENTIFIC EDITOR

Ivone Evangelista Cabral https://orcid.org/0000-0002-1522-9516

Publication Dates

• Publication in this collection
  04 Aug 2023
• Date of issue
  2023

History

• Received
  03 Nov 2022
• Accepted
  31 May 2023