Introducing a Quiet Time on a Maternity Ward: Engaging Patients and Staff to Assess Benefits and Barriers

Transcription

1 Introducing a Quiet Time on a Maternity Ward: Engaging Patients and Staff to Assess Benefits and Barriers Safina Adatia, Department of Family Medicine, McGill University, Montreal QC Submitted August 2015 A thesis submitted to McGill University in partial fulfillment of the requirements of a degree of Master in Family Medicine. Safina Adatia 2015 August 10,

2 Contents Abstract... 5 English... 5 French... 7 Acknowledgements Preface and Contribution of Author Introduction Statement of the Problem Background and Context Research Questions Theoretical Framework Literature Review Postpartum Hospital Stay Hospital Noise, Potential Interruptions and their Effects Quiet Time Interventions Knowledge Gap Methodology Research Design Participatory Research Baseline Environment Measurements, Patient Experiences and Difficulty Breastfeeding due to Potential Interruptions or Visitations Participants Recruitment Data Collection Noise Levels and Potential Interruptions Survey of Patient Experience Sample Size Noise Levels per 30 min Session Total Number of Potential Interruptions per 30 min Session Canadian Patient Experiences Survey Data Analysis Noise Level Calculations August 10,

3 Number of Patients and Bed Occupancy Descriptive Statistics Statistical Analysis Qualitative Exploration of Patient Experiences and Perspectives Participants Recruitment Data Collection Sample Size Data Analysis Process of Implementation Participants Recruitment Data Collection Ethical Considerations Results Baseline Environment Measurements, Patient Experiences and Difficulty Breastfeeding due to Potential Interruptions or Visitations Noise Levels Quantitative Qualitative Potential Interruptions Quantitative Qualitative Canadian Patient Experiences Survey Qualitative Exploration of Patient Experiences and Perspectives Challenges and Concerns Postpartum Perceptions of the Environment Opinions on Quiet Time Advice and Other Comments Process of Implementation Discussion Implications for Practice, Policy and Future Research August 10,

4 5.2 Strengths and Limitations Conclusions References Appendix A: Stakeholder Meeting Notes Appendix B: Data Collection Tool Appendix C: Canadian Patient Experiences Survey Appendix D: Interview Guide Appendix E: Consent Forms Appendix F: Thematic Map August 10,

5 Abstract English Background A postpartum hospital stay should provide new mothers an environment conducive to resting and healing. However, these patients often experience disruptions from activities related to visitors, clinical care, hospital services, and intercom announcements. This can lead to potential interruptions in important activities such as breastfeeding and teaching, and can increase the risk of postpartum mental health problems. A possible solution is a quiet time, a period of time where lights are dimmed, potential interruptions are reduced, and routine care processes are scheduled outside of this time as possible. However, only one unpublished study related to such an initiative on a maternity ward was found. The goal of this study is to contribute to the general pool of knowledge regarding noise levels and number of potential interruptions on a maternity ward along with an understanding of the benefits, barriers and implementation issues associated with the introduction of a quiet time on a maternity ward. Methods This study took place on a maternity ward in a community general hospital in Montreal. A mixed methods research design was adopted within a larger pre-post evaluation involving a participatory research approach. Noise levels were measured via Decibel 10 th iphone app; potential interruptions were noted by observation. A modified version of the Canadian Patient Experiences Survey (CPES) was distributed to inpatients. Qualitative interviews were conducted with postpartum mothers and observation notes were recorded at stakeholder meetings. An average mean A-weighted equivalent sound level (Leq) was computed, and average minimum and average maximum decibel levels were calculated and identified. We performed August 10,

6 ANOVA and chi-square analyses of the patient experience survey results to determine characteristics of women who experience difficulty breastfeeding due to potential interruptions. Thematic content analysis was used to analyze the qualitative interviews. Results A total of minute sessions for the measurement of noise levels and potential interruptions were completed. Average mean decibel levels across all stations were between db. Potential interruptions were highest from family members and nurses. 204 patients completed the CPES survey. Tests of comparison demonstrated that primips (N=115) were more likely to perceive difficulty breastfeeding due to interruptions or visitations than multips (N=84, p=0.028). Qualitative interviews were conducted with 10 postpartum women. Interviewed postpartum mothers felt that the hospital environment was noisy and that they experienced multiple potential interruptions throughout the day. All mothers felt that a quiet time would be beneficial. The interviewed mothers highlighted potential challenges to implementing the quiet time with some advice to staff and expectant mothers. Conclusion Noise levels and potential interruptions were higher than recommended WHO maximum of db (quiet rural area); this is consistent with other studies. Average decibel levels of db are similar to a washing machine. These levels of noise and potential interruptions can interfere with recovery. Potential benefits of a quiet time were identified by postpartum mothers and staff. Both postpartum mothers and staff welcomed the idea of a quiet time. The findings of this study will contribute to the larger pre-post evaluation following the implementation period. August 10,

7 French Contexte Un séjour à l'hôpital, après l'accouchement, devrait fournir aux nouvelles mères un environnement propice au repos et la guérison. Ces patientes subissent souvent des perturbations causées par le bruit lié aux va-et-vient des visiteurs et du personnel, aux soins cliniques et services hospitaliers, et aux annonces d'interphone. Cela peut nuire aux besognes comme l'allaitement maternel et l'enseignement, et peut augmenter le risque de problèmes de santé mentale post-partum. Une solution possible est de désigner un moment de calme, une période où les lumières sont tamisées. Les perturbations sont réduites, et les processus de soins sont planifiés pour être effectués en dehors de cette période protégée, si possible. Une seule étude non-publiée portant sur l exécution d une telle initiative en service de maternité a été trouvée. Le but de cette étude est d informer sur les niveaux de bruit et le nombre d'interruptions en service de maternité et d'améliorer la compréhension des avantages, obstacles et problèmes de mise en œuvre d'un temps de calme. Méthodes Cette étude a eu lieu dans le service de maternité d un hôpital communautaire général situé à Montréal. Une méthodologie mixte a été adoptée dans une évaluation avant-après avec recrutement basé sur une approche participative. Le niveau de bruit a été mesuré par l application Decibel 10e de iphone; les interruptions potentielles ont été constatées par observation. Une version modifiée de l'enquête Expérience des Patients Canadiens (CPES) a été distribuée aux patients hospitalisés. Des entrevues qualitatives ont été menées auprès de mères après l'accouchement et des notes d'observation ont été enregistrées lors des réunions avec les parties prenantes. August 10,

8 Une moyenne équivalente pondérée du niveau sonore mesuré en décibels (Leq) a été calculée, ainsi que les moyennes de valeurs minimales et maximales. Nous avons effectué des analyses de variance et de chi-carré sur les résultats de l'enquête sur l'expérience des patients afin de déterminer les caractéristiques des femmes qui éprouvent des difficultés à allaiter en raison d'interruptions potentielles. Une analyse de contenu thématique a été utilisée pour analyser les entretiens qualitatifs. Résultats Un total de 52 séances de 30 minutes dans le but de mesurer le niveau de bruit et les interruptions potentielles ont été achevées. Le niveau de décibels moyen a varié entre 55 et 66 db. Les interruptions potentielles les plus fréquentes étaient avec les membres de la famille et les infirmières. 204 patients ont complété le sondage CPES. Les tests de comparaison ont démontré que les mères avec 1 enfant (N = 115) étaient plus susceptibles de se plaindre de difficultés à allaiter en raison de potentielles interruptions ou de visites (N = 84, p = 0,028). Les entrevues qualitatives ont été menées auprès de 10 femmes post-partum. Les mères post-partum interrogées disent que l'environnement de l'hôpital était bruyant et qu'elles ont connu des interruptions potentielles multiples tout au long de la journée. Toutes les mères ont estimé qu'un moment de calme serait bénéfique. Les mères interrogées ont mis en évidence les défis potentiels à la mise en œuvre d un moment de calme et prodigué des conseils au personnel et aux femmes enceintes. Conclusion Le niveau de bruit et des interruptions potentielles étaient plus élevés que les niveaux recommandés par l'organisation Mondiale de la Santé qui sont de db (zone rurale tranquille), en accord avec d'autres études. Le niveau de décibels moyen de db est August 10,

9 semblable au bruit d une laveuse. Ces niveaux de bruit et les potentielles interruptions peuvent interférer avec la récupération. Les éventuels avantages d'un moment de calme ont été identifiés par les mères postpartum et le personnel. Ces derniers ont salué l'idée d'un moment de calme. Ces résultats contribueront à une plus grande étude avant-après qui suivra la période de mise en œuvre. August 10,

10 Acknowledgements Project Team Members First, I would like to thank my supervisors Dr. Susan Law and Dr. Jeannie Haggerty for their feedback and continuous guidance over the past year. I would also like to thank Marie- France Brizard (MB), the program manager for maternal and child health and Jennifer Somera (JS), the nursing leads for this project. I am also very appreciative of the support from Alina Dyachenko, a statistician at St. Mary s who advised on the statistical analysis portion of this thesis and Ilja Ormel who provided advice on the qualitative analysis. Thesis Committee Members Thesis committee members included Dr. Susan Law and Dr. Jeannie Haggerty, Safina Adatia s supervisors and Dr. Stephanie Morel and Jennifer Somera. These members attended various meetings throughout the year to provide guidance and feedback on the thesis and I am grateful for their support. Sources of Funding This thesis was made possible due to financial support from St. Mary s Hospital Foundation, which provided me with an annual stipend of $22,000 per year and the Department of Family Medicine that awarded me with an entrance award of $1,500 and travel award worth $1,250. Thank you also to the staff of the St. Mary s Research Centre and on the maternity ward for the many ways in which they provided in-kind support for the work related to my thesis and contributed to my learning about research and about healthcare organizations. August 10,

11 Preface and Contribution of Author Safina Adatia conducted the literature review with the help of a McGill librarian. She collected all the quantitative data (noise levels, potential interruptions, CPES survey) and conducted the qualitative interviews in English and French with supervision. The statistical analyses were performed in conjunction with a statistician, Alina Dyachenko, who is based at St. Mary s Hospital and the qualitative analyses were performed in conjunction with her supervisor Dr. Susan Law, with help from Ilja Ormel, a senior qualitative researcher and project coordinator based at St. Mary s Hospital. Safina Adatia wrote the entire thesis with incorporated feedback from her supervisors and members of the thesis committee. August 10,

12 1.1 Statement of the Problem 1.0 Introduction Postpartum hospital stay is meant to provide a space and time for a mother to rest and recover from childbirth. 1 Yet, in a typical hospital environment, postpartum mothers rest and recovery are disrupted throughout the day including visits by a variety of health professionals, hospital staff, students, family members and friends. In addition, noise levels from medical equipment, corridor conversations, intercom announcements, construction, doors opening and closing, cleaning equipment and food carts 2 may disrupt rest. For postpartum patients, high levels of potential interruptions can lead to disruptions in important learning activities such as breastfeeding, which is critical to establish within the first few days of childbirth. 3 A highly disruptive environment can also lead to acute sleep deprivation, increasing the risk of postpartum mental health disorders, 4,5 vascular dysfunction 6 and cardiovascular changes. 7 A potential solution to the problem of noise is the institution of a quiet time for patients in a hospital environment. This has been implemented in a variety of settings such as intensive care units, acute care wards, and surgical units. It typically involves controlling noise levels through, for example, silencing pagers and cell phones, closing patient doors and discouraging staff interactions beside patient rooms It has been demonstrated that introducing a daily quiet time during the day can improve patient satisfaction, 4,12,13 increase the likelihood of patients sleeping during that time 9 and increase staff satisfaction. 13 However, there is only limited evidence about the potential benefits and other consequences for patients and staff on other hospital units, including maternity wards. At St. Mary s Hospital, a university-affiliated community hospital in Montreal, maternity ward staff identified the introduction of a quiet time as a priority for improving patient care, and August 10,

13 approached the research team for help to design the evaluation around the preparation for this change and the implementation. A joint project team was created to investigate patient and staff perceptions of the benefits and barriers of a quiet time intervention, before and after the introduction of the quiet time. 1.2 Background and Context The project team identified and recruited key stakeholders to form a wider advisory group including physicians and nurses from the maternity ward, representatives of hospital departments associated with services to the maternity ward, and patient representatives. On September 10 th, 2014, and on March 12 th, and April 22 nd, 2015, the maternity staff hosted advisory group meetings of all key stakeholders in order to introduce the idea and discuss issues regarding feasibility, and potential benefits and barriers to implementation of the quiet time. Meeting notes can be found in Appendix A. The invitation to participate as an advisory group member can also be found in Appendix A. The community general hospital involved in this project serves a multicultural population. 14 It is one of the largest birthing centres in Montreal with 42 beds and over 4500 deliveries per year. 15 It is also the first hospital in Montreal to have been recognized with Baby Friendly Hospital Status from the World Health Organization (WHO). 15 According to hospital reports on monthly trends of births at this hospital, the number of births each month is relatively consistent over time (data available on request). 1.3 Research Questions The work conducted for this thesis is nested within a larger project which aims to evaluate the environment on a postpartum unit before and after the implementation of a quiet time intervention. This will be done by answering the following research questions: August 10,

14 1. What are pre-intervention noise levels, number and type of potential interruptions, patient experiences and postpartum women s difficulty breastfeeding due to potential interruptions or visitations? 2. What is the patient experience in the current postpartum environment, and postpartum patients perceptions of potential benefits and challenges of a quiet time? 3. What are the barriers and enablers to implementation that emerge during discussions with the advisory group? 4. Does a quiet time intervention on a maternity ward improve levels of noise, number of potential interruptions and experiences for patients? This thesis addresses the first three questions. The fourth research question will be addressed by the larger pre-post evaluation (outside the scope of this thesis). 1.4 Theoretical Framework Programme theory is the most appropriate theoretical perspective to inform this evaluation and was used to better understand the impact of the proposed intervention. 16 Programme theory aims to provide a framework for thinking through the processes by which an intervention contributes to outcomes and impacts. 17,18 A logic model was created for the larger quiet time study to summarize the program processes and activities with the short and long-term impacts of the intervention. 18 Logic models are often employed to guide the evaluation of programs and interventions and represent the chain of processes involved in the evaluation of an intervention or program. August 10,

15 Figure 1: Logic model Included in thesis Assumptions Indicators Activity Outputs Impacts Hospitals are loud and noisy Noise can lead to negative mental and physical health problems A quiet time is a possible solution Quiet times have been shown to increase patient/staff* satisfaction; reduce noise levels; increase breastfeeding success Noise levels Number and type of potential interruptions Patient experience Staff satisfaction* Advisory committee meetings Quiet Time Dimmed lights Reduced intercom use Closed patient rooms Restriction of visitors/family members Performance of diagnostic and other laboratory tests outside of this time as much as possible Reduced noise levels Reduced number of potential interruptions Improved patient experience Improved staff satisfaction* Reduced stress levels (patients and staff) Improved breastfeeding outcomes Improved patient and staff* experiences Improved postpartum mental health status *= not measured as part of thesis The assumptions above are based on the background literature, described in further detail below. 18 The indicators as in the second column are the objects of measurement for the pre-intervention phase. 18 The activity in the third column is related to aspects of the actual intervention, in this case the proposed quiet time intervention. 18 The outputs in the fourth column are the direct results of the quiet time and are measurable using the same methods for the indicators. 18 The impacts in the last column are higher level changes that are expected to result from the quiet time intervention. 18 As can be seen, programme theory provides a conceptual framework and the logic model, the diagram used here to represent the programme theory, assists in the monitoring and organization of the intervention. Following this logic model, through the implementation of a quiet time intervention, it is anticipated that hospitals will see a reduction in noise levels and potential interruptions and August 10,

16 improved patient experience. On a larger scale, this may lead to reduced stress levels for both patients and staff, along with improved health outcomes for postpartum patients. August 10,

17 2.0 Literature Review The purpose of the literature review is to provide an overview of current evidence related to the problem of noise in hospitals; in particular for postpartum women. It also presents evidence regarding a possible solution to the problem of noise, a quiet time intervention. A literature search was conducted with a librarian who specializes in health care literature searches. The databases MEDLINE, PsycINFO, Embase, CINAHL and the Cochrane Library between the years 2000 to present day were searched. English and French language documents were included. Snowballing techniques were also used and references and review papers from retrieved articles were examined to expand the search. The main key terms used were: quiet time, rest, sleep, relaxation, naptime, peace, maternal health, maternity, postpartum and hospital. 2.1 Postpartum Hospital Stay The postpartum environment is important to study since, in Canada, 98% of childbirth takes place in the hospital setting, 19 and the environment can influence the recovery process. 20 Factors that have been identified as interfering with recovery include excessive noise as well as hospital staff entering patient rooms without patients knowledge. 1,21 In a qualitative study conducted on the experiences of women receiving postnatal care, an emerging theme was the negative impact of the hospital environment on recovery. 22 For example, postpartum mothers found it difficult to rest in an environment where lights were on until very late in the night and switched on very early in the morning. 22 Moreover, not only does the hospital environment impact patients ability to recuperate, but it can also influence important teaching and learning activities that take place after delivery. Breastfeeding is an important activity that postpartum mothers learn within their first few days after giving birth. However, interruptions and noise may have an impact on breastfeeding opportunities and satisfaction for new mothers In one study conducted in the United States August 10,

18 (U.S.), postpartum mothers experienced overall approximately 53 interruptions within a 12 hour period. 23 This study also found that frequent interruptions had a progressive impact on their breastfeeding experience. 2.2 Hospital Noise, Potential Interruptions and their Effects The definition of noise according to the Merriam Webster dictionary is a loud or unpleasant sound. 26 Noise is measured using decibels (db) on a logarithmic scale. 27 Therefore, a 10 db increase corresponds with a noise level 10 times greater than the baseline. As such, an environment with noise levels around 50 db has levels 100 times greater than one measured at 30 db. 27 The WHO has recommended that hospitals should maintain noise levels around 30 db, with peak levels not reaching more than 40 db, 28,29 comparable to a quiet rural area. 30 However, several studies conducted in the U.S. and Turkey demonstrated that average noise levels in healthcare settings often exceeds these recommendations, measuring from 60 to 70 db, 29,31,32 comparable to the noise level of a typical vacuum cleaner at close range. 30 An interruption is defined as a diversion of attention from a primary activity in order to pursue a secondary task. 33 Interruptions within a hospital setting have been evaluated for many years, 34 however these studies mostly focused on the impact of interruptions on patients at night. Few studies have examined interruptions that take place in the daytime even though it is thought that during the day there are more opportunities for potential interruptions to take place, for instance, from noise and interactions with the care team. 35 For the purposes of this study, the term potential interruptions is used, as it was not possible to ascertain whether or not the potential interruption caused a break or diversion from an activity that the postpartum mother was involved in. When making reference to other studies that have measured potential interruptions, the term used by the authors of the study has been applied. August 10,

19 While it has been difficult to identify direct links between noise, potential interruptions and health effects, there is some evidence that noise acts as a stressor for both patients and staff, 11 which can cause a multitude of negative health effects. As reported by the WHO, an increased risk of ischemic heart disease and hypertension are effects of a noisy environment. 28 Noise acts as a constant stimulator of the sympathetic nervous system, the results of which are an increased heart rate and blood pressure. 36 In addition, the secretion of cortisol as a result of noise may also be a factor related to these cardiovascular effects. 37 Noise and potential interruptions on a maternity ward can lead to sleep loss, which is important for recovery. 38 Sleep loss has been documented to have an association with decreased immune function. As stress levels increase, cortisol levels will also increase reducing the number of lymphocytes and monocytes present and therefore, contribute to a suppressed immune system. 36 Furthermore, substantial sleep loss in general has been associated with a myriad of psychological and/or neurocognitive impairments such as memory loss, irritability, inattention, delusions, hallucinations, slurred speech, and blurred vision. 39 Recent studies conducted on the effects of sleep loss, have found that acute sleep deprivation is correlated with an increase in negative emotion. 40 Additionally, postpartum women have cortisol levels nearly three times as high as non-pregnant women, 41 which may be caused by a number of factors including increased physical stress due to sleep loss. 41,42 Increased cortisol levels may be associated with postpartum depressive symptoms. 43,44 Furthermore, 36 hours of sleep deprivation is associated with increased sympathetic and decreased parasympathetic cardiovascular modulation 7 while exposure to 40 hours of sleep deprivation appears to have an association with vascular dysfunction. 6 Shorter sleep duration has been found to have an association with increased appetite. 45 Results of this study indicated that those with 5 hours of sleep per night had elevated ghrelin and reduced leptin levels 45 compared to those with August 10,

20 8 hours of sleep. This may result in a higher body mass index (BMI). Finally, sleep deprivation has also been linked to postpartum mental health disorders. 5,13 These results are particularly relevant as postpartum mothers remain in a hospital setting on average 2 days following vaginal births and 3.4 days after a caesarean birth. 19 As this section shows, noise and potential interruptions are a significant problem on hospital units and in particular for postpartum patients. 2.3 Quiet Time Interventions Some hospitals in the Unites States have addressed the problem of noise and potential interruptions within the hospital through the implementation of a daily quiet time on a variety of wards. 2,4,8-13,46-51 A quiet time often consists of, but is not limited to, dimming the lights, decreasing telephone and pager volumes, closing patient rooms, discouraging staff interactions close to patient rooms, and performing diagnostic tests and other laboratory procedures outside of this time. 4,9-11,49 Most studies introduced the quiet time between 2:00pm and 4:00pm, where circadian rhythms reach a natural low. During this time, human bodies are more sensitive to external stimuli and require more protection. 10 Measurements of noise levels in these studies demonstrated a significant reduction in decibel level before and after the intervention. 8,11,12,50 Studies claimed that during the quiet time, patients were more likely to be found asleep. 9,11 As well, patient satisfaction increased with patients reporting that they enjoyed the intervention. 12,13 Staff reports also indicated that they welcomed the quiet time 11-13,48 and that it positively influenced patient care. 8 In the majority of studies cited above, the quiet time intervention involved critical care units. 8-11,48,50-52 Other studies looked at the effects of a quiet time on a surgical unit 2,46 and in acute care. 12 However, to our knowledge, only one study to date has evaluated a quiet time on a mother/infant unit. 13 This study (Driver et al, 2010), conducted in Columbus, Ohio, is as yet August 10,

21 unpublished (retrieved as a poster presentation) and indicated that postpartum women appreciated a period of daily quiet time. The authors of this study examined the effects of a quiet time on patient and staff satisfaction as well as breastfeeding outcomes. Results of the study included increased patient and staff satisfaction as well as an improvement in breastfeeding outcomes Knowledge Gap In sum, while the evidence on the impact of quiet time interventions is encouraging, the preliminary review has revealed a dearth of literature on quiet time interventions on hospital maternity wards, and particularly on the process of implementation and effects of a quiet time on the recovery and well-being of postpartum mothers and their babies. In general, it appears that disturbances during hospital stay are a concern for patients even in short hospitalizations, as there are negative effects associated with acute sleep deprivation. Given the detrimental effects of a disruptive environment on the healing environment, in particular for postpartum mothers, it is vital to evaluate solutions that may reduce the potential interruptions experienced by these patients. The goal of this study is to contribute to the general pool of knowledge regarding noise levels and number of potential interruptions on a maternity ward along with an understanding of the benefits, barriers and implementation issues associated with the introduction of a quiet time on a maternity ward. August 10,

22 3.0 Methodology This thesis pertains to the pre-intervention baseline measurement of the current environment and process of implementation of the quiet time intervention. The overall goals of the study are to (1) evaluate the need for a quiet time through quantifying noise levels, potential interruptions, patient reports of care, and difficulty breastfeeding due to interruptions or visitations; (2) explore patient experiences of the environment and perceived benefits and challenges of the implementation of a quiet time for patients through qualitative methods; and (3) document the anticipated barriers and enablers to the implementation of a quiet time. The methods section begins by describing the overall research design and research approaches. The next sections are organized by objective, where sections 3.3, 3.4 and 3.5 outline the participants, recruitment methods, data collection and data analysis methods for each objective. 3.1 Research Design For the overall quiet time study (pre-post), a convergent parallel mixed methods pre-post evaluation design was adopted. A parallel design involves concurrent qualitative and quantitative data collection and analysis prior to and after the intervention in order to understand a research problem more completely. 53 Here complementary numerical and qualitative data will be obtained on the same topic, from different sources, ensuring a holistic representation of the data. The statistical data will be compared and contrasted with the qualitative data in order to corroborate and validate our results both before and after the intervention is implemented. 53 The overall study has 4 phases: (1) Pre-implementation analyses, (2) Analysis/design of intervention, (3) Implementation, and (4) Post-implementation analyses. A diagram outlining the details and organization of the phases can be seen in Figure 2. August 10,

23 Figure 2: The four phases of the quiet time study CC Phases included for thesis The pre-implementation phase consisted of baseline measures of noise levels, counts of the number and type of potential interruptions, a survey of patient experience, and qualitative interviews with patients. The analysis/design phase involved analysis of baseline data, determination of the characteristics of the quiet time and other details and observation at meetings to discuss the intervention (project advisory group meetings). During the implementation phase, the clinical team will conduct information sessions for patients and staff, the quiet time will be introduced on the ward on the prescribed date, and agreed changes to staff schedules and ward activities will begin. Finally during the post-implementation phase, patient experience, noise levels and number of potential interruptions will be measured again, along with qualitative interviews with patients. August 10,

24 3.2 Participatory Research This study adopted a participatory research (PR) approach, where the end-users of the research products are involved directly in the investigation process. 54 Participatory research aims to promote the relevance of the research questions and empowers participants or potential beneficiaries to identify and solve problems they feel are important. 54 The goal is to involve the experiences and perspectives of end-users in the redesign of service delivery, which will lead to a positive experience with the intervention, and potentially more commitment to long-term changes in service. 55 Members of the maternity unit staff proposed this intervention and evaluation and are actively engaged in project design, implementation, and evaluation activities. The project team and advisory group include both patient and staff representation alongside research team members. The project team recruited various representatives as members of the advisory group including physicians, nursing staff, housekeeping staff, kitchen staff, a social worker, laboratory staff and research representatives. Patients who have recently experienced births at the hospital site were invited to participate as members of the advisory group for the duration of the study and engage in discussions about the design of the quiet time intervention with staff and the research team. 3.3 Baseline Environment Measurements, Patient Experiences and Difficulty Breastfeeding due to Potential Interruptions or Visitations Participants The target populations for this portion of the study are postpartum wards and postpartum patients in community hospitals. The specific study population for this thesis included postpartum patients (both primip and multip) admitted to the university-affiliated community general hospital site during the 6-month period from November 2014 to April Selected August 10,

25 patients were over the age of 18, and able to respond to oral and verbal questions in English or French. Mothers whose babies were transferred to a neonatal intensive care unit (NICU) outside of the hospital site or who were clinically unwell themselves were excluded (nursing staff advised the research team regarding who was unwell at the time of recruitment). Recruitment Recruitment of patients for this study took place on the maternity ward. The nurses and SA were responsible for gaining the participation of postpartum mothers on the maternity ward for the patient survey. SA worked with members of the nursing staff to invite patients to fill out the patient experiences survey. Recruitment for the survey involved random sampling during different time points of the day and multiple days of the week to ensure the data was representative within the sample of the larger maternity ward population. Data Collection Noise Levels and Potential Interruptions Noise levels and number of potential interruptions were measured between 1:30pm and 4:00pm, the time period supported by the evidence and identified by the advisory group as feasible for the quiet time. Over the 6-month period from November 2014 to April 2015, SA collected data between Monday-Friday, alternating days, with multiple data sets per day of the week, to ensure a wide representation of data. The author (SA) alternated between the three different hallways (labelled as stations) of the maternity ward every 30 minutes. SA sat in the middle of each hallway to measure noise and potential interruptions. This location was chosen to assure that the data was representative of the entire hallway, and that observations of the potential interruptions were as accurate as possible. A diagram of the maternity ward can be seen in Figure 3. August 10,

26 Figure 3: Layout of the maternity ward showing the position of the nursing station relative to the 3 hallways : SA s approximate position on each of the three stations. Data collection tools were drafted and piloted during the study. At the start and end of every session, SA gathered and recorded data on the total number of patients along with the number of patients in each hallway. Noise levels were measured using Decibel 10 th, a free iphone app that measures decibel levels continuously, and exports into an excel file. 56 SA also recorded the number and type of potential interruptions observed on the ward during each 30- minute period using the form developed for this study by SA in Appendix B. A potential interruption was defined as a crossing of the threshold (doorway) into the room e.g. visitors or hospital staff entering patient room. Only those who entered the room were counted as an potential interruption. 23 Hospital staff or visitors who left the room were not counted. Survey of Patient Experience As part of the larger study, the project team also wanted to measure patient perspectives on the healthcare they received. This majority of this survey is going to be used to compare patient experience pre and post-implementation and will not be analysed for the purpose of this thesis. From January to April 2015, SA went on the ward between 10:00am and 4:00pm, and asked a random sample of the eligible patients to anonymously complete the Canadian Patient Experiences Survey (CPES). SA left the survey instrument with the patient after explaining its purpose and instructions. SA picked up completed surveys later on the same day, or patients had August 10,

27 the option to leave completed surveys in a labeled box at the nursing station. This survey was developed by the Canadian Institute of Health Information (the CPES was launched in Spring 2014) and has been endorsed by Accreditation Canada. Accreditation Canada will be introducing this tool as a requirement in all Canadian hospitals beginning in The CPES is based on the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey tool. It is a standardized tool to measure patients perspectives on hospital care 57 and is becoming a standard measure in Canadian hospitals as it has become in the U.S. The survey was altered to remove questions not pertinent to the study, such as discharge experience. Questions more specific to the postpartum hospital experience were added. Our key question of interest related to difficulties experienced during breastfeeding due to visitations or interruptions. We identified a need for the question based on the current literature on maternity ward environments and breastfeeding success. 13,23 The response scale has been validated and the question was informed by previous questions that have been validated on issues related to accessibility. The project team also asked patients to include information about their length of stay, and number of children delivered in hospital. A copy of the survey can be found in Appendix C. It was formatted to be more user-friendly and contact information of research team members was printed on the back of the survey. Sample Size Noise Levels per 30 min Session With an expected average noise level of 60 db pre-intervention, and a standard deviation of 3 db per group, a sample size of 30 sessions both pre and post intervention will have 99.9% power to a detect a 10 db reduction in the average noise level using a two sided T-test for two independent groups and with a confidence level α = Other power calculations for five different sample sizes per group and two different standard deviations are presented in Table 1. August 10,

28 Table 1: Power estimation by number of sessions and standard deviations for average noise level N Per Group StdDev >99.9% >99.9% >99.9% >99.9% >99.9% 3 >99.9% >99.9% >99.9% >99.9% >99.9% Total Number of Potential Interruptions per 30 min Session With an expected mean total number of potential interruptions per hallway of 25 preintervention, and a standard deviation of 10 per group, a sample size of 30 measurement sessions both pre and post intervention will have 96.8% power to detect a 40% reduction (10 potential interruptions) in the mean number of potential interruptions using a two sided T-test for two independent groups and with a confidence level α = Other power calculations for five different sample sizes per group and four different standard deviations are presented in Table 2. Table 2: Power estimation by number of sessions and standard deviations for total number of potential interruptions N Per Group StdDev % 99.7% >99.9% >99.9% >99.9% % 96.8% 99.3% 99.9% >99.9% % 88.8% 95.7% 98.5% 99.5% % 77.6% 88.4% 94.3% 97.3% Canadian Patient Experiences Survey In the absence of knowledge of variable behaviour and after consultation with a senior survey methodologist at McGill University, it was determined that 200 completed surveys preintervention and 200 completed surveys post-intervention would be enough to find a large main effect and permit sub-analyses. The main outcome of interest for this survey is the percent of women reporting difficulty with breastfeeding because of interruptions or visitations. Secondary outcomes are measures of a positive care experience. Given that this is a pilot of this survey, and August 10,

29 recent studies on this ward with similar tools have indicated a very low refusal rate, a sample of this size was judged adequate for this dimension. Data Analysis Noise Level Calculations The equivalent sound level for each 30-minute session conducted on the maternity ward was computed. The equivalent sound level is the sound pressure level in db that results in a single decibel value and takes into account the total sound energy over the period of time of interest. 59 Technically, the equivalent sound level is the level of the time-weighed, exponentially averaged, A-weighted sound pressure. The equivalent sound level across each session was calculated using the formula 60 : L eq = 10 log 10 ( 1 n 10x i 10) Number of Patients and Bed Occupancy At the start and end of every session, SA gathered information on the total number of patients and number of patients per hallway. The purpose of this was to investigate relationships between the number of patients per hallway and noise levels and potential interruptions. The start time was usually 1:30pm and the end time was usually 4:00pm. The data was used to calculate the bed occupancy percentage using linear approximation. The formula for calculating this percentage is: n i=1 Percent = (N start + N end N start (T T end T session T start )) Total_Nb_Bed start where Nend, Nstart are the number of patients at the beginning and the end of the session; Tend, and Tstart, are the end and starting time periods, Tsession is the session time and Total_Nb_Bed is the August 10,

30 total number of beds in the respective hallway. Once calculated, this number was used as the number of patients per station. Descriptive Statistics Noise level was summarized per session and assessed separately for each station using the following descriptive statistics: A-weighted sound level mean, minimum, and maximum. The noise level versus time and session date for each station was graphically presented on a linear scale. A further average was computed for the mean, minimum and maximum values per station. The total number of potential interruptions per half hour session per station were organized and presented graphically. From this data, the average number of potential interruptions by type per station was calculated. In addition the average and median number of potential interruptions by time in total and per patient were calculated independent of station. The correlations of interest (number of patients and noise levels by station, number of patients and number of potential interruptions by time and by station) were calculated separately for each station. Pearson correlation coefficients were interpreted using categorisation by Dancey and Reidy (2011) where a weak correlation is defined as ±0.1 to ±0.3, a moderate correlation is from ±0.4 to ±0.6, a strong correlation is between ±0.7 to ±0.9 and ±1.0 corresponds to a perfect correlation. 61 Descriptive statistics for the CPES survey were calculated: count and proportion for categorical variables of interest; and mean, standard deviation, minimum and maximum for continuous variables. Statistical Analysis The focus of the statistical analysis was on a question in the Canadian Patient Experiences Survey related to difficulty breastfeeding due to interruptions and visitations. Statistical analyses for other questions in the CPES survey were not completed as they were not relevant to the research objectives. Quantitative data analysis methods included ANOVA August 10,

31 analysis and chi-square tests to test for statistical differences in patient demographics, patient health and hospital variables for the survey question related to difficulty breastfeeding. These variables included ethnicity, age, physical health, mental health, length of hospital stay and number of children. Difficulty breastfeeding was also compared with station, room type, education level and method of delivery. P values of less than 0.05 were considered statistically significant. Software for data analysis was SAS Systems version Qualitative Exploration of Patient Experiences and Perspectives Participants The target populations for this portion of the study are postpartum patients who had normal births in community hospitals. The study population for this portion of the thesis was a sample of postpartum patients (both primip and multip) admitted to the university-affiliated community general hospital site during the 3-month period from February to April Criteria for selecting women for qualitative interviews included mothers who had been in the hospital for at least hours which included an overnight stay. Similar to the patient experiences survey, mothers whose babies were in the NICU or who were themselves clinically unwell were excluded. Recruitment The nursing practice consultant (JS) invited patients to participate in the qualitative interviews on days that the author was to be on the ward. JS consulted with the nursing staff to identify eligible patients and to ensure a diverse sample from amongst who was on the ward. Selection of patients for individual interview involved purposive sampling methods in order to increase credibility of results despite a small sample size. 62 Once those patients had been identified, JS approached them to ask if they would be willing to participate and what time was convenient for them to be interviewed. JS then told SA which patients on the ward agreed to be August 10,

32 interviewed and what time was convenient for the interview to take place. SA went on the ward at those specified times to recruit and interview those patients. Data Collection During the pre-intervention phase, SA (with supervision) employed face-to-face semistructured interviews with postpartum mothers on the maternity ward. 62 Semi-structured interviews involve topics to be provided by the interviewer, however, participants choose to provide whatever information they feel is important and relevant to the topic. 63 A semi-structured interview guide was created and can be found in Appendix D. This guide was developed by the author and her supervisor (SL) and sought to learn about current perceptions of levels of noise and potential interruptions on the maternity ward as well as thoughts about the benefits and challenges of a potential quiet time. The interview began by asking postpartum mothers to describe the environment, and if they have been able to rest. Then they were asked about their perceptions of the noise levels and potential interruptions they experienced during their stay. Next, postpartum mothers were told about the potential quiet time intervention and asked about their perceptions of the benefits and challenges of a quiet time. Finally, the interview concluded by asking the mothers if they had any advice for incoming new mothers and staff regarding the noise and potential interruptions in the hospital. The project team reviewed and approved the interview guide for postpartum patients. As the project team wanted to avoid creating any further disruptions to patients, the author aimed to have interviews last no longer than minutes. No more than 2 interviews were conducted per day that SA was on the ward. They were conducted in either English or French, audiorecorded and transcribed. English interviews were transcribed by SA and French interviews were transcribed using a professional French to French transcription service. Participants were provided with a consent form to inform them about the study and the details of the intervention. August 10,

33 They were assured that the information they provided us with would remain confidential and anonymous. Consent was obtained prior to the interview and administered by SA. A copy of the consent form for patients pre-intervention, patients post-intervention and the advisory group can be seen in Appendix E. Sample Size To ascertain patient views on their environment and proposed quiet time, postpartum patients were to be recruited pre-intervention for individual interviews or until data saturation was reached. 64 A wide scope of participants for all aspects of this study is particularly important as our study is assessing the implementation of an intervention in an environment that has not been studied in this capacity before. Additionally, this hospital serves a diverse, multicultural population. 14 Therefore, the goal was to obtain a variation sample within the available pool of eligible participants in order to include a diverse range of participants. Data Analysis For the qualitative component thematic content analysis, was used as per standard qualitative data analysis. 63 The goal of this type of analysis is to present a summary of key themes from participants responses to questions and accounts of their experiences. Themes emerge from the review of the transcripts based on how common they are or how often they occur. When new themes or topics are raised, the data is checked again to see if it appears elsewhere in the data. Qualitative data analysis software (NVivo10) was used to help manage the data, and support the analysis. 65 Analysis of the qualitative data consisted of five phases, as outlined by Braun and Clarke (2008). 66 The first phase required familiarizing oneself with the data, by reading and re-reading the transcript multiple times. Next, codes were assigned to various phrases and paragraphs across the entire data set. This initial coding was done using a buddy system involving independent August 10,

34 reading of the first 2-3 transcripts by SA and her supervisor, followed by a meeting to compare and discuss codes. These codes were used to develop a coding frame, which was then applied to further transcripts. Codes and emerging themes were defined. A thematic map to illustrate the codes and their relationship to each other or to the mother s story was developed. After coding the entire data set, the codes themselves were reviewed. Similar codes were merged and the coding frame was adjusted. A summary of the findings was prepared under each theme, with illustrative quotes. 3.5 Process of Implementation Participants A project advisory group was created at the outset of the project. The purpose of this group was to provide advice on the design of the project; feasibility of the intervention; knowledge transfer; and identify implementation issues. The author (SA) acted as an observer in meetings of this group, and recorded notes to prepare a summary of the key decisions and observations. Recruitment The project team was responsible for the recruitment of the advisory group. They approached members from key stakeholder groups and hospital departments, described the project to them and asked them to participate in the group. The project team members explained the purpose of the advisory group and the commitment required. Data Collection As mentioned, SA acted as an observer at the advisory group meetings. These observations included field notes of the team meetings and setting for care. She observed the events that took place, listened to what was said during interactions between advisory group members and collected any other data relevant to barriers or enablers to change. 63 August 10,

35 3.6 Ethical Considerations The primary ethical concerns for participants in this study were related to privacy, disruption of patients, confidentiality, informed consent, and security of data. During the conduct of this research, there were concerns about interrupting patients privacy and interfering with usual patient care processes. To address this issue, during the study period, the author (SA) was situated outside the patient rooms in the ward corridor for observation of potential interruptions and noise. This way, there was minimal invasion of their privacy. Furthermore, the author worked with the nursing staff to determine what time point in the day would be the best to approach patients for an interview. Patients who agreed to participate in an interview told JS what time was best for SA to conduct the interview. All participants were fully informed about the study and its aims by the author, and signed a consent form prior to the interview. SA obtained consent for the interview at the time of interviews for all participants. Any identifying information obtained in the audio recordings was removed from the transcript. The interview transcript was assigned a code and pseudonym and there was a master list linking patient names to interview data kept in a secure place to maintain confidentiality. These transcripts will be kept for five years. Only SA and the principal investigator have access to the transcripts for analysis. Results of the qualitative interviews will be presented anonymously in any reports, papers or presentations of the study results. This study was reviewed by the St. Mary s Hospital Research Ethics Committee; approval was received in November, August 10,

36 4.0 Results In this chapter, major findings are presented. Sections have been organized by objective. Each section will include a brief introduction followed by the results. Under the sections regarding noise and potential interruptions, quantitative data is presented followed by qualitative data pertinent to these 2 sub-themes. Quotes that help illustrate the particular context and themes have been selected from the qualitative text and integrated within the qualitative results. 4.1 Baseline Environment Measurements, Patient Experiences and Difficulty Breastfeeding due to Potential Interruptions or Visitations Baseline environment measurements included evaluation of noise levels, potential interruptions and the administration of the CPES survey. A total of minute sessions, between 1:30pm and 4:00pm were completed that evaluated noise levels and potential interruptions. Recruitment for the survey took place between January and April Of the 269 eligible patients identified and approached, 204 (76%) patients aged (mean age 32.9) completed the CPES survey. Reasons for refusal were unknown. Self-reported sociodemographic and delivery characteristics for postpartum patients who responded to the survey can be seen in Table 3. General ward characteristics of respondents can be seen in Table 4. August 10,

37 Table 3: Key self-reported socio-demographic and delivery characteristics of CPES survey respondents (N=204) Characteristic Mean age, years (SD) 32.9 (4.8) Mean ease of labour (SD) 5.6 (3.0) (1=difficult, 10=easy) Physical health, Percent (N) Fair-Good 30.9% (63) Very Good-Excellent 68.6% (140) Mental health, Percent (N) Fair-Good Very Good-Excellent Parity, Percent (N) Primip Multip Distribution of delivery type, Percent (N) Vaginal C-section 22.5% (46) 76.9% (157) 53.9% (110) 41.2% (84) 65.8% (133) 34.2% (69) Distribution of respondents education level, Percent (N) High school or less College/CEGEP Undergraduate Postgraduate 11.4% (23) 23.4% (47) 37.8% (76) 27.4% (55) Distribution of respondents ethnicity, Percent (N) White 30.4% (62) Arab 12.3% (25) Black 11.3% (23) Mixed 8.3% (17) Latin 7.4% (15) Chinese 6.4% (13) South Asian 5.9% (12) Filipino 5.4% (11) Other 5.4% (11) West Asian 2.0% (4) August 10,

38 Table 4: Ward characteristics of CPES survey respondents (N=204) Characteristic Self-reported mean time on the ward, hrs (SD) 57.8 (32.4) Number of respondents by station, Percent (N) Number of respondents per month, Percent (N) January February March April Number of respondents by room type, Percent (N) Private (1) Semi-Private (2) Ward room (4) 51.5% (105) 36.3% (74) 12.3% (25) 8.3% (17) 27.5% (56) 22.6% (46) 41.7% (85) 47.1% (96) 29.9% (61) 23.0% (47) Noise Levels This section presents quantitative and qualitative results of noise levels. Quantitative results are presented first, followed by qualitative results from the interviews. Quantitative For each 30-minute session of data collection at a station on the ward, a mean, minimum and maximum decibel level was calculated and identified for noise levels. These values were plotted and organized by station and an example can be seen in Figure 4. Absolute peak levels for all stations ranged between db, comparable to an airplane landing, and absolute minimum noise levels for all stations ranged between db, similar to the sounds of bird calls and quiet conversation. Average noise levels were consistently around the db mark for all 3 stations, similar to a washing machine and approaching the sound of a vacuum cleaner. From these values, an average mean, minimum and maximum decibel level was calculated for each station. This can be seen in Table 5. Average mean decibel levels across all stations were between db. Average minimum values across all stations were between 44- August 10,

39 November 17, :00 November 17, :30 November 19, :30 November 27, :30 December 1, :30 December 12, :30 December 12, :00 December 15, :30 December 18, :30 December 18, :00 January 19, :30 January 19, :00 January 21, :30 January 21, :00 January 22, :30 January 22, :00 January 27, :30 January 27, :00 February 3, :30 Decibel Level 58 db and average maximum values across all stations were between db. In summary, there is a range of noise levels across all stations; however these levels are consistently quite high. Figure 4: Minimum, average and maximum noise levels for station Noise Levels per Session - Station Session Maximum Session Average Session Minimum Session Date and Time Table 5: Average mean, minimum and maximum decibel levels by station Noise Level (db) Average Mean Average Minimum Average Maximum Station 1 Station 2 Station 3 (N=19)* (N=18)* (N=15)* Mean (SD) Mean (SD) Mean (SD) 64.2 (2.1) 49.2 (1.6) 92.1 (3.4) 60.6 (2.8) 48.4 (2.1) 89.5 (3.4) 62.3 (2.2) 55.1 (2.0) 89.7 (3.4) *N=number of sessions included in calculation August 10,

40 Decibel Level Additionally, average noise levels by time independent of station were also computed to understand if there were times in the afternoon that were noisier. These have been plotted graphically in Figure 5. Computed Leq levels were above 60 db for all time points in the afternoon. Average noise levels across all time points did not vary significantly by time. Figure 5: Average noise level by time 80.0 Average Noise Level by Time Noise Level :30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM Finally, correlations between noise levels and number of patients by station were calculated to determine if a higher number of patients was associated with increased noise levels. There was a weak association between the number of patients and noise levels for Station 1 and 2, and no association between the number of patients and noise levels for Station 3. This can be seen in Table 6. Table 6: Correlation between number of patients and noise levels by station August 10,

41 Qualitative Consistent with the above, all interviewed mothers commented on the various types and sources of noise on the maternity ward such as people in the hallways, machines in the corridors, babies crying, other patients, staff changing shift and visitors. In particular, many postpartum mothers felt the intercom was quite loud and intrusive. Yeah it s really, it is really loud. They turn it down at night, but it s still loud. (Patient 119) I don t know, it s just weird you just, out of nowhere, you just hear a message and you just kind of go woah, ok. And they all get the message and they can all communicate instead of doing it over the intercom, because sometimes the patients are like lost, like yesterday, there was a message and I didn t understand it I had to beep them and ask I don t get this message, does that pertain to me? So. (Patient 105) While most postpartum mothers perceived noise levels to be high, many felt that noise is normal within hospital settings, especially during the daytime. Well I think it s something expected, I mean you re at a hospital if you wanted, I think a lot of privacy maybe be at a birthing centre, or something different, or at home a hospital is a hospital. (Patient 013) It s normal. Because right now it s the day, so there is a lot of work compared to last night. A lot of work. During the day there is more work in comparison to last night. (Patient 146 translated from French) For close to half of the postpartum mothers that were interviewed, the noise did not bother them. Some of these mothers also favourably compared the noise levels on the postpartum unit with other units of the hospital and even other hospitals, saying that even though noise was present on the maternity unit, in comparison to other areas or other hospitals, it was more calm and quiet. The other half did feel noise was a problem and that it prevented them from sleeping and resting. Furthermore, at night, with the exception of one mother, the noise levels were reported to be lower. August 10,

42 Interestingly, for mothers who were affected by the high levels of noise, some mentioned that the reason the noise bothered them was because it would disturb the baby and cause them to cry, which would in turn prevent the new mom from being able to rest. cause she had to get used to the noise and that was hard on me recuperating and resting, so on and so forth. (Patient 188) Therefore, all mothers experienced noise during their stay on the unit. Specifically, the intercom was a source of unpleasant noise for many mothers. The perception of how loud the noise was however, varied by individual mother. Some thought noise levels were normal and expected to be high on the hospital unit, especially during the daytime. Potential Interruptions This section presents quantitative and qualitative results of potential interruptions. Quantitative results are presented first, followed by qualitative. Quantitative For each 30-minute session of data collection on the ward, the number of potential interruptions were counted and organized by type. These values were plotted by station and an example can be seen in Figure 6. From these values, an average number of potential interruptions for each type was calculated per station and includes all rooms in that station. These values can be seen in Table 7. Family members caused the highest number of potential interruptions, averaging 4.6 (station 3), 11.3 (station 2) and 9.3 (station 1) potential interruptions per 30- minutes. Nurses caused the second highest number of potential interruptions, with an average of 7.0 (station 3), 9.1(station 2) and 7.1 (station 1) potential interruptions per half hour. The average total number of potential interruptions per half hour per station was 24.1 (station 1), 31.5 (station 2), and 18.1 (station 3). August 10,

43 Number of Potential interruptions Figure 6: Total potential interruptions by type station Total Potential Interruptions per Session by Type - Station 1 Session Date and Time Total Nurse Family Intercom Kitchen MD Housekeeping Orderly Other Lab Table 7: Average number of potential interruptions by type per station Type of Potential Interruption Family/Visitors Nurse Intercom Kitchen MD Housekeeping Lab Orderly Other Total *N=number of sessions included in calculation Station 1 Station 2 Station 3 (N=19)* (N=18)* (N=15)* Mean (SD) Mean (SD) Mean (SD) 9.3 (7.5) 7.1 (3.8) 2.7 (2.5) 3.3 (4.7) 0.7 (1.4) 0.3 (0.9) 0.1 (0.2) 0.1 (0.3) 0.6 (1.1) 24.1 (13.9) 11.3(10.1) 9.1 (3.6) 3.6 (2.5) 1.3 (3.7) 1.5 (1.9) 3.3 (6.0) 0.2 (0.5) 0.3 (1.2) 0.8 (1.0) 31.5 (18.2) 4.6 (4.5) 7.0 (5.9) 3.3 (2.3) 0.7 (2.1) 0.5 (1.0) 1.3 (3.4) 0.1(0.5) 0.3(0.6) 0.4 (0.7) 18.2 (11.0) August 10,

44 Number of Potential interruptions Number of Potential interruptions Average and median number of potential interruptions by time overall and per patient were computed to examine if there was any variation by time and can be seen in Figures 7 and 8. Average total potential interruptions were highest at 1:30pm (37.3) and lowest at 3:30pm (17). When calculated per patient, average potential interruptions were highest at 1:30pm (3.8) and lowest at 3:00pm (2.2). Figure 7: Average and median number of potential interruptions by time Median and Average Number of Potential Average Interruptions by Time Period Median Interruption, Total Median Interruption, Total Average 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM Figure 8: Average number of potential interruptions per patient by time Average Number of Potential Interruptions per Patient by Time Period 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM Interruptions/Patient Average August 10,

45 Correlations between number of potential interruptions and number of patients by station were computed to evaluate whether a higher number of patients is associated with increased amounts of potential interruptions. Results demonstrate a weak association between number of potential interruptions and number of patients for Station 3, and a moderate association for number of patients and potential interruptions for Stations 1 and 2. A similar correlation was calculated for number of patients and number of potential interruptions by time and revealed a negative, weak correlation at 2:30pm for number of patients and number of potential interruptions, moderate associations between number of patients and number of potential interruptions at 2:00pm and 3:00pm and strong correlations at 1:30pm and 3:30pm respectively. These results can be seen in Tables 8 and 9. Table 8: Correlation between number of patients and number of potential interruptions by station Table 9: Correlation between number of patients and number of potential interruptions by time Therefore, the number of potential interruptions that patients experience is moderately associated with the number of patients on the station, for stations 1 and 2, and weakly associated with the number of patients for station 3. At 1:30pm, 3:00pm and 3:30pm, an increased number of patients has a strong association with an increased number of potential interruptions. At August 10,

46 2:00pm, there is a moderate relationship between the number of patients and the number of potential interruptions they experience, while at 2:30pm the number of patients has hardly any relationship with the number of potential interruptions they receive. Qualitative Consistent with the quantitative results, all interviewed postpartum mothers said they experienced multiple potential interruptions throughout the day, from nurses, physicians, lactation specialists, family members, friends, students and other hospital staff. Similar to perceptions of noise levels, half the interviewed mothers felt the number of potential interruptions they experienced were too high, while the other half did not find the potential interruptions to be bothersome. During the interviews, the number of potential interruptions and number of intercom announcements were counted. Interestingly, during each interview, it was observed that between 1 and 3 potential interruptions or intercom announcements occurred. Some mothers, mostly first time mothers, welcomed the potential interruptions, as they felt they needed as much help and information as possible. I d rather be safe than sorry, so I prefer them coming around several times checking up on status of baby and me as opposed to like not feeling that they re kinda around enough. (Patient 013) I don t feel any uncomfortable for the potential interruptions because this is the first time I give birth, so I I like to nurse and other people to check whether I m doing well. (Patient 014) What seemed to matter most for all mothers was the type of potential interruptions. Potential interruptions that were generally welcomed by most mothers included visits from healthcare providers such as nurses and doctors. I think they are doing their work, they are always welcome for me. What is important is that the baby is in good health. So, I don t care. (Patient 108- translated from French) August 10,

47 Unwelcomed potential interruptions were usually visitors and crying from other patients babies, though for the latter, new mothers tended to understand that this could not be helped. or other peoples baby, like crying you cannot control it right. Um you cannot blame them but it s just like naturally you don t want to, want to get interrupted. (Patient 014) For new mothers who were bothered by potential interruptions from visitors, this was amplified if the patient was in a shared room. Now the, my issue was, is that there are certain cultures that perhaps maybe have different ways of doing things and that was really annoying. So when I put my daughter to sleep and there s like 12 people in here that can be very frustrating. You know, we re alone today, we re speaking at a certain volume, if not, you whisper. You re in a maternity ward, you re not in a discothèque you don t play music, your kids are not here to run around it s not a daycare. (Patient 188) Oh well, there, there s a lot of people coming in and out of the room. And it s not only for you either; it s for the person next to you. (Patient 119) For patients in private rooms, the number of potential interruptions they experienced were less, and were often by people they wanted to be there. I m doing well, um, cause it s private room, so no other people interrupt me. But if it s shared room then maybe you don t want to see other people like they have too many visitors. (Patient 014) To conclude, what was most important for postpartum mothers was the type of potential interruption they experienced. Many mothers, especially first time mothers, welcomed visits from nurses and physicians. For patients in shared rooms, it was sometimes bothersome to experience visits from other patients family members and friends and hear another patients baby cry, though they understood this could not be helped. Canadian Patient Experiences Survey As mentioned, 204 patients completed the survey. Results from the CPES survey do not report on the data collected from all questions. The focus of statistical analysis was based on the August 10,

48 survey question How difficult is it to breastfeed because of interruptions or visitations? Of the 204 participants, 199 responded and 5 were missing. Results of the survey are shown in Figure 9. Figure 9: Distribution of responses to difficulty to breastfeed question in CPES survey (N=204) How difficult has it been to breastfeed because of interruptions/visitations? % 27% 18% 6% 3% Not at All A little Moderately Quite a Bit Extremely Due to the relatively low percentile of responses for the moderately, quite a bit and extremely categories, these categories were combined into one for the purposes of statistical analysis. A one-way ANOVA and chi-square tests for comparison were used to create a profile of participants who experienced at least moderate difficulties breastfeeding due to interruptions or visitations. An ANOVA was used to compare the continuous variables age, physical health, mental health, length of hospital stay and perceived difficulty of labour. The ANOVA analysis revealed no statistically significant differences between those who responded with (1) moderately, quite a bit, or extremely; (2) those who responded with a little and; (3) those who responded with not at all (p>0.05). August 10,

49 Chi-square analysis was used to compare the categorical variables station, self-reported room type, actual room type, education levels, delivery method, ethnicity, parity (primup or multip) and discharge month. There was no statistically significant difference in the distribution of breastfeeding difficulty by station, room type (self-reported and actual), education level, delivery method, ethnicity and discharge month (p>0.05). Tests of comparison demonstrated that primips (N=115) were more likely to perceive difficulty breastfeeding due to interruptions or visitations than multips (N=84, p=0.028). 4.2 Qualitative Exploration of Patient Experiences and Perspectives Patient perspectives were examined through semi-structured interviews with postpartum mothers. A total of 13 mothers were approached by JS, of which 11 agreed to participate in the interview. Reasons for refusal to participate were not disclosed. Of the 11 interviewed mothers, 1 mother decided to discontinue participation due to a language barrier. Therefore, analysis included data from 10 postpartum mothers. Interviews took place between February, March and April They typically lasted between minutes and took place during the day at times requested by the patient. Table 10 presents characteristics of the interviewed mothers. This data was extracted from the CPES surveys and the interview recordings. August 10,

50 Table 10: Characteristics of interviewed mothers (N=10) Variable Room Type Private (1) Semi-Private (2) Ward Room (4) Station Education High school Level College/CEGEP Undergraduate Postgraduate Unknown Age* Parity Ethnicity West Asian Other White Chinese African-American Arab Language of English Interview French Percent (N) 30% (3) 40% (4) 30% (3) 50% (5) 50% (5) 0% (0) 10% (1) 30% (3) 20% (2) 30% (3) 10% (1) 30% (3) 70% (7) 60% (6) 30% (3) 10% (1) 30% (3) 20% (2) 20% (2) 10% (1) 10% (1) 10% (1) 60% (6) 40% (4) *categories chosen according to Statistics Canada stratification 67 As can be seen in Table 10, this sample constituted a variation sample according to parameters set in the methods. Interviewed mothers were of many different ages, ethnicities and education backgrounds and had varied experiences during their postpartum stay (station, room type). It also appeared within the sample that there was sufficient saturation within demographic categories. Four major themes emerged for qualitative results. These included challenges and concerns postpartum, perceptions of the environment, opinions on the quiet time and advice and other comments. Details of major themes and sub-themes can be seen in Table 11. The thematic map can be found in Appendix F. August 10,

51 Table 11: Themes, brief description of themes and associated sub-themes Qualitative Theme Challenges and Concerns Postpartum Feelings during childbirth and afterwards, concerns and quality issues not related to noise or potential interruptions Perceptions of Environment Perceptions of the environment related to noise and potential interruptions; during coding, the number of potential interruptions and intercom announcements was counted Opinions on Quiet Time Thoughts on the idea of the quiet time; potential benefits, challenges and possible solutions Advice and other comments Advice for staff regarding the quiet time, quality issues on noise and potential interruptions; advice for expectant mothers Sub-themes Feelings postpartum Childbirth experience Other quality issues Other concerns/worries Description of environment Noise Potential interruptions Ability to rest Count of potential interruptions Count of intercom announcements General comments on Quiet Time Quiet Time characteristics Quiet Time potential benefits Quiet Time potential challenges Advice for new mothers Advice for staff As mentioned, qualitative data related to noise and potential interruptions were presented with the previous objective related to baseline environment measurements. Challenges and Concerns Postpartum The interviews suggest women had a variety of feelings on their postpartum experience. Most first time mothers felt it was difficult to comment on their experience because they could not compare it to previous births. Postpartum mothers with multiple children felt the maternity ward was an escape from their reality at home, where there is no break to rest or recover. Additionally, most postpartum mothers expressed feelings of pain and discomfort following birth. Two mothers discussed feelings of fear or paranoia which affected their ability to rest. One mother in particular felt fear of her baby being kidnapped from the postpartum unit because she heard a number of people walking in the hallways. August 10,

52 Some mothers also discussed general quality issues with the maternity ward. These quality issues related to inconvenience for new mothers. Some new mothers mentioned that they felt the rooms were quite small and this caused some difficulties in accommodating their partner or family members. Two mothers mentioned a desire for a refrigerator being located in the room, since, following birth, it was difficult to walk and get things they might need. One mother said offering more private rooms might be a way to improve the experience for postpartum patients. Another concern involved the frequent changes in healthcare professionals that were assigned to them. A few mothers said that they would have preferred to have the same nurses and physicians treating them for the entirety of their stay so that they had a sense of better continuity of care. Moreover, one mother felt that the amount of information and teaching provided was overwhelming, and at times, during a point in the day inconvenient for her and the baby. In sum, most mothers would have appreciated services more tailored to their needs, either as first time mothers or postpartum mothers with more than one child. Postpartum mothers also experienced varying levels of pain following childbirth, which may have impacted the experience and perception of their hospital stay. This however, was not related to noise or potential interruptions. Perceptions of the Environment In speaking about their environment on the maternity ward, the following sub-themes emerged: description of environment, noise, potential interruptions, and ability to rest. The number of intercom announcements and potential interruptions the patient experienced during the interview were also counted. Subthemes count of potential interruptions and count of intercom announcements were created to note these experiences. The results of the sub-themes noise, potential interruptions, count of potential interruptions, and count of intercom announcements were presented with the quantitative results above. August 10,

53 Postpartum mothers used a variety of mostly positive words to describe the environment such as: well-organized, clean, comfortable, friendly, helpful, happy, busy and noisy. Many mothers felt the staff were available to help and assist them at all times. A few mothers also made comparisons to other hospitals or units within the hospital, saying that it was calmer than other units and a much happier place to be. It s a part of the hospital that most people are happy being in, so you know, you don t really hear a lot of complaining and yelling, and you know, verbal aggression, you hear more happy like Congratulations! (Patient 013) Despite the generally positive comments about the hospital environment and postpartum experience, some new mothers did feel they were unable to rest during their stay. Reasons for not being able to rest included multiple potential interruptions, answering to the needs of the baby, corridor conversations, and pain or other physical discomfort. However, most mothers who felt they were unable to rest did not blame the hospital or staff, and in fact, seemed to expect potential interruptions from staff for various purposes. Sometimes I don t but it has nothing to do with the hospital it s just I m in pain It s hard to find a, a good position to sleep in. (Patient 105) I wouldn t say I wasn t given the time to rest I was, it s just that, that time that I did have, she was either fussy or they had to do a test so the potential interruption I couldn t say had to do per say with the staff or their job. (Patient 188) A further factor in postpartum mothers ability to rest and perception of the environment was whether they had a shared or private room. New mothers who were staying in a private room felt more often that they were able to rest, whereas mothers who were in semi-private (2 patients) or ward (4 patients) rooms said they had a harder time resting because of increased visitation and noise. Otherwise the first night, it was my baby was calm. The second the second night her baby cried a lot, so we were not on the same wavelength. (Patient 108 translated from French) August 10,

54 So if it s private, it s good for you. It s almost like you can control how many people you want to see. But if it s a shared room then it s a different story. (Patient 014) In conclusion, most new mothers felt positively about their experience and the environment during their hospital stay. Less positive comments were usually not blamed on the hospital or staff, and the new mothers who perceived the environment as noisy or busy felt that was normal. Patients in shared rooms however, did experience more disruptions than those in private rooms which impacted their ability to rest more so than patients in private rooms. Opinions on Quiet Time During the interview, new mothers were asked their opinions about the potential for a quiet time on the maternity ward. Most mothers had not heard of a quiet time at other hospitals or knew what it was. After explaining what a quiet time is, all mothers interviewed thought that a quiet time was an excellent idea. just to be able to relax, even if it was for an hour or two hours. Just to have no potential interruptions at all, just to be able to rest. (Patient 119) It s great now, it s just going to make it even better. (Patient 188) Mothers who were not bothered by the noise or potential interruptions they experienced also supported the idea of introducing a quiet time. Reasons for support of the quiet time were multiple. Patients believed the quiet time would provide time to bond with the baby and family, rest, privacy, self-care, time to heal, fewer intercom announcements and less visitation in general. Some patients even highlighted the benefits for staff members. Being a new mom you re tired, the baby s crying, you have visitors, you have staff it s overwhelming sometimes, so if you give them that hour and a half break well it s kinda like Ahhh, I can have time to myself and I can sleep or I can do something else you know? You re not worrying about people walking around, and the intercom going on, so and the staff it gives them a bit of a break too. (Patient 105) August 10,

55 Most mothers thought the afternoon would be the best time for the quiet time, at some point between 12:00pm to 4:00pm. Only two mothers mentioned both morning and afternoon options. Additionally, the new mothers discussed a range of length of time for the quiet time, from one hour up to three hours although one to two hours was the most commonly discussed length of time. Some mothers provided suggestions for things that might need to change, such as the intercom and less visitors. During the interviews, potential challenges were also highlighted. Potential problems included the organization and coordination of the quiet time amongst hospital staff, enforcing restriction of visitation from family members and friends and mothers potentially not wanting to participate perhaps due to culture. Restriction of visitors in particular, was a challenge that multiple mothers felt might be difficult. time. It s hard to control. You cannot say you don t want to see other people and you just don t let them in right it s hard to control (Patient 146) A few mothers talked about the increased responsibility staff would have to run the quiet So it will be a little more difficult for the staff because they have to keep the ambiance and environment more quiet the responsibilites of the staff will be more than now. (Patient 146 translated from French) Moreover, some new mothers noted the idea that the hospital staff, particularly the nurses, would lose time in their day to complete their work. Well I think for them, they have a lot and I think they re very saturated with what they need to do and I think for them it s gonna be like, now you re taking away an hour and a half of my day? (Patient 188) This same mother also highlighted the challenge of finding a time in the day that would work for everyone. With all the activities associated with having a new baby, it might be difficult to implement a convenient time for all patients and staff. August 10,

56 it s a lot of info to have to digest, especially as a new mom to begin with and, things are limited in terms of time I had to deal with sutures, a fussy baby, learning how to do it all, having to come in, doing the tests but yes you are given that time [to rest] but it s just even if they give you that hour and a half that doesn t necessarily mean that it s at the right time. (Patient 188) A final challenge specified by some of the mothers was losing the ability to communicate using the intercom. I think that would be the only challenge, would be finding a way that is easy and efficient to contact a nurse. I m sure you could still do a system of pressing the button and saying what you need, but to not disturb the others is part of the challenge that you would find. (Patient 013) Along with challenges, postpartum mothers also advised on potential solutions to deal with these issues. time. Maybe they should have little walkie-talkies, or ear-pieces or beepers or something, instead of intercoms and that so if they need to get hold of a staff member if there s an emergency, they have like a beeper thingy. (Patient 119) Most mothers also said they would feel comfortable telling their family to visit at a later Because all my friends ask me okay, when can I, when can we come to visit you, and uh, yes, there is a special hours for coming visitors, but if they have a special hours for quiet time, yes I should tell them. (Patient 159) To deal with visitors, many mothers suggested that marketing the quiet time as a hospital policy would help them feel empowered enough to tell them to visit at different times. Oh I would tell my family, if it s the hospital. I mean if I understand the reason why the hospital does it and I see the benefit, I ll tell them. (Patient 105) I think a lot of people, you know, have a hard time saying no to a lot of people that want to come visit, so when it s uh a hospital policy, it s great. (Patient 013) August 10,

57 One patient proposed creating a waiting room for visitors until the quiet time is done, in order to accommodate the family members. In summation, all interviewed mothers felt the quiet time was a great idea for them, their families, their babies and hospital staff. Most mothers recommended the afternoon for the quiet time, and suggested that visitation and intercom use be restricted during the time. They also highlighted important challenges and presented practical solutions to tackle these issues. Advice and Other Comments The interviews also allowed mothers to provide advice to both incoming postpartum mothers and staff members. A few mothers mentioned they hope the staff seriously considers implementing a quiet time on the maternity ward, as they feel it will enhance both patient and staff experience. Another mom recognized that new interventions may require adjustments and modifications and encouraged the staff to not be afraid to modify the intervention during the trial phase. Advice for postpartum mothers included resting as much as possible, both before and after the baby is born. Additionally, a few mothers noted the importance of taking advantage of resources offered and learning as much as possible from the healthcare providers, since patients spend such limited time on the unit. Of course you need to rest to the maximum, because when the baby decides to cry there is nothing we can do about it... I'm trying to learn the maximum from the nurses, especially if it is the first baby. I did not know many things, and I have to take advantage of their presence. (Patient 108 translated from French) I took advantage of the, well the gestational diabetes clinics, I took advantage of the virtual tours, I took advantage of um you know, going to St. John s ambulance, the CLSC s in my area, there s a lot of resources. And they tell you, it s busy. Okay? This is not the time for people to come in, everybody wants to take a look at baby, but you need to really maximize that time with doctors, the nurses and the staff. Because they re gonna give you what you need, as a basic set of tools. (Patient 188) August 10,

58 Two mothers also stated that new mothers should expect some noise, since they are choosing to give birth within a hospital setting. Finally, some mothers stressed the importance of being honest with family members and advised that new mothers should explain to their family members their needs. well that s exactly what was done in the courses here when we did the virtual tours, is they said it, do not be afraid to tell your family members and your friends, you know, please, today might not be a good day. If you text me or you call me I might not answer the phone. (Patient 188) Most patients seemed to have enjoyed participating in the interviews, and enjoyed contributing to the development of the quiet time intervention. It seems that most mothers feel the quiet time is beneficial and want the staff to implement it. Furthermore, they emphasized the importance of rest before and right after delivery, since post-delivery, there is little time for selfcare. The quiet time would be an ideal way to encourage rest during the first few precious days following childbirth. 4.3 Process of Implementation Evaluation of barriers and enablers to change along with implementation issues were measured through observation of the advisory group meetings. This group met 3 times (September 10 th, 2014, and March 12 th and, April 22 nd, 2015) pre-intervention to discuss barriers, benefits and implementation issues. They developed recommendations for the design based on results from the pre-intervention phase. Notes were taken during advisory group meetings (with consent from the members) by the author to review to identify perceived barriers, benefits and implementation issues and as stated, can be seen in Appendix A. A summary of the discussions and key points pertinent to this thesis is presented here. Initial feedback on the idea of a quiet time was very positive, where all members acknowledged and recognized the benefits of a quiet time for new mothers, their babies, their August 10,

59 families and the staff. Consensus was achieved in the first meeting that the quiet time would take place in the afternoon, sometime between 1:00pm and 4:00pm. Physician support for the project was raised at the second meeting; however this was resolved by the following meeting. It was agreed with the advisory group that the specific quiet time intervention at this hospital would involve reducing noise levels by discouraging interactions close to patient rooms and by limiting nursing activities, and rescheduling, when possible, all routine potential interruptions during the designated quiet time including housekeeping, diagnostic tests and other laboratory procedures that require patient contact during this time; all of which will require a collaborative effort amongst those staff and departments involved in maternity care at this hospital. Furthermore, the quiet time will likely also involve dimming the lights, reducing telephone and pager volumes and reducing the number of intercom announcements. As well, this will be a period of time where up to one visitor will be allowed (whom the mother will decide). The biggest challenge to the introduction of the quiet time was determining the best time period for the quiet time. This was discussed during the second meeting. Once everyone provided their input on the time that would work best for the department, it was decided the quiet time would occur from 2:45pm to 3:45pm every day. This was a major achievement for the group, as finding a time that would work for all staff members was a major challenge for implementation. The next major decision was choosing a date to introduce the quiet time. This decision happened more quickly than the conversation around the time for the quiet time. It was decided to begin the quiet time on Monday June 1, This date was chosen because it provided the project team with enough time to advertise the project, and allowed the various representatives of the advisory group to notify their departments and prepare for the change. August 10,

60 Following the discussion that took place regarding the actual time and start date of the quiet time, the meetings mostly consisted of the logistics of implementation. The intercom was seen as a significant challenge to implementation, since this is the way postpartum administrative staff communicates with the team of nurses. Upon further consideration, it was decided that the intercom would not be used during the quiet time unless there was an emergency. This was a feasible solution since, during the quiet time, most nurses would be gathered at the nursing station and therefore, it would not be a problem to reach them if a patient required immediate assistance. Finally, the clinical leads were extremely effective in mobilizing different members to take charge of certain activities to organize communication and logistics for the first days (e.g. creating posters, banners, notifying security, recruitment of volunteers). In conclusion, the advisory group meetings were an effective way of garnering support for the quiet time from across the various services involved with the maternity ward, discussing and resolving logistical issues (changes in service routines, time, length, start date), and building consensus on key aspects of implementation. Leadership for this group and facilitation skills by the program manager was key to this process. It appeared that all members enjoyed participating in the group and were very enthusiastic about the project. August 10,

61 5.0 Discussion This chapter begins with a brief summary of the results and then a more detailed discussion of the results in the context of the existing literature. This study found that noise levels and potential interruption rates are quite high on the maternity ward of this hospital. Interviews with patients corroborate these findings, as many of the postpartum patients indicated that noise levels and the number of potential interruptions they experienced were excessive. Statistical analyses revealed that first time mothers are more likely to experience difficulty breastfeeding because of interruptions or visitations. Interviews with postpartum mothers showed that all mothers were enthusiastic about the idea of a quiet time intervention and presented ideas about potential benefits for both patients and staff. Consultation with stakeholders at advisory group meetings similarly identified these benefits and also discussed implementation issues. Staff involved in the advisory group established practical solutions to these implementation issues and all members were very supportive of the quiet time intervention. Results of this study demonstrated that noise levels were quite high on all three stations of this maternity ward. Average noise levels were above WHO recommendations of db, in line with studies that have measured noise levels on other hospital units. 29,31,32 Average (Leq) noise levels were consistently above 60 db, and peak levels reached between db, similar to an airplane landing. These levels of noise are high enough to interfere with rest and recovery, which is important for women who have just given birth. Qualitative interviews with postpartum mothers revealed that they perceived high levels of noise on the ward, however not all interviewed mothers found the noise disruptive, and in fact expected it during their hospital stay. As hospitals are meant to be a place for healing, it is troublesome that high levels of noise, which all interviewed mothers perceived, was considered normal and expected. August 10,

62 While there are no guidelines or recommendations for the amount of potential interruptions patients should experience during their hospital stay, measurement of the number and type of potential interruptions in the afternoon indicate that postpartum patients experienced frequent potential interruptions from visitors, nurses, physicians, the intercom and other hospital staff. These findings support findings from the American study that concluded postpartum patients experience an excessive number of interruptions. 23 The results of our study showed that the highest numbers of potential interruptions were caused by visitors (family and friends) and nurses. Qualitative interviews informed that the type of potential interruption mattered most to the interviewed postpartum mothers. For example, some of them preferred to have more visits from nurses and physicians but did not appreciate potential interruptions from other patients visitors. The type of room also played a role in the interviewed mothers perception of the number of potential interruptions, with mothers in shared or ward rooms more often citing that they felt the number of potential interruptions was quite high. These mothers also reported feeling that they lacked control over who entered their room during their time on the unit. Feelings of a lack of control may impact the establishment of maternal confidence and competence 23 which may increase maternal parenting stress. 68 Furthermore, during their short stay on the postpartum unit, new mothers have to absorb a wealth of new information. Excessive amounts of potential interruptions can interfere with breastfeeding, rest and other important learning activities. 24,25 As many of the interviewed mothers welcomed visits from hospital staff, stricter rules on visitation hours may help to reduce the number of potential interruptions overall, without affecting the important teaching and learning activities that take place during this limited time. To measure patient experience, the project team employed a modified Canadian Patient Experiences Survey tool with additional questions, including one related to breastfeeding August 10,

63 difficulty. While one previous study evaluated the number of interruptions postpartum patients experienced during breastfeeding, 23 no other study to date to our knowledge investigated the characteristics of postpartum women most likely to have difficulty breastfeeding due to interruptions or visitations. Approximately half of the survey respondents did not experience any difficulty breastfeeding because of interruptions or visitations, while the other half of respondents indicated that they experienced a range of difficulties from a little, moderate, quite a bit, to extreme amounts of difficulty breastfeeding due to interruptions. These results are concerning as no postpartum patient should experience difficulty breastfeeding from interruptions or visitations. Postpartum hospital units should take measures to schedule potential interruptions at times convenient for patients as much as possible, and restrict visitation in order to promote breastfeeding success. Chi square analyses showed that first time mothers were more likely to experience trouble breastfeeding due to interruptions than mothers with more than one child. These results are consistent with recent literature that indicates postpartum women felt that interruptions impacted breastfeeding activities. 23,25 As well, these women are most likely to benefit from lowered noise levels and potential interruptions, perhaps through the implementation of a quiet time intervention. For postpartum mothers who have more than one child, it is possible that they are less likely to experience these difficulties because they have previous experience in breastfeeding, and are accustomed to the potential interruptions and noise following the birth of a child. As stated, a quiet time is a possible solution to control the noise and potential interruptions patients experience on the maternity ward. Both interviewed mothers and staff from the advisory group felt the quiet time would positively contribute to the postpartum environment. New mothers appreciated the idea of dedicated time for self-care, and rest activities promoted August 10,

64 in quiet times that have taken place on other hospital units. 2,8,9,47 Some of the interviewed mothers stressed the importance of branding the quiet time as a hospital or departmental policy, so that they would not feel guilty for telling their family members or friends to leave or not visit during that time. New mothers should feel empowered and in control of their environment. Along with a hospital policy that enforces a restriction on visitation during a quiet time period, pre-natal resources especially for primips, could be further developed to include material on this topic, so that following delivery, new mothers feel they are able to exhibit more control over their surroundings and limit visitation outside of the quiet time, should they want to. This project employed a participatory research approach, where end-users of the intervention were part of the research process. The advisory group contained representatives from many different departments that helped expose significant barriers to implementation. Consistent with the literature on the benefits of using a participatory research approach, 54 the advisory group helped the project team understand the potential challenges (e.g. communication between staff during the quiet time) and develop feasible solutions to overcome these issues. The participation of stakeholders in the advisory group also strengthens the likelihood that there will be full participation of staff and patients in the quiet time, and increases the future sustainability of the intervention Implications for Practice, Policy and Future Research Similar studies that have measured noise levels and interruptions have been conducted largely in the United States and on units other than a maternity ward. This study conducted an evaluation of noise levels, potential interruptions and patient experience on a postpartum unit in a Canadian context, something previously lacking in the literature. This data revealed that noise and potential interruptions are a problem for postpartum patients and can impact important activities such as breastfeeding, which is critical to establish August 10,

65 within the first few days following birth. Further studies are needed to establish the more precise impact of noise and frequent potential interruptions on postpartum physical and mental health and breastfeeding success. The patient experiences survey that was administered established that first time mothers are more likely to experience difficulty breastfeeding due to interruptions or visitations. This data can be used to inform hospital staff on the problem of noise and excessive potential interruptions and motivate them to create and further develop solutions to this problem, such as the implementation a quiet time. These findings may also prompt hospital staff to develop targeted solutions, specifically for patients who are more likely to encounter difficulties in teaching and learning activities following birth. This study demonstrated that postpartum women feel the idea of a quiet time has many potential benefits for postpartum patients, their families and hospital staff. Some of the perceived potential benefits of a proposed quiet time include more time to bond with the baby and partner, time to rest and recover, sleep and general self-care. These potential benefits may lead to improved postpartum mental and physical health, issues often dealt with within a primary care setting. Future research is needed to evaluate the effects of a quiet time on breastfeeding success and postpartum mental and physical health. Creation of an advisory group was extremely important in the identification and resolution of potential implementation issues. Members of the advisory group were hospital staff on the maternity ward, and they were able to provide insight into the feasibility of the quiet time and helped develop practical solutions to potential challenges. Their participation will influence the permanency of this solution; since they were part of the process in the development of the quiet time, it is more likely to continue being part of practice for years to come. Future studies that research solutions to problems within the hospital environment, may be inclined to adopt a August 10,

66 participatory research approach to assure full support from the hospital staff and durability of the proposed intervention. 5.2 Strengths and Limitations This study employed multiple measures, both qualitative and quantitative to evaluate the phenomena of interest, providing a more complete picture of the current environment on the postpartum unit. With the establishment of the advisory group, and development of clear methods, as well as analysis and presentation of findings for the pre-intervention phase, measurement of post-intervention outcomes should be relatively straightforward. Data from the pre-intervention will also contribute to the full pre-post implementation evaluation. Due to time restrictions, a limitation of this project is the smaller sample size for the CPES survey. However, patients that were included in this study broadly represented the diversity of the patient population served at this Montreal-based hospital. Future studies could administer a similar survey to a larger sample to increase the statistical power of any tests performed. Additionally, this hospital is university-affiliated teaching site, and therefore the setting may not be representative of all maternity wards, since patients may experience greater potential interruptions due to the involvement of medical, nursing and other types of students. The evaluation also only took place on one unit in one community general hospital, although the evaluation was in-depth, and therefore we are cautiously optimistic that the results are generalizable to other postpartum units. When measuring potential interruptions, the patients were not asked whether the potential interruption was bothersome or not, or if they had requested the potential interruption (e.g. it was unknown if the call button had been pressed when a nurse entered). As well, the study did not measure the impact of the potential interruptions or noise on actual breastfeeding rates, therefore, August 10,

67 no conclusions can be drawn as to whether or not the potential interruptions and noise impacted the patients ability to establish breastfeeding with their newborn. Questions about perceptions of noise levels and potential interruptions were only posed to interviewed mothers and were not asked through the CPES survey. Future survey instruments should incorporate these types of questions to gather more representative data on perceptions of noise and potential interruptions. However, this study does demonstrate through the quantitative data that noise levels and the amount of potential interruptions postpartum patients experience is quite high on this particular unit. August 10,

68 6.0 Conclusions Through the measurement of noise levels, potential interruptions and patient experiences, as well as observation of committee processes, this study evaluated the pre-intervention environment of a maternity ward at a Montreal hospital. Our evaluation revealed that patients experience high levels of noise and potential interruptions during their stay, with volumes reaching levels well above WHO recommendations. Results are consistent with the previous literature, which indicates that the high levels of noise and potential interruptions are a problem for patients and their families. The patient experiences survey demonstrated that postpartum mothers, specifically primips are more likely to experience difficulty breastfeeding due to potential interruptions and/or visitations. A possible solution to the problem of noise and potential interruptions is a quiet time intervention, an idea that patients and hospital staff on the maternity ward are supportive of. According to postpartum mothers, a quiet time will provide them with protected time for selfcare in the form of, for example, bonding with their family and newborn, time for rest and recuperation, and uninterrupted sleep. Members of the advisory group, which included representatives from a range of departments were also supportive and enthusiastic about the idea of a quiet time and contributed to discussions regarding the logistics of implementation. While there are important implementation issues to consider before the introduction of the quiet time, this group helped develop solutions to overcome them. The advisory group was able to find an appropriate time for the quiet time that would minimize disruptions for patient care, developed methods to promote the quiet time to ensure full participation, and discussed feasible characteristics of the quiet time. Postpartum mothers and hospital staff are receptive to the idea of a quiet time to reduce the high levels of noise and potential interruptions that patients experience. August 10,

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73 Appendix A: Stakeholder Meeting Notes Members Present: Appendix A: Stakeholder Meeting Notes Quiet Time Stakeholder Meeting Notes Wed, Sept 10 th, 2014 Program/Department Project Leaders (Maternal Child) Family Physician Kitchen/Nutritional Services Administrative Clerk (4 Main) Labs Assistant Head Nurse Nurse Counselor Patient Representative Social Services Quality & Risk Management Research Centre Names Marie-France Brizard Jennifer Somera Dr. Roxanne Arel Stephanie Iasenza Susan Hutchison Lily Roberta Silvia Frank Miesnikowicz Mary DeSantis Tracey Ruckenstein Sonia Deschenes Mary-Pat Hebert Christine Husser Safina Adatia Program of Meeting Jennifer and Safina began with a background presentation on literature review Lead into discussion of intervention and stakeholders thoughts Overall Thoughts/Attitudes Extremely positive feedback everyone liked the idea of a quiet time Felt it was great that the intervention was focused on the mother and her need to rest Different stakeholders were suggesting ways to shift activities to accommodate the quiet time Timing of the Quiet time (QT) Was established that QT will occur in the afternoon received feedback from key stakeholders as to what time would be most appropriate for them o Labs thought 12-2 was most appropriate (pm rounds around 1:30 but they could delay) o Kitchen Tray drop off around 12 and pick up around 1/1:30 o Family medicine afternoon, but no set time o Consensus built around 1pm-3pm although exact time has not been decided on yet August 10, 2015

74 Appendix A: Stakeholder Meeting Notes Barriers Family medicine do not perform rounds at a set time which makes it difficult to adapt schedule Concern about mother being able to rest at a scheduled time when babies don t really have a schedule (feed on demand) Biggest barrier is deciding on a time that works for everyone will need to be a real team effort Characteristics of the QT Dimmed lights Reduced hallway conversation (Marie-France said that it would be encouraged for nurses to gather in the nursing station) Care will NOT stop if necessary (this is a first priority) Debate about intercom use (still deciding on whether it will completely be not used or decreased volume) Debate about visitation allowances (perhaps one family member to aid in the care for the baby so the mother can rest) Signs will be posted to inform everyone who comes onto the floor that a QT is happening No unnecessary visits into patient rooms by staff Shifting of staff schedules to accommodate for QT Below you will find the invitation to stakeholders to be a part of the working group. August 10, 2015

75 Appendix A: Stakeholder Meeting Notes Quiet time Postpartum study (Part of Patient Engagement Project) Dear Colleague, You have been chosen to be part of the working group in implementing a quiet time in the postpartum unit. To prepare for our first meeting scheduled for September 10th, 2014 from 9h00 to 10h00, please read the information below. At the end, you will find several questions to help prepare for the meeting. Please confirm your attendance to Marie-France Brizard (#3805) and Jennifer Somera (#3659). The meeting room will be arranged and you will be informed closer to the date. Thank you in advance. Marie-France and Jennifer Project Description: The postpartum hospital stay varies between 36 to 48 hours post-vaginal birth and 72 hours post-cesarean birth. During their stay, mothers, newborns and their partner/support person receive many visits to their room. For example, nurses visit several times during any given shift, to perform a health evaluation to ensure mothers and babies are stable. Nurses also provide teachings on newborn care (diaper, feeding, and handling) and newborn safety (car seat, prevention of SIDS and shaken baby syndrome). In addition, they receive multiple visits from other sources (i.e. labs for blood-drawing, housekeeping, kitchen services for meals, visits from family and friends, etc ) When considering the multiple sources of visits (i.e. potential interruptions) while in hospital, we would like to gain information from the health care team as to if/how it would change their work flow if a quiet time is implemented in the postpartum unit. A quiet time will be a designated time period (e.g. every day from 13h30-14h30) when patients are encouraged to rest/sleep. The lights will be dimmed, and there will be less noise in the hallway and nursing station. The unit s announcement system will be unidirectional where only patients will be able to use it to communicate their needs thereby minimizing disruption in the unit. Visitors will be limited or requested to return at a later time. Patients will be encouraged to participate as it has been shown to have positive effects on patient satisfaction, exclusive breastfeeding, bonding with baby, receptiveness to learning and self-care. Project objectives: To improve patient s hospital stay by having the opportunity to rest thereby be more receptive to learning and bonding with her newborn. To promote patient satisfaction in the postpartum period. To optimize the functioning of the health care team. Objectives of Working Group members: To participate in a quality improvement initiative by sharing how their work flow would change if a quiet time is implemented on the postpartum unit. August 10, 2015

76 Appendix A: Stakeholder Meeting Notes To be open and willing to adjust work flow to successfully implement a quiet time on the postpartum unit. Questions to consider: (For September meeting) 1. Have you heard about Quiet time/nap time in a hospital unit? Quiet time is a designated time period (e.g. every day from 13h30-14h30) when patients are encouraged to rest/sleep. The lights will be dimmed, and there will be less noise in the hallway and nursing station. The announcement speaker volume will also be lowered to minimize disruption. Visitors will be limited or requested to return at a later time. Patients will be encouraged to participate as it has been shown to have positive effects on patient satisfaction, exclusive breastfeeding, bonding with baby, and self-care. 2. What are your thoughts on this from a nursing/professional perspective? Positive/Negative 3. What are your thoughts on this from a patient s perspective? Positive/Negative 4. If we propose a quiet time between 13h30-14h30, how would it change your usual work flow? Would you suggest another time/time period? 5. How could the work be re-organized? August 10, 2015

77 Appendix A: Stakeholder Meeting Notes Members Present: Program/Department Project Leaders (Maternal Child) Research Centre Obstetrician Family Physician Head Nurse (Postpartum) Kitchen/Nutritional Services Administrative Clerk (4 Main) Labs Assistant Head Nurse Nurse Counselor Patient Representative Social Services Quality & Risk Management Quiet Time Meeting Notes March 12, 2015 Names Marie-France Brizard Jennifer Somera Safina Adatia (student) Susan Law Dr. Louise Johnson Dr. Roxanne Arel Chantal Vincelette Caroline Turmel Susan Hutchison Lily Roberta Silvia Mary DeSantis Tracey Ruckenstein Sonia Deschênes Mary-Pat Hebert Christine Husser 1. Intro + Welcome Marie-France (MF) welcomed all members Refresher about 3 projects related to the QT o Jennifer: Student projects + staff surveys/interviews o Safina: Noise levels + potential interruptions + CPES survey + patient interviews Media attention people are watching us, and wondering when we are going to implement the QT MF to propose 2-3 times and ask each representative what difficulties they might face with proposed times, and what their preference is 2. Presentation from Safina Safina presented the results of initial descriptive statistical analysis o Highest number of potential interruptions from family members, nurses, then intercom o 1:30 has the most number of potential interruptions (mostly because kitchen comes to collect trays) o Other analyses were presented 3. Discussion about Results August 10, 2015

78 Appendix A: Stakeholder Meeting Notes While Safina measured all potential interruptions, partners counted as an potential interruption; we really don t know what type of potential interruption was disturbing for the patient Overall people were pleased with the results, found them informative 4. Results from Staff Survey (Jennifer) 23 nurses, 2 admin staff, 1 PAB, 2 Housekeeping, 1 Pediatrician filled out the survey 26/29 think the QT will be beneficial Jennifer highlighted reasons participants thought that it will be beneficial for both staff and patients o Some answers: charting, lunch breaks, update care plans, less stress/noise for pts and staff, promote sleep, call bell not used Some reasons it may not be beneficial: stress for those who have routine, affect patient care, less time to help mom, mom may feel abandoned o When these were mentioned, pt rep Sonia said she doesn t think these would be a problem Time: 8 said 1:30-2:30; 4 said 3-4pm; 3-4pm is most realistic 5. Quiet Time Brainstorm Inclusion/Exclusion of Patients Was suggested that we could exclude patients that are being discharged, however it is difficult to exclude anyone o Patients will have to be informed by physicians and nurses and we want to empower them to tell their family/friends and choose to be a part of the QT If patients are being discharged or admitted, will aim to have them discharged before that time, and hold admissions for that hour What Time? Labs o PM rounds are from 1:30-3pm, so 3pm would be ideal o If from 1:30-2:30 it means only 30 mins for labs not enough o Could make 2:30-3:30 work since they have an hour to do labs Kitchen o Lunchtime is from 12-1:45 (including dropping and picking up trays) o 2:30-3:30 is possible, but 1:30-2:30 is tough because they finish at 1:45 o Also have to keep in mind they service other floors o Some patients will not be finished eating everything if they come around earlier MF mentioned that we could empower patients to bring back their trays if they haven t finished eating everything o To create less disturbance, patients could leave their trays outside for kitchen staff so that they don t have to enter the room August 10, 2015

79 Appendix A: Stakeholder Meeting Notes Nurses o 1:30-2:30 could work, most are done break at 2pm o MF mentioned that it is important we don t use the intercom unless there are emergencies, but how do we communicate? If many nurses are on break at 1:30, there will be less nurses to deal with emergencies, so perhaps not a good time o Also mentioned that during the QT not all the nurses will be at the nursing station, even though this is ideal o 2:30-3:30 could work but is least ideal because last rounds usually start at 2pm before change of shift, and this only gives 30 mins to do this o 3-4pm is most feasible Physician o 3-4pm is good for doctors Patient Rep o 1:30-2:30pm is good because you have just finished lunch o 3-4pm is also fine Admin Rep o 3-4pm is most ideal, majority of patients have been discharged; everything is done by 3pm Social Work Rep o Doesn t really affect her work; by emergency Nursing rep then brought up that maybe 2:45-3:45 would be better since new nurses who are starting shift wouldn t have to wait 45 minutes to see their patients, would only wait 30 minutes which would be part of the handover o Most agreed that this would be fine Characteristics of QT Intercom announcement 15 minutes prior to the QT to give everyone the chance to prepare Designated nursing floats to go and help; but noted that floats are not available necessarily everyday o Maybe buddy system for nurses, to overcome intercom challenge o Dr. Arel suggested a volunteer could be on the maternity ward and go from room to room to find the nurses and help with visitors o Nurses can write down which room they are going to Security can do rounds from 3-4pm (during QT), after intercom announcement We should allow one person in the room (mom can choose) to help with the baby; difficult to kick people out Also need to consider parents who have other children o MF suggested having 2 volunteers, 1 to look after other children of mothers, and 1 to promote the QT and help with visitors/communication between nurses August 10, 2015

80 Appendix A: Stakeholder Meeting Notes 6. Next Steps Next meeting will be in a month to discuss implementation and results of further analysis (from Safina) Jennifer to talk to evening housekeeping regarding cleaning schedule MF to talk to security and volunteering Safina to continue analysis to present at next meeting August 10, 2015

81 Appendix A: Stakeholder Meeting Notes Members Present: Program/Department Project Leaders (Maternal Child) Research Centre Head Nurse (Postpartum) Kitchen/Nutritional Services Labs Nurse Counselor Social Services Quality & Risk Management Quiet Time Meeting Notes April 22, 2015 Names Marie-France Brizard Jennifer Somera Safina Adatia (student) Susan Law Chantal Vincelette Caroline Turmel Lily Roberta Silvia Tracey Ruckenstein Mary-Pat Hebert Christine Husser 1. Intro + welcome Marie-France (MF) welcomed all members, proposed that we should talk about the starting date and results so far of the study Because of the fact that there were 2 other projects on the ward, didn t want to do the QT at the same time so wanted to push the start date of the QT 2. Timing of QT Chantal mentioned that 2:30 could work, but has to end by 3:45; can start a bit earlier Will make an announcement at 2:30 and then the QT will officially start at 2:45 3. Patient perspective 4. Logistics Safina discussed some of the results of the patient interviews Mothers like the idea of a quiet time Some not bothered by the noise, but all 10 mothers think the quiet time is a good idea Qualitative analysis to continue and be presented by the next meeting Would be good to find out which visitors are actually causing the disturbances (according to the mothers) - is it us or the family? Also find out why patients are leaving early? Mary-Pat asked if the doctors were on board MF responded and said yes they are, she has spoken to reps from paeds August 10, 2015

82 Appendix A: Stakeholder Meeting Notes Delivering family physicians were originally against it because they didn t see the relevance for the new mothers since they are on the ward for just 2-3 days, however after presenting the literature they are convinced it is a good idea MF to talk to security and volunteers; going to see if security can do their rounds right before the QT starts; MF to meet with nurses to see if they can change things in schedule We aren t changing schedules for most people, it only affects mostly the nurses and housekeeping staff We will communicate to all departments that it doesn t really change their schedules Need to delay admissions as much as possible Figure out method of communication other than intercom for that hour; perhaps buddy system Hospital-wide intercom only in hallways, not in patient rooms 5. Marketing/Creating awareness To make the quiet time a hospital policy would take a long time, but for the patients, a policy might be something less set in stone ( something on the wall ) Brainstormed ideas of what to call it: recommendation, quality initiative pilot project Concerns that if we don t call it a policy, it won t be followed We are not allowed to post anything by the elevator We are going to post in info flash, have a big banner in the cafeteria, but is this enough to raise awareness we will have to submit for May 11 th (take group picture by May 6 th ) Banner was mutually agreed to be a good idea, for the nursing station We want to create awareness of the policy before patients enter the room We need to create two types of visuals, one targeting patients and the other targeting staff Posters and banners to be made over the next month Include information such as top 10 reasons for doing this or did you know and create different messages for different departments Would be best to create awareness for patients on the ground floor, and for the staff the cafeteria Include quote from mothers on banner 6. Date for the introduction August 10, 2015

83 Appendix A: Stakeholder Meeting Notes June 1 st yay! 7. Other important considerations It was brought up that knowing the reasons for doing the quiet time would be good for the staff We will host information sessions when the departments tell us we can talk to them Apply for CARE grant so project is funded and evaluation can continue into the fall 8. Next Steps Summary of Major Decisions Jennifer in charge of coordinating banner production, come up with plan for security Safina will come up with the list of facts to include on the banner MF will connect with volunteers and security; ask permissions; will submit to info-flash and put our names in the announcement; hold info sessions for the different departments (perhaps MDC, rounds, quality forum 2 nd week of June) Caroline will help with banners Susan communication with physicians Chantal to discuss at staff meeting We will include an information card in patients pre-natal folder with different facts June 1 st start date, it s a Monday and people seemed quite on board and excited/happy with that Banner and poster-making to advertise the QT was also a big topic of conversation, split up the work amongst advisory group members MF to submit info flash on May 11 th, so we need to take a group picture by May 6 th Nurses going to figure out way of not using the intercom, they realize it is a problem and for the purposes of the QT needs to be changed Everyone seems to be really on board with the quiet time and very happy to be involved August 10, 2015

84 APPENDIX B: Data Collection Tool Appendix B: Data Collection Tool Number of Potential interruptions Number of Potential interruptions: DATE: Station 1: Beds Station 2: Beds Station 3: Beds Time Station Count and type of potential interruption 1:30pm 1 RN MD Fam Nutr House Labs Ord Other Intercom 2:00pm 2 RN MD Fam Nutr House Labs Ord Other Intercom Notes August 10,

85 APPENDIX B: Data Collection Tool 2:30pm 3 RN MD Fam Nutr House Labs Ord Other Intercom 3:00pm 1 RN MD Fam Nutr House Labs Ord Other Intercom RN=nurse, MD=doctor, Fam=family visitors, Nutr=nutritionist, House=Housekeeping, Labs=Laboratory, Ord=Orderly August 10,

86 APPENDIX C: Canadian Patient Experiences Survey (CPES) Appendix C: Canadian Patient Experiences Survey Centre hospitalier de St. Mary St. Mary s Hospital Center L excellence au coeur de nos soins Caring through excellence Canadian Patient Experiences Survey Quiet Time Project Tell us about your experience on the maternity ward. This will help us better meet our patients needs. August 10,

87 APPENDIX C: Canadian Patient Experiences Survey (CPES) CANADIAN PATIENT EXPERIENCES SURVEY QUIET TIME PROJECT ST. MARY S HOSPITAL St. Mary s wants to improve patient experience on the maternity ward. This study is about noise levels and patients needs. Before you answer, please remember: You should fill out this questionnaire only if you are the patient. You may need to get help from a family member or friend to answer the questions. That s okay. You have the choice to fill in the questionnaire or not, but in doing so will provide us with important information. Your choice will not affect how well you are treated here. No one will know who answered this questionnaire. There are no right or wrong answers. If you are unsure, check the answer that best corresponds to your experience. When you are finished, a research assistant will come by and collect the questionnaire from you, OR you may leave it in the box at the nursing station. Thank you for your time! August 10,

88 APPENDIX C: Canadian Patient Experiences Survey (CPES) Please answer the questions about your current stay at the hospital named on the cover letter. Do not include any other hospital stays in your answer. For each question, please check a single box. Your Care from Nurses 1. During this hospital stay, how often did nurses treat you with courtesy and respect? Never Sometimes Usually Always 2. During this hospital stay, how often did nurses listen carefully to you? Never Sometimes Usually Always 3. During this hospital stay, how often did nurses explain things in a way you could understand? Never Sometimes Usually Always 4. During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? Never Sometimes Usually Always I never pressed the call button August 10,

89 APPENDIX C: Canadian Patient Experiences Survey (CPES) Your Care from Doctors 5. During this hospital stay, how often did doctors treat you with courtesy and respect? Never Sometimes Usually Always 6. During this hospital stay, how often did doctors listen carefully to you? Never Sometimes Usually Always 7. During this hospital stay, how often did doctors explain things in a way you could understand? Never Sometimes Usually Always The Hospital Environment 8. During this hospital stay, how often were your room and bathroom kept clean? Never Sometimes Usually Always 9. During this hospital stay, how often was the area around your room quiet at night? Never Sometimes Usually Always August 10,

90 APPENDIX C: Canadian Patient Experiences Survey (CPES) Your Experiences in This Hospital 10. During this hospital stay, did you need help from nurses or other hospital staff in getting to the bathroom or in using a bedpan? Yes No If No, go to Question How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? Never Sometimes Usually Always 12. During this hospital stay, did you need medicine for pain? Yes No If No, go to Question During this hospital stay, how often was your pain well controlled? Never Sometimes Usually Always 14. During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? Never Sometimes Usually Always 15. During this hospital stay, were you given any medicine that you had not taken before? Yes No If No, go to Question 18 August 10,

91 APPENDIX C: Canadian Patient Experiences Survey (CPES) 16. Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? Never Sometimes Usually Always 17. Before giving you any new medicine, how often did hospital staff describe possible side effects in a way you could understand? Never Sometimes Usually Always Overall Rating of the Hospital Please answer the questions about your recent stay at the hospital named on the cover letter. Do not include any other hospital stays in your answer. 18. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the best hospital possible, what number would you use to rate this hospital during your stay? Worst hospital possible Best possible hospital 19. Would you recommend this hospital to your friends and family? Definitely No Probably No Probably Yes Definitely Yes August 10,

92 APPENDIX C: Canadian Patient Experiences Survey (CPES) Here we ask several more questions about your stay at the hospital 20. When you arrived at the hospital, did you go to the emergency department? Yes If Yes, go to Question 23 No If No, please continue below 21. Before coming to the hospital, did you have enough information about what was going to happen during the admission process? Not at All Partly Quite a Bit Completely Your Arrival at the Hospital 22. Was your admission into the hospital organized? Not at All Partly Go to Question 27 Quite a Bit Completely Answer questions 23 to 26 only if you were admitted through the emergency department. 23. When you were in the emergency department, did you get enough information about your condition and treatment? Not at All Partly Quite a Bit Completely 24. Were you given enough information about what was going to happen during your admission to the hospital? Not at All Partly Quite a Bit Completely August 10,

93 APPENDIX C: Canadian Patient Experiences Survey (CPES) 25. After you knew that you needed to be admitted to a hospital bed, did you have to wait too long before getting there? Yes No 26. Was your transfer from the emergency department into a hospital bed organized? Not at All Partly Continue with Question 27 Quite a Bit Completely During Your Hospital Stay 27. Do you feel that there was good communication about your care between doctors, nurses and other hospital staff? Never Sometimes Usually Always 28. How often did doctors, nurses and other hospital staff seem informed and up-to-date about your hospital care? Never Sometimes Usually Always 29. How often were tests and procedures done when you were told they would be done? Never Sometimes Usually Always I did not have any tests or procedures August 10,

94 APPENDIX C: Canadian Patient Experiences Survey (CPES) 30. During this hospital stay, did you get all the information you needed about your condition and treatment? Never Sometimes Usually Always 31. Did you get the support you needed to help you with any anxieties, fears or worries you had during this hospital stay? Never Sometimes Usually Always Not Applicable 32. Were you involved as much as you wanted to be in decisions about your care and treatment? Never Sometimes Usually Always 33. Were your family or friends involved as much as you wanted in decisions about your care and treatment? Never Sometimes Usually Always I did not want them to be involved I did not have family or friends to be involved August 10,

95 APPENDIX C: Canadian Patient Experiences Survey (CPES) Your Overall Ratings 34. Overall, do you feel you were helped by your hospital stay? Please answer on a scale where 0 is not helped at all and 10 is helped completely. Overall... (Please circle a number) Not helped at all Helped Completely 35. Overall... (Please circle a number) I had a very poor experience I had a very good experience About You 36. In general, how would you rate your overall physical health? Poor Fair Good Very Good Excellent August 10,

96 APPENDIX C: Canadian Patient Experiences Survey (CPES) 37. In general, how would you rate your overall mental or emotional health? Poor Fair Good Very Good Excellent 38. What is the highest grade or level of school that you have completed? 8 th Grade or Less Some high school but did not graduate High school or high school equivalency certificate College, CEGEP or non-university certificate or diploma Undergraduate degree or some university Post-graduate degree or professional designation 39. What is your year of birth? (please write in; for example 1965 ) 40. Since admission, how long have you been on this ward? (please write in) days hours 41. What type of delivery did you have? Vaginal Delivery C-Section 42. What type of room are you in? Private (1 bed) Semi-Private (2 beds) Ward Room (4 beds) August 10,

97 APPENDIX C: Canadian Patient Experiences Survey (CPES) 43. Please rate the ease of your labour and delivery. Using any number from 0 to 10, where 0 is the most difficult labour possible and 10 is the easiest labour possible, what number would you use to rate the ease of your labour and delivery? Not at all easy Easiest labour possible 44. Including this baby, how many babies have you delivered in hospital? (please write in) babies 45. During your visit, how difficult has it been to breastfeed because of potential interruptions or visitations? Not at All A little Moderately Quite a Bit Extremely 46. The following question will help us to better understand the communities that we serve. Do you consider yourself to be... (Check all that apply) White Chinese First Nation, Métis, Inuk or mixed (others may say Aboriginal or Indigenous) South Asian (East Indian, Pakistani, Sri Lankan, etc.) Black Filipino Latin American Southeast Asian (Vietnamese, Cambodian, Malaysian, Laotian, etc.) Arab West Asian (Iranian, Afghan, etc.) Korean Japanese Other August 10,

98 APPENDIX C: Canadian Patient Experiences Survey (CPES) 47. Is there anything else you would like to share with us about your hospital stay? Thank you for your help! August 10,

99 APPENDIX C: Canadian Patient Experiences Survey (CPES) Thank you on behalf of the study investigators! Susan Law PhD Jeannie Haggerty PhD Marie-France Brizard BScN, MGdO Jennifer Somera N, MSc (A), I.B.C.L.C. St. Mary s Quiet Time Project St. Mary s Research Centre Hayes Pavillion, room 4720 (4 th floor) 3830 Lacombe Avenue Montreal, QC H3T 1M5 If you have any questions, feel free to contact Safina Adatia, BSc, MSc (c) Research Assistant safina.adatia@ssss.gouv.qc.ca X 3921 August 10,

100 Appendix D: Interview Guide APPENDIX D: Interview Guide Quiet Time Interview Guide for Patients (pre and post included) NB: This interview guide may be modified during the course of the study based on continuous analysis of participants data and thus is provisional only. The interview questions may be refined based on relevance and on emergent themes during data analysis. The trainee s supervisors will approve all changes. Preamble after introduction to patient. Thank you for taking the time to participate in this study. We are interested in learning more about your perceptions and experiences regarding the maternity ward environment, particularly with respect to noise and potential interruptions. I will be using an audio recorder during the interview and will be taking notes just to ensure that your experiences are recorded accurately. All the information shared during this interview will remain private and confidential; the results will be reported anonymously so that no one can identify you or any personal information. If you would like to pause or take a break at any point, please let me know and we can stop the interview. Do you have any questions before we begin? Pre-intervention: Questions: 1. What words would you use to describe the environment on the maternity ward? [prompts if having trouble responding: would you say it is restful, noisy, busy, calm, pleasant, stressful, ] Why can you give examples to illustrate what you mean? 2. Do you feel you have been able to rest since you have been here? [prompts: Yes/No/perhaps?] a. why or why not? [baby, self, environment?] 3. Can you tell me your perceptions of the noise levels on the ward? 4. And the same for the number of potential interruptions you have experienced during your stay? [prompts: too many, just right, too few?] 5. The staff are considering a quiet time during the day for new mothers on this ward. What do you think about this idea? What would it mean for you? [prompt if no response: a quiet time could be a 1-2 hour daily period of time where the lights will be dimmed and potential interruptions and noise levels will be reduced] 6. What sorts of benefits might you expect from an organized quiet time? 7. What sorts of challenges do you think might be encountered from your or your family s perspective? from the staff perspective? What sorts of things would need to change? Any ideas about what might help with these challenges? 8. What time do you think would be the best for a quiet time? 9. Is there anything else you feel the staff or hospital should consider in thinking about this change? 10. Advice for other mothers coming into hospital regarding the noise or potential interruptions during your stay? August 10,

101 APPENDIX D: Interview Guide Post-intervention: Questions: 1. What words would you use to describe the environment on the maternity ward? [prompts if having trouble responding: would you say it is restful, noisy, busy, calm, pleasant, stressful, ] Why can you give examples to illustrate what you mean? 2. Do you feel you have been able to rest since you have been here? [prompts: Yes/No/perhaps?] a. why or why not? [baby, self, environment?] 3. Can you tell me your perceptions of the noise levels on the ward? 4. And the same for the number of potential interruptions you have experienced during your stay? [prompts: too many, just right, too few?] 5. The quiet time for new mothers on this ward has recently been implemented. Can you tell us what you think of this arrangement? Pros, cons, how might be improved? 6. Do you think the current time for the intervention is appropriate? 7. Is there anything you think should be modified to make this work better for patients and families? 8. Any other comments? Thank you very much for your time we will be compiling all the responses to these interviews and will prepare a summary for presentation to the working group. August 10,

102 APPENDIX E: Consent Forms Appendix E: Consent Forms St. Mary s Hospital Centre 3830 ave Lacombe Montreal QC H3T 1M5 Introducing a Quiet Time on a Maternity Ward: Engaging Patients and Staff to Assess Benefits and Barriers Project Information and Consent Form For patients, pre-intervention Principal Investigator: Susan Law, PhD, McGill University Co-Principal Investigators: Jeannie Haggerty, PhD, McGill University; Marie-France Brizard, St. Mary s Hospital Co-Investigator: Jennifer Somera, M.Sc, St. Mary s Hospital Student Researcher: Safina Adatia, M.Sc (c) McGill University You are being invited to participate in this research study. The objective of this study is to better understand the effects of the implementation of a quiet time intervention on the experiences of both patients and staff on the maternity ward. A quiet time consists of reducing the number of potential interruptions and noise levels during a two-hour period on a daily basis. Your participation in this study is voluntary and you may withdraw or refuse to participate in the study at any time. You may refuse to answer any questions during the study or you may stop at any time with no consequences for your care at St. Mary s Hospital. Purpose of the Study The purpose of this study is to evaluate (1) to what extent do postpartum mothers and staff on a maternity unit perceive the need for a quiet time, (2) identify anticipated benefits or desired outcomes from different perspectives, (3) determine the barriers and enablers to implementing the quiet time from patient and staff perspectives and (4) evaluate if a quiet time intervention on a maternity ward improve levels of noise, number of disruptions and experiences for patients and staff. For this portion of the study, we will be asking you questions related to your perception of the current hospital environment and potential value of a quiet time in the postpartum period. Your opinions will contribute to the development of the quiet time intervention which will be implemented in the coming months. Description of the Study s Procedures In order to better understand the potential impact of the quiet time intervention, we will be measuring noise levels and potential interruptions on the ward, asking postpartum mothers to complete a survey about their experiences in hospital, and interviewing some postpartum mothers about their perceptions of the need for a quiet time. We will also do the survey and interview another group of mothers after the quiet time has been implemented. It should take 30 minutes to complete the interview. This interview may be audio recorded with your permission. Benefits We hope that this study will contribute to improvements in the current environment on the maternity ward and provide a period of time for patients to rest. Results of this study will be used to provide better care to patients on the maternity ward and create an environment conducive to healing and rest. August 10,

103 APPENDIX E: Consent Forms Risks There are no foreseen risks associated with your participation in this research. Confidentiality and Anonymity All information provided to us will be kept confidential. A number will be used in place of a name on the sheets recording the interview information to provide confidentiality. All information will remain anonymous. No identifying information will be used. The master list of names will be kept in a locked file cabinet and available only to members of the research team. All audio recordings, transcripts, field notes and data analyses will be kept locked in a filing cabinet in the St. Mary s Hospital Centre (SMHC) research unit. The investigators of this study and the student researcher are the only people who will access this material. All electronic information will be kept on a password-protected computer in the Research Centre at St. Mary s Hospital, and accessible only by the research assistant and co-principal investigators. Conservation of data: All documents for this study will be conserved for a period of 5 years, after which it will be destroyed. All electronic files will be permanently deleted. All paper files will be shredded. Termination of Participation Participation in this interview is voluntary and you can withdraw participation at any time. If you become upset during the interview, please feel free to inform them and they will end the interview right away. Your care at SMHC will not be impacted if you refuse to participate. Copy of Consent Form If you decide to participate in this research study, a copy of this consent form will be given to you. For further information about this study contact: Principal Investigator: Susan Law at susan.law@mcgill.ca Student Researcher: Safina Adatia at safina.adatia@mail.mcgill.ca Before You Sign this Document: By signing below, you are agreeing to participate in this research study. Make sure that any questions have been answered to your satisfaction, and that you have a thorough understanding of the study. If you want to talk to someone not connected with the study about your rights as a study participant, or if you have any complaints about the research, you can call the St. Mary's Ombudsperson at (514) ext I,, agree to participate in the study entitled, Introducing a Quiet Time on Maternity Ward: Engaging Patients and Staff to Assess Benefits and Barriers. Print Participant Name Participant Signature Date Print Interviewer s Name Interviewer s Signature Date August 10,

104 APPENDIX E: Consent Forms St. Mary s Hospital Centre 3830 ave Lacombe Montreal QC H3T 1M5 Introducing a Quiet Time on a Maternity Ward: Engaging Patients and Staff to Assess Benefits and Barriers Project Information and Consent Form For patients, post-intervention Principal Investigator: Susan Law, PhD, McGill University Co-Principal Investigators: Jeannie Haggerty, PhD, McGill University; Marie-France Brizard, St. Mary s Hospital Co-Investigator: Jennifer Somera, M.Sc, St. Mary s Hospital Student Researcher: Safina Adatia, M.Sc (c) McGill University You are being invited to participate in this research study. The objective of this study is to better understand the effects of the implementation of a quiet time intervention on the experiences of both patients and staff on the maternity ward. A quiet time consists of reducing the number of potential interruptions and noise levels during a two-hour period on a daily basis. Your participation in this study is voluntary and you may withdraw or refuse to participate in the study at any time. You may refuse to answer any questions during the study or you may stop at any time with no consequences for your care at St. Mary s Hospital. Purpose of the Study The purpose of this study is to evaluate (1) to what extent do postpartum mothers and staff on a maternity unit perceive the need for a quiet time, (2) identify anticipated benefits or desired outcomes from different perspectives, (3) determine the barriers and enablers to implementing the quiet time from patient and staff perspectives and (4) evaluate if a quiet time intervention on a maternity ward improve levels of noise, number of disruptions and experiences for patients and staff. For this portion of the study, we will be asking you questions related to your perception of the quiet time intervention. Description of the Study s Procedures In order to better understand the potential impact of the quiet time intervention, we will be measuring noise levels and potential interruptions on the ward, asking postpartum mothers to complete a survey about their experiences in hospital, and interviewing some postpartum mothers about their perceptions of the need for a quiet time. We will also do the survey and interview another group of mothers after the quiet time has been implemented. It should take 30 minutes to complete the interview. This interview may be audio recorded with your permission. Benefits We hope that this study will contribute to improvements in the current environment on the maternity ward and provide a period of time for patients to rest.the results of this study will be used to provide better care to patients on the maternity ward and create an environment conducive to healing and rest. Risks There are no foreseen risks associated with your participation in this research. Confidentiality and Anonymity All information provided to us will be kept confidential. A number will be used in place of a name on the sheets recording the interview information to provide confidentiality. All information will remain anonymous. No identifying information August 10,