Issues in Mental Health Nursing, 35:444–454, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.879358

Depression Screening on a Maternity Unit: A Mixed-Methods Evaluation of Nurses’ Views and Implementation Strategies Lisa S. Segre, PhD University of Iowa, College of Nursing, Iowa City, Iowa, USA

Lauren O. Pollack, MA University of Missouri—Kansas City, Department of Psychology, Kansas City, Missouri, USA

Rebecca L. Brock, PhD University of Iowa, Department of Psychology, Iowa City, Iowa, USA

Jeana R. Andrew, MSN, RNC-OB University of Iowa Hospitals and Clinics, Nursing—Children’s and Women’s Services, Iowa City, Iowa, USA

Michael W. O’Hara, PhD University of Iowa, Department of Psychology, Iowa City, Iowa, USA

Postpartum women often suffer clinically significant depressive symptoms, a problem addressed by nurse-delivered screening programs. In the past, success of these identification programs was measured in terms of screening rates; however, merely evaluating the screening rate does little to inform how to implement depression screening in clinical practice. This article describes the experiences of nurses in implementing depression screening on a maternity unit. We evaluate the practice qualitatively, by asking nurses to describe their screening strategies and their views about implementation, as well as quantitatively by assessing their screening rates and the number of women identified. Utilizing a framework of program evaluation, 20 maternity unit nurses completed qualitative assessments investigating their day-to-day experiences with this practice. To include the perspectives of nurses that declined to participate in qualitative assessments, 14 additional maternity unit nurses completed a brief survey assessing their views. We also assessed screening rates, defined as the number of women screened divided by the number eligible for screening. Maternity unit nurses viewed depression screening positively and were able The authors acknowledge the administrative nurses from the maternity unit: Ellen Eulberg, RN, Alexis Hanson, RN, and Linda Myers, RN. We also acknowledge Alberto Segre, PhD, for comments on an earlier draft, Erica Prussing, PhD, for consultation on ethnographic field methods, Ms. Cassidy Bell for assistance in data collection and analysis, the College of Nursing editor, Diana Colgan, PhD, and, importantly, the nurses who participated in this study. Address correspondence to Lisa S. Segre, University of Iowa, College of Nursing, 50 Newton Road, Nursing Building, Iowa City, IA 52242 USA. E-mail: [email protected]

to screen patients in relatively few steps, which they implemented using strategies they had developed themselves. Despite nurses’ ongoing concern about finding time to screen, they achieved high screening rates and, with one exception, indicated they would opt to continue voluntarily. Depression screening on the maternity unit is feasible and embraced by attending nurses. The clinical strategies used to implement screening are extensively described and provide a basis for implementation in other settings that serve perinatal women.

Depression, a frequent complication of childbirth, has a substantial negative impact on maternal well-being. Depression is the second most common cause of lost years of healthy life among women, worldwide (World Health Organization, 2001); and the leading cause of non-obstetric hospitalization among US women (Jiang et al., 2002) and maternal deaths in the UK (Oates, 2003). Universal screening improves detection of depression in perinatal women (Chaudron, Szilagyi, Kitzman, Wadkins, & Conwell, 2004); indeed, without screening depression in these women is often overlooked (Smith et al., 2004). Perinatal women, particularly those in developed nations, have frequent contact with health professionals. Maternity unit nurses are, therefore, ideally situated to screen women for depression early in the postpartum period. Although, implementing depression screening appears to be a relatively straightforward task, implementation is complicated, a fact that has been duly noted: “Its introduction into primary care is anything but simple. In its wake it carries widespread system change as

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well as a new philosophy” (Elliott, 1994, p. 229). Nevertheless, when depression screening programs are implemented, subsequent evaluations document excellent compliance by the staff, which yields high screening rates (Heneghan, Silver, Bauman, & Stein, 2000; Smith et al., 2004). Still, when a program is evaluated solely on compliance, the evaluation report contains few “lessons learned or pearls for practice” that might inform how depression screening was accomplished in these settings (Cook & Lowe, 2012, p. 3). To provide practical information of how maternity unit nurses implemented screening, we used program evaluation as a framework for capturing experienced nurses’ screening practices. Our program evaluation gathered both quantitative and qualitative assessments, as well as screening rates, from nurses who had been implementing a depressionscreening program on a maternity unit for 19 months.

BACKGROUND Approximately 19% of mothers report having experienced significant depressive symptoms in the first three months after delivery (Gavin et al., 2005). This is true for mothers in both developed nations and low- and lower-middle income countries (Fisher et al., 2012). Significantly, maternal depression can affect the entire family and have long-term consequences because it diminishes a woman’s parenting abilities and increases the infant’s risk for a broad range of developmental delays (O’Hara & McCabe, 2013). The importance of the early identification of maternal depression has been recognized internationally in several best practice guidelines (Austin & The Marc´e Society Postion Statement Advisory Committee, 2013; beyondblue, 2011; National Collaborating Center for Mental Health, 2007; Scottish Intercollegiate Guidelines Newtwork, 2012). In the US, the Preventative Services Task Force (2009) recommends systematic depression screening of all adults in settings that are prepared to complete follow-up care. Relying on patient presentation alone appears not to work, because many women do not seem depressed in informal clinical assessments. For example, one study found that pediatricians who relied on their clinical assessment alone had identified only 25 of 86 mothers that a screening tool identified as depressed (Heneghan et al., 2000). What remains to be determined is the most efficient and effective setting for implementing a sustainable systematic program of maternal depression screening in the real-world context of a nation’s local health care system. In the US, where nurses are a key element of early maternal postpartum care, a state-of-the-science report asserts that depression screening should be the responsibility of nurses in obstetrics, pediatrics, and family practice (Beck, 2008). In accordance with the Institute of Medicine’s (2010) Future of Nursing Report, which recommends that nurses be full partners in redesigning US health care, several high-profile nursing organizations recognize the importance of identifying perinatal depression (American College of Nurse-Midwives, 2002; As-

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sociation of Women’s Health Obstetric and Neonatal Nurses, 2008; National Association of Pediatric Nurse Practitioners, 2003). Moreover, US nurses specializing in maternal and child health generally embrace the practice of perinatal depression screening and are well-positioned for the task (Sanders, 2006; Segre, O’Hara, Arndt, & Beck, 2010). Previous evaluation studies followed nurses’ compliance with depression screening and tracked screening rates in both obstetric and pediatric clinics, highlighting notable success stories (Chaudron et al., 2004; Gordon, Cardone, Kim, Gordon, & Silver, 2006; Rowan, Greisinger, Brehm, Smith, & McReynolds, 2012; Sheeder, Kabir, & Stafford, 2009). In practice, however, true screening rates are much lower, simply because at-risk women are not regularly seen in the outpatient care settings followed in these published studies. For example, surveillance data from 11 states and New York City indicate that 12% of women do not attend the 6th-week postpartum check-up (Center for Disease Control and Prevention, 2007). Similar surveillance data from the state of Texas (Cheng, Fowles, & Walker, 2006) revealed postpartum health checks were missed at markedly higher rates by women covered by any insurance (35%) and particularly among lowincome women covered by Medicaid (75%). The latter group are at much higher risk for postpartum depression (Segre, O’Hara, Arndt, & Stuart, 2007). Because the overwhelming majority (99%) of US women of all ethnicities and socio-economic strata deliver their children in the hospital (MacDorman, Mathews, & Declercq, 2012), the maternity unit provides a unique opportunity to ensure that the vast majority of women are assessed for depression at least once in the early postpartum period. Still, the inpatient context of care is very different than typical outpatient settings; and existing evaluations do not assess how nurses implemented screening. Thus, there exists a significant information gap for anyone interested in introducing the practice into their own clinics and institutions (Bucknall, 2012). In this article, we describe the first evaluation of a nursedesigned maternal depression screening program in an inpatient setting. We moved beyond the usual goal of assessing quantitative outcomes (i.e., screening rates and the percentage of women identified as depressed) by capturing nurses’ views about implementing depression screening and, importantly, by describing the strategies that these nurses used. Therefore, to evaluate the training programs, we chose a model that assessed outcomes on four levels (Kirkpatrick & Kirkpatrick, 2006): (1) Reaction/Views (the nurses’ views or perspectives on putting the depression screening into practice); (2) Learning (the strategies and procedures maternity unit nurses used to screen); (3) Behavior (screening rates); and (4) Results (the percentage of women with depressive symptoms the screening flagged for treatment). Our Results are categorized and presented using these four levels. Qualitative inquiry is an increasingly-used method to assess and describe provider behavior and perspectives (Tripp-Reimer & Doebbeling, 2004); in this study this method enabled us to

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assess not only what the nurses accomplished but how they approached implementing this new practice.

METHOD Setting/Establishment of Depression Screening The setting for this study was a maternity unit of a Midwestern academic medical center that delivers approximately 1900 newborns annually. In 2008, four administrative nurses of the maternity unit, including the fourth author, participated in a benchmarking project that identified maternal depression assessment after delivery as a key performance measure. In response, the four maternity unit nursing administrative staff initiated and implemented maternal depression screenings and referrals through their participation in the Train-the-Trainer Maternal Depression Screening Program, or TTT (Segre, Brock, O’Hara, Gorman, & Engeldinger, 2011). From January 2008 to May 2008, as part of the TTT program, the four maternity unit administrative staff were themselves educated about perinatal depression and screening. Consistent with the TTT program, the four administrative nurses each developed their own training materials so they could, in turn, educate their own maternity unit staff about perinatal depression. In consultation with perinatal depression experts from the TTT program, the four maternity unit administrators also developed a depression screening protocol tailored to their maternity unit. The TTT program required that all agencies use the Edinburgh Postnatal Depression Scale (EPDS), setting a cutoff score of 12 or above as the indicator for the need for referral or services. The EPDS is a ten-item, self-report scale that was developed to assess depressive symptoms in postpartum women and has been validated as an assessment tool for pregnant women and women with toddlers (Cox & Holden, 2003). In the validation study, the cutoff score of 13 or greater has a sensitivity and specificity of 0.86 and 0.78, respectively (Cox & Holden, 2003). Additionally, the screening protocol dictated that maternity unit nurses would conduct the screen and that the screen would be completed prior to the woman’s discharge. After completing the TTT program in May 2008, the four administrative nurses from the maternity unit were equipped with materials to teach their own nursing staff about perinatal depression and implement a depression screening protocol tailored to their setting. From June to August 2008, the four administrative nurses prepared to implement depression screening. They set the dates for staff trainings; held a multi-disciplinary meeting to integrate the maternity unit depression screening protocol with protocols developed by three other clinical areas at the hospital; and obtained six language translations of the EPDS tool. From September through October 2008, the administrative nurses launched depression screening on the maternity unit by using lectures and activities to train their staff to administer the screening tool. During screening implementation, the administrative nurses then provided feedback on screening rates

at staff meetings and via posters, the unit newsletter, and the quality-management committee. In June 2010, 19 months after implementing the maternal depression screening program, we conducted the current mixedmethods evaluation. We asked nurses about their views on implementing depression screening and how they accomplished this task, and we determined screening rates and how many women were identified as possibly depressed. Participants The participants in this study were not the mothers who were screened, but rather the maternity unit nurses who implemented the screening. In June 2010, all 48 nurses from the maternity unit were invited to participate in this study, which entailed completing a demographic questionnaire, a mapping exercise, and a semi-structured interview. Less than half (n = 20) of the nurses completed the task of describing the steps of administering screening (mapping exercise); 18 of those also completed the semi-structured interview. Given the risk for potential positive bias in this convenience sample, in August 2010, we repeated the recruitment procedure, inviting nurses to complete a brief survey assessing their views of implementing depression screening. An additional 14 nurses who had not completed either of the previous qualitative assessments returned a completed survey. In total, 70.7% (34/48) of maternity unit nurses participated in this program evaluation. These two subgroups of participants (n = 34) shared demographic profiles so similar that they are displayed together in Table 1. As indicated in the Table, most of the nurses who participated in this study were white/non-Hispanic and ranged from 36 to 55 years of age. The majority had a bachelor’s degree; and approximately one third were employed full-time. Recruitment Procedures To recruit, researchers attended all maternity unit shiftchange report meetings for a period of approximately three weeks. This was done to ensure that all of the maternity unit nurses were aware of the study. In a five-minute presentation, recruitment staff described the study and distributed a consent letter. Nurses wishing to participate were given a packet containing the study forms: a demographic questionnaire, a mapping exercise, and a sheet in which they could indicate their interest in participating in the interview portion of the study. Participants completed study forms at their convenience and left completed forms in a designated box in the shift-change room. Research assistants collected the completed forms, provided gift cards as compensation, and (if the participant was interested in completing the semi-structured interview) arranged a time for the interview assessment. During the nurses’ free time, the research assistants conducted a semi-structured audio-taped interview in the hospital that lasted approximately 30 to 45 minutes. In August 2010, we repeated the recruitment procedure, this time to invite nurses to complete a brief survey to assess their

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TABLE 1 Participant Demographic Characteristics Demographic Variable Race White Black More than one race Ethnicity Latina Education 1-year post-high school Associates degree BA/BS degree MA/MS degree Other Age category 18–35 36–55 56–65 Employment status Full-time

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We are interested in your description of this procedure from the very beginning to the end. You may describe this process in words or draw a map or picture.

n

%

31 1 2

91.2 2.9 5.9

2

5.9

1 11 17 3 2

2.9 32.4 50.0 8.8 5.9

12 18 4

35.3 52.9 11.8

13

38.2

Note. Demographics are reported for the 34 maternity unit nurses who participated in some aspect of the program evaluation.

views of implementing depression screening. Nurses returned the completed survey to the designated box in the shift-change room. Researchers collected the completed surveys and provided gift cards as compensation. Ethics Research procedures involving human participants were reviewed and approved by the university’s Institutional Review Board and the Department of Nursing review committee. Measures A summary of the study measures/items and the assessed outcomes are provided in Figure 1. Demographic Questionnaire A six-item questionnaire assessed nurses’ demographic characteristics, including age group, race, ethnicity, education, licensure, and employment status. Mapping Exercise In ethnography, the technique of “mapping” assesses a person’s mental representation of their environment (Bennardo, 2002). In this study, a modified mapping exercise assessed how nurses implemented the screening protocol. Accordingly, our question stated: We are interested in how you conduct the postpartum depression screen. Please list out, step by step, how you complete the screening.

Semi-Structured Interview Three questions assessed maternity unit nurses’ perspectives about implementing depression screening on the maternity unit, specifically asking how they felt about screening when it was first introduced, whether they would continue this service if given a choice, and their level of comfort in screening. Four questions assessed the strategies they used to implement screening (e.g., how they introduced screening to their patients, the strategies they used to ensure that women completed screening, the challenges they experienced, and their suggestions for improving the screening process). Survey Three Likert-scaled items assessed nurses’ perspectives of implementing depression screening, including whether they thought screening is a good idea, whether they would opt to continue this practice if given a choice, and their level of comfort in screening women for depressive symptoms. Hospital Database A record of whether women on the maternity unit completed the depression screening (including the women’s scores) was entered into the electronic database. To assess nurses’ screening rates during the study, we obtained de-identified data from this electronic database, including the number of women screened and the total number of women admitted. To assess how many women were identified as having an elevated score, we similarly used the de-identified screening data. Data Analyses Mapping Exercise In response to the mapping query, all nurses provided a written description of the procedures they used to implement screening. In a first data-analysis pass, coders read all of the responses and reached a consensus about what constituted a single step. They agreed that everything that happens in one physical place would be coded as one step. Coders then independently coded the number of steps for each nurse’s response, discussing discrepant numbering until a consensus was reached. Descriptive statistics calculated the average number of steps. Semi-Structured Interviews The purpose of the semi-structured interviews was to assess how nurses viewed the implementation of depression screening on the maternity unit and to find out the strategies they used. Because we did not have prior knowledge about their views or practices, an inductive-content, analytic approach was used to identify themes that emerged from nurses’ responses to

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Program Evaluation Outcome Levels Level 1 Nurses’ reactions/views of implementing screening

Measure/Items

Semi-structured interview • When you heard that you would be screening what did you think of the idea? • How comfortable are you with doing the screening? • If you had a choice, would you continue this service? Why or why not? • What is the most challenging aspect to screening? • Do you have any suggestions that you think might improve the screening process? Survey • How comfortable are you with doing the screening? • If you had a choice, would you continue to screen for postpartum depression?

Level 2 Mapping exercise Nurses’ learning • Please list out, step by step, how you complete the screening. (screening strategies) We are interested in your description from the very beginning. Semi-structured interview • How do you introduce the screening to the woman? • What have you found works best to get them to complete it? Level 3 Nurses’ screening behavior (screening rates) Level 4 Results of nurses’ screening (identification rates)

Hospital electronic database • Number of women that nurses screened/number of women eligible for screening.

Hospital electronic database • Number of women identified with EPDS* scores > 12/number women screened.

*EPDS = Edinburgh Postnatal Depression Scale FIGURE 1 Program Evaluation Outcome Levels by Study Measures/Items

open-ended questions (Elo & Kyngas, 2008). Specifically, digitally recorded interviews were transcribed verbatim. The unit of analysis was the nurse’s entire response to a specific question. To develop the codes/themes, three coders read through all responses to each open-ended question and generated a list of emergent themes. Based on the coders’ consensus, a final list of themes/codes was established for each question. Coders re-read responses and assigned coding categories to each response. The final code(s) for each nurse’s response was the one selected by the majority of coders. Discrepancies in coding were resolved through a discussion until at least two coders reach a consensus. Finally, the data analysis included a quantitative summary of the themes encompassing the nurses’ responses. Survey and Hospital Database Descriptive statistics summarized the nurses’ survey responses. Data on screening rates and the Edinburgh Postnatal Depression Scale (EPDS) scores were obtained as de-identified

data from the hospital’s electronic records for the time period corresponding to the assessment of nurses’ practice and views: June, July, and August, 2010. Screening rates were defined as the number of women screened (which was detectable as an EPDS score in the hospital database) divided by the number of women admitted to the maternity unit in a given month. Elevated EPDS scores were defined as ≥12. Descriptive statistics were used to calculate screening rates and the percentage of elevated scores. RESULTS Level 1—Reaction/Views: Semi-Structured Interviews Initial Views Nurses were asked how they felt at the outset of the screening program; their responses were categorized into four groups. The first group, which encompassed 50% of the maternity unit

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nurses, began the practice of maternal depression screening with positive views. A typical comment from this group was:

Finally, four nurses (22.2%) described challenges related to the wording or format of the screening tool:

If we can assess these moms before they leave the hospital, it’s a good idea.

I think the most challenging thing is people don’t realize that we’re asking them to look in the last seven days . . . people are looking back months before. Sometimes you have to actually tell them again, “You realize this is just the last seven days.”

The second group, 33% of those interviewed, initially held negative views or concerns, but became more positive after they had done the screening for a while: I remember sitting in a classroom and going over the PowerPoint presentation and it was all about postpartum depression . . . I have to tell you, that my first thought was that we see these moms for such a short period of time and we already give them so much paperwork, how are we going to incorporate this? But I do have to say that, after using it, even for a short time, even just a week, you see how small of a tool it is. It’s very short, it’s very brief, and there is time for the typical patient.

A few nurses (11%) initially had positive views but developed concerns during implementation: I thought it was a good idea from the beginning . . . It doesn’t take a lot of time. I think sometimes it can be challenging just to get people to complete it.

One nurse had started the program with a negative/hesitant view about screening, but her view switched to a positive one with, however, ongoing concerns: Oh here’s another job to do, another little survey we get to fill out, another something we have to do on the computer. But after we’d done it for a while, I thought it is a good thing. But we’re having problem with explaining it to women that don’t speak English.

Comfort with Screening and Willingness to Continue The maternity unit nurses who completed the semi-structured interviews unanimously responded that they were “comfortable to very comfortable” implementing depression screening. All said that, if given a choice, they would opt to continue: I think it [screening] is helping people to open up that [otherwise] may not talk about how they feel or things that they’re worried about.

Screening Challenges As indicated in Table 2, the most frequently encountered challenge (mentioned by 44% of the nurses) was getting women to complete the screen during their relatively short maternity unit stay: The most difficult thing is just getting them to fill it out in a timely manner.

Another challenge that four nurses (22.2%) identified was related to language or cultural barriers. As one nurse stated: We have a lot of different cultures of women and a lot of different languages and . . . you can think that she speaks and reads English . . . but I think . . . [it] might not be quite understood.

Suggestions for Improving the Screening Process Two issues were the topic of the most frequent suggestions made by the nurses (Table 2): more translations (27.8%) of the tool were needed; and the specification “last seven days” should appear in bold type (16.7%). In addition, a few nurses suggested changing some aspect of the screening process: for example, screening first in prenatal clinics to raise awareness during pregnancy and set the stage for depression screening on the maternity unit (22.%); giving mothers on the maternity unit an informational brochure about postpartum depression to help normalize her experience and provide the opportunity to read about depression in private (16.7%); and screening women earlier in their maternity unit admission to ensure ample time for follow-up referral (5.5%). Finally, a little less than one quarter (22%) suggested improving communication about screening among nursing staff: The one thing I can think of within our system is [that we need] more consistent [reporting]. We are doing it, but not consistently. In our nursing [shift-change] reports [we could] say where we are with it . . . they sometimes say, “Oh the postpartum was a 4 and 0 [on item 10 which assesses suicidal thought]” and then they move on. Or they could say, “I gave them the EPDS, or I’ve asked them to do it.” You know, it’s nice to know where they are at with it.

Level 1—Reaction/Views: Survey The 14 nurses who only completed the survey assessment had generally positive views about the program. All agreed that depression screening is a good idea; over half (64.3%) indicated they were comfortable implementing this practice; and all but one (92.9%) indicated they would opt to continue screening if given a choice. Level 2—Learning (Screening Strategies): Mapping/Semi-Structured Interview Mapping Exercise/Screening Steps Based on nurses’ responses to the mapping exercise, we concluded that nurses completed the screen in four steps, on average, with a range of two to seven steps. The most commonly described steps were (1) giving the EPDS to the patient and explaining it; (2) either reminding patients to complete it or, if completed, collecting the form; (3) scoring the EPDS and entering the score into the computer; and (4) returning the scale to women and reviewing their responses with them. Two additional steps were common: before giving the EPDS to the patient, some nurses explicitly mentioned needing to obtain a copy of the EPDS form. Also, at the end of the screening process, some nurses mentioned the need to refer women with elevated

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TABLE 2 Themes: Nurses’ Responses in Semi-Structured Interviews (N = 18) Screening Challenges

n (%)

Time/completing task Language/cultural Wording/format Getting patients to take screening seriously Referrals Nothing

8 (44.0%) 4 (22.2%) 4 (22.2%) 2 (11.1%) 1 (5.5%) 1 (5.5%)

Strategies to Improve Screening

n (%)

Provide more translations of the EPDS∗ Improve staff communication Screen in prenatal clinics to raise awareness Reformat tool; e.g., show seven-day time frame in bold type Provide brochure on postpartum depression No changes Screen earlier in the maternity unit admission

5 (27.8%) 4 (22.2%) 4 (22.2%) 3 (16.7%) 3 (16.7%) 3 (16.7%) 1 (5.5%)

Introduction Techniques

n (%)

Use a script Emphasize that the scale assesses the past seven days Emphasize that they bring the screening tool to the patient Normalize the screen when introducing it, indicating that the assessment provides a baseline and is given to all women Give deadline/time limit to collect completed screen when giving screen to patient Mention that the physician requires the screening score before discharge Strategies Ensuring Completion

15 (83.3%) 13 (72.2%) 8 (44.4%) 7 (38.9%) 4 (22.2%) 1 (5.5%) n (%)

Remind patients Give a deadline Give screen during calm period Require screen to be completed before discharge Tie screen to another task Make screen accessible Feign to forget whether screening was administered Communicate importance of screen when introducing it Talk about practical advantages of screening, getting help early Enlist patient’s help in getting nurse’s tasks done

8 (44.4%) 5 (27.8%) 4 (22.2%) 4 (22.2%) 3 (16.7%) 2 (11.1%) 1 (5.6%) 1 (5.6%) 1 (5.6%) 1 (5.6%)

Note: Nurses could mention more than one theme, so the total of percentages may exceed 100%. ∗ EPDS = Edinburgh Postnatal Depression Scale

EPDS scores to the physician. An example of a typical response is provided below; movement to a different step is demarcated by a “/“. I show the patient the PPD screening. I state that “we screen all of our patients for postpartum depression. This is a 10-question survey that we would like you to answer according to how you have been feeling in the last seven days.”/Later in the shift I will ask if they have had a chance to fill it out./If so, I take it to a computer and

chart their responses./I then return the survey, usually immediately, to them and point out the resources on the back.

Semi-Structured Interview—Introducing Screening Nurses described the range of techniques they used to introduce depression screening to new mothers (Table 2). Most of the nurses (83%) had developed a script, which normalized screening. Noteworthy is the fact that, when explaining

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the screening tool to a patient, the majority of nurses (72%) emphasized the seven-day timeframe of the EPDS. The following script exemplifies these two common introductory strategies: I have a pen and I hand the survey to the patient with the pen and I say: “This is a mood survey, we give it to all new moms, we just want to check in with you and make sure you are feeling okay. I need you to answer these ten questions about how you’ve been feeling over the last seven days. I will be back to pick this up at such and such a time.”

Semi-Structured Interview—Strategies to Ensure Completion Nurses had developed ten strategies to ensure that women completed the EPDS (Table 2). Simply reminding patients to complete the EPDS was the most frequently used strategy (44%): I’ll ask a couple of times. Some are just so forgetful. The max I like to try and do is three times and then that’s it, and then maybe, you know, the next day.

Other frequently used strategies included giving mothers a deadline to complete the EPDS (27.8%), handing out the screening during a calm period (22%), and reminding women that completing the screening was one requirement for discharge (22%). One nurse kept it simple: Basically, give them the tools that they need to complete it, like a pen.

Another nurse liked to tie screening to other tasks, to avoid sounding bothersome: I try and tie it in with pain. We have certain protocols that we ask for pain levels and things like that. So, you know, when I ask them, “How’s your pain? Have you had a chance to take care of your postpartum depression screening? No, okay that’s fine. I’ll just stop back later.” I incorporate it into other things, so it doesn’t seem to be such a nagging thing.

A “purposely forgetful approach” was suggested by one nurse, meaning that she feigned tentativeness as a way to avoid sounding too nagging: I don’t know if you misplaced this [EPDS tool], but we are still looking for this and would you mind doing that today?

Level 3—Behavior (Screening Rates): Hospital Database During the three-month program evaluation period, nurses’ depression screening rates were high. During June 2010, a total of 159 women were screened out of 163 women who delivered (97.6%). During July 2010, a total of 175 women were screened out of 182 (96.2%). In August 2010, 139 women out of 143 were screened (97.2%).

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Level 4—Results (Percentage of Elevated Depression Scores): Hospital Database The average EPDS score among all women screened during the study timeframe was 4. Few women (n = 18; 4.4%) had elevated scores on the EPDS scale (≥12). Among the women with elevated EPDS scores, the most frequent score was 14 (n = 4).

DISCUSSION Nurses believe depression screening of perinatal women is their responsibility (Beck, 2008; Sofronas, Feeley, Zelkowitz, & Sabbagh, 2011) and would be willing to screen women accordingly (Segre et al., 2010), but the views of nurses who have actually implemented maternal depression screening have never been assessed. Utilizing a program evaluation framework, our study assessed four implementation outcomes of a program of depression screening on the maternity unit. Our first key finding is that the practice is supported by nurses who have had considerable experience screening new mothers for depression. Half of the nurses we queried began the study with positive views that did not change. Another third initially had reservations, but these diminished over time and with familiarity with the screening. Some nurses supported depression screening from the outset, but in practice found challenges in getting women to complete the EPDS during their short hospital stay, or in screening women who do not speak English. Importantly, after 19 months of experience implementing depression screening, most maternity unit nurses indicated they were “comfortable to very comfortable” with the practice, including all of the nurses who completed the semi-structured interview and approximately two-thirds of those who only completed the brief survey. Perhaps most noteworthy, however, is the finding that all but one nurse would, if given a choice, continue to screen, including some who had indicated they were not yet completely comfortable with this practice. Our assessment also included nurses’ perspectives on the challenges they had when screening and their suggestions for improving the process. Three frequently mentioned challenges were: (1) finding time to complete the screening process during the short inpatient stay of busy new mothers; (2) ensuring that women understood that the screening tool assessed mood in the past week only; and (3) screening women who are not fluent in English. These experientially informed views are consistent with the barriers reported by obstetric and neonatology nurses (Sofronas et al., 2011). Still, in spite of these ongoing challenges, the high screening rates indicate that the nurses succeeded in performing this duty by devising their own strategies. Moreover, none of the nurses indicated that screening was a burden; and the majority elected to continue the practice. In terms of their perspectives on directions for improvement, nurses most frequently suggested organizational changes: obtain the EPDS in additional languages, improve staff communication at shift-change report, and introduce screening during the prenatal

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visit to prepare women for the assessment early in the postpartum period. The program evaluation framework assesses the skills learned by program participants (Kirkpatrick & Kirkpatrick, 2006). In this evaluation, learning was broadly defined as the strategies and procedures nurses used to implement depression screening in the maternity unit setting. Nurses’ responses to the mapping exercise indicated that depression screening is typically achieved in just four steps—giving patients the screening tool, reminding them to complete it or collecting the form, scoring and entering score into the computer, and reviewing the woman’s responses with her. For the subset of patients with depressive symptoms, nurses noted the additional step of referring the patient to a physician or mental health professional. In the semi-structured interviews, nurses described the strategies they used to complete these four steps, providing narrative “sound bites” (Kearney, 2005) that might guide implementation in other settings. To ensure completion of the screening process, the maternity unit nurses described a wide range of strategies, which most frequently included simply reminding patients, providing a clear deadline, and giving patients the screen during a calm period. The third part of program evaluation assessed whether behavior changed (Kirkpatrick & Kirkpatrick, 2006). In this study, we defined behavior change as nurses’ compliance with screening and quantified success by tracking their screening rates. After 19 months of implementing depression screening, the nurses’ screening rates were high (> 96%), supporting both the feasibility and sustainability of screening. In other perinatal settings, depression screening rates have varied widely, from 46% to 100% (Chaudron et al., 2004; Gordon et al., 2006; Rowan et al., 2012; Sheeder et al., 2009). The high rates achieved on this maternity unit are consistent with the perfect compliance achieved in prenatal and postpartum checks (Rowan et al., 2012), as well as the 98% screening rate of adolescent mothers in well-baby clinics that employed electronic flagging reminders (Sheeder et al., 2009). Two factors may have contributed to our high screening rates. First, although physicians or psychologists led other, similar initiatives, this program was initiated by maternity-unit nurse administrators. Thus, our screening protocol and procedures were informed by an in-depth understanding of the organizational system and staff capacity. Moreover, the four maternity-unit nurse administrators who implemented the program were available during the implementation phase and remained available throughout the program to ensure the practice continued. Second, the maternity unit nurses were educated about depression and screening before implementation—a key point that cannot be overlooked. This step is in accordance with the finding that appropriately trained nurses are more likely to comply with depression screening (Massoudi, Wickberg, & Hwang, 2007). Through the TTT program (Segre et al., 2011), the four nursing administrative staff from the maternity unit developed extensive education materials about maternal depression and the screening

procedure. Before implementation, each maternity unit nurse attended a four-hour workshop that included education about maternal depression and the importance of screening. Additionally, during the training workshops, nurses practiced giving the EPDS screen, and were given scripts to act out experiences they might encounter when screening a woman with elevated scores. This training activity likely boosted the confidence of nurses as they began screening. The importance of confidence in achieving high screening rates has been consistently noted in other research: Nurses who felt confident were more likely to implement the practice (Connelly, Baker, Hazen, & Mueggenborg, 2007; Massoudi et al., 2007; Sofronas et al., 2011). The final part of the evaluation assessed program results (Kirkpatrick & Kirkpatrick, 2006), which we defined as the percentage of women the screening identified as possibly depressed. This measure quantifies the usefulness of the program in terms of ultimate outcome: early identification of depressive symptoms to allow nurses to refer women for further assessment and help before discharge. In the three-month period, 4.5% of mothers were identified as possibly depressed and referred for further assessment. Because early postpartum EPDS scores correlate well with scores at six-weeks postpartum (Teiss`edre & Charbrol, 2004), screening on the maternity unit provides an opportunity to identify potential depression earlier. Importantly, screening on the maternity unit provides nurses an opportunity to educate all women about depression, even those with low scores, and the opportunity to advise them to call for help if symptoms develop. Limitations Several methodological limitations of this study are noteworthy. First, this program evaluation only assessed the views and practice of 34 nurses in a single maternity unit, at one tertiary hospital in an academic setting. Thus, the screening strategies and outcomes described here may not necessarily generalize to diverse maternity unit settings. Further, although 20 maternity unit nurses completed some aspect of the qualitative assessments, 14 opted out of the qualitative assessments and completed only a brief quantitative survey. We were, therefore, concerned that the 20 nurses who participated readily might represent only those with positive views about screening. We therefore elected to distribute a brief survey to capture the views of nurses who had not completed the qualitative assessments. Although they expressed positive views on the survey—with the majority (64%) indicating they felt comfortable with screening and 92% opting to continue screening if given a choice—they may not have been as positive as the “first comers” had they also completed the qualitative assessment portions. Thus, there is still some risk of positive bias in the views reported here. Second, for those who completed the semi-structured interview, questions concerning their initial views required that they remember how they felt 19 months earlier. Distinguishing their current and prior views may have been difficult, thus calling into question the reliability of this information.

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Third, while this evaluation tracked the percentage of women identified as possibly depressed during the screening program, it is difficult to interpret this outcome without comparing it to a time when no screening was implemented. Finally, no data were available on the outcomes for the women who were screened and identified as possibly depressed, that is, whether screening and referral resulted in mental health treatment and, ultimately, improvement. Counterbalancing any limitations are several contributions. This study is the first evaluation in a maternity unit setting of a depression screening program that was both initiated and implemented by nurses. In line with the call for practice-based evidence to enhance the utility of research findings (Leeman & Sandelowski, 2012), this program evaluation uniquely described the strategies used by clinical nurses, thus providing practicing nurses with experienced guidelines in how to implement depression screening in this setting. In conclusion, the need to improve early identification and treatment of perinatal depression is an important public health priority. Maternity unit nurses are well-positioned to identify depressive symptoms early in the postpartum period, as well as to provide education that increases new mothers’ awareness of symptoms and courses of action. The results of this evaluation indicate that maternity unit nurses are willing to screen new mothers for depression, and that the implementation of a nurse-initiated, depression screening program is a feasible and sustainable practice. Declaration of Interest: During the period of the conduct of this research, Lisa S. Segre, PhD, was supported by an NIMH K-23 Award grant MH075964. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

REFERENCES American College of Nurse-Midwives. (2002). Depression in women: Position statement. Retrieved from http://www.midwife.org/siteFiles/position/ Depression in Women 05.pdf Association of Women’s Health Obstetric and Neonatal Nurses. (2008). The role of the nurse in postpartum mood and anxiety disorders. Retrieved from http:// www.awhonn.org/awhonn/content.do?name=05 HealthPolicyLegislation/ 5H PositionStatements.htm Austin, M.-P., & The Marc´e Society Postion Statement Advisory Committee. (2013). Marc´e International Society position statement on psychosocial assessment and depression screening in perinatal women. Best Practice & Research Clinical Obstetrics and Gynaecology. Retrieved from http://www. sciencedirect.com/science/article/pii/S1521693413001284 Beck, C. T. (2008). State of the science on postpartum depression: What nurse researchers have contributed: Part 2. The American Journal of Maternal Child Nursing, 33, 151–156. doi: 10.1097.01.NMC.0000318349.70364.1c Bennardo, G. (2002). Map drawing in Tonga, Polynesia: Accessing mental representations of space. Field Methods, 14, 390–417. doi: 10.1177/15258 2202237727 beyondblue. (2011, Febrary 2011). Clinical practice guidelines. Depression and related disorders—anxiety, bipolar disorder and puerperal psychosis—in the perinatal period. A guideline for primary care health professionals. Retrieved

453

from https://www.bspg.com.au/dam/bsg/product?client=BEYONDBLUE& prodid=BL/0891&type=file Bucknall, T. (2012). Bridging the know-do gap in health care through integrated knowldege translation. Worldviews on Evidence-Based Nursing, 9, 193–194. doi: 10.1111/j.1741-6787.2012.00263.x Center for Disease Control and Prevention. (2007). Postpartum care visits—11 States and New York City, 2004. Morbidity and Mortality Weekly Report, 56, 1312–1316. Chaudron, L. H., Szilagyi, P. G., Kitzman, H. J., Wadkins, H. I. M., & Conwell, Y. (2004). Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics, 113, 551–558. Cheng, C.-Y., Fowles, E. R., & Walker, L. O. (2006). Postpartum maternal health care in the United States: A critical review. The Journal of Perinatal Education, 15, 34–42. doi: 10.1624/105812406×119002 Connelly, C. D., Baker, M. J., Hazen, A. L., & Mueggenborg, M. G. (2007). Pediatric health care providers’ self-reported practices in recognizing and treating maternal depression. Pediatric Nursing, 33, 165–172. Cook, P. F., & Lowe, N. K. (2012). Differentiating the scientific endeavors of research, program evaluation, and quality improvement studies. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 41, 1–3. doi: 0.1111/j.15526909.2011.01319.x Cox, J., & Holden, J. (2003). Perinatal mental health: A guide to the Edinburgh Postnatal Depression Scale (EPDS). London, UK: Gaskell. Elliott, S. A. (1994). Uses and misuses of the Edinburgh Postnatal Depression Scale in primary care: A comparison of models developed in health visiting. In J. Cox & J. Holden (Eds.), Perinatal psychiatry: Use and misuse of the Edinburgh Postnatal Depression Scale (pp. 221–232). London, UK: Gaskell. Elo, S., & Kyngas, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107–115. doi: 10.1111/j.1365-2648.2007. 04569.x Fisher, J., Cabral de Mello, M., Patel, V., Rahman, A., Tran, T., Holton, S., & Holmes, W. (2012). Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: A systematic review. Bulletin of the World Health Organization, 90, 139–149. doi: 10.2471/BLT.11.091850 Gavin, N. I., Gaynes, B. N., Lohr, K. N., Meltzer-Brody, S., Gartlehner, G., & Swinson, T. (2005). Perinatal depression: A systematic review of prevalence and incidence. Obstetrics and Gynecology, 106, 1071–1083. doi: 10.1097/01.A0G.0000183597.31630.db Gordon, T. E. J., Cardone, I. A., Kim, J. J., Gordon, S. M., & Silver, R. K. (2006). Universal perinatal depression screening in an academic medical center. Obstetrics and Gynecology, 107, 342–347. doi: 10.1097/01. AOG.0000194080.18261.92 Heneghan, A. M., Silver, E. J., Bauman, L. J., & Stein, R. E. K. (2000). Do pediatricians recognize mothers with depressive symptoms? Pediatrics, 106, 1367–1373. doi: 10.1542/peds.106.6.1367 Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. Washington, DC: Author. Jiang, H. J., Elixhauser, A., Nicholas, J., Steiner, C., Reyes, C., & Bierman, A. S. (2002). Care of women in U.S. hospitals 2000 HCUP Fact Book No. 3. Rockville, MD: Agency for Healthcare Research and Quality. Kearney, M. H. (2005). Seeking the sound bite: Reading and writing clinically useful qualitative research. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34, 417. doi: 10.1111/j.1552-6909.2005.tb00361.x Kirkpatrick, D. L., & Kirkpatrick, J. D. (Eds.). (2006). Evaluating training programs: The four levels (3rd ed.). San Francisco, CA: BerrettKoehler. Leeman, J., & Sandelowski, M. (2012). Practice-based evidence and qualitative inquiry. Journal of Nursing Scholarship, 44, 171–179. doi: 10.1111/j.15475069.2012.01449.x MacDorman, M. F., Mathews, T. J., & Declercq, E. (2012). Home births in the United States, 1990–2009. Washington, DC: Center for Disease Control and Prevention, National Center for Health Statistics.

454

L. S. SEGRE ET AL.

Massoudi, P., Wickberg, B., & Hwang, C. P. (2007). Screening for postnatal depression in Swedish child health care. Acta Paediatrica, 96, 897–901. doi: 10.1111/j.1651-2227.2008.00292.x National Association of Pediatric Nurse Practitioners. (2003). The PNP’s role in supporting infant and family well-being during the first year of life: Position statement. Journal of Pediatric Health Care, 17, 19A– 20A. National Collaborating Center for Mental Health. (2007). Antenatal and postnatal mental health: Clinical management and service guidance: National Institute for Health and Clinical Excellence. O’Hara, M. W., & McCabe, J. E. (2013). Postpartum depression: Current status and future directions. Annual Review of Clinical Psychology, 9, 379–407. doi: 10.1146/annurev-climpsy-050212-185612 Oates, M. (2003). Perinatal psychiatric disorders: A leading cause of maternal morbidity and mortality. British Medical Bulletin, 67, 219–229. doi: 10.1093/bmb/ldg011 Rowan, P., Greisinger, A., Brehm, B., Smith, F., & McReynolds, E. (2012). Outcomes from implementing systematic antepartum depression screening in obstetrics. Archives of Women’s Mental Health, 15, 115–120. doi: 10.1007/ s00737-012-0262-6 Sanders, L. B. (2006). Attitudes, perceived ability, and knowledge about depression screening: A survey of certified nurse-midwives/certified midwives. Journal of Midwifery & Women’s Health, 51, 340–346. doi: 10.1016/j.jmwh. 2006.02.011 Scottish Intercollegiate Guidelines Newtwork. (2012). Management of perinatal mood disorders. Retrieved from http://www.sign.ac.uk/guidelines/ fulltext/127/index.html Segre, L. S., Brock, R. L., O’Hara, M. W., Gorman, L. L., & Engeldinger, J. (2011). Disseminating perinatal depression screening as a public health initiative: A train-the-trainer approach. Maternal and Child Health Journal, 15, 814–821. doi: 10.1007/s10995-010-0644-1

Segre, L. S., O’Hara, M. W., Arndt, S., & Beck, C. T. (2010). Nursing care for postpartum depression. Part 1: Do nurses think they should offer both screening and counseling? The American Journal of Maternal Child Nursing, 35, 220–225. doi: 10.1097/NMC.0b013e3181dd9d81 Segre, L. S., O’Hara, M. W., Arndt, S., & Stuart, S. (2007). The prevalence of postpartum depression: The relative significance of three social status indices. Social Psychiatry and Psychiatric Epidemiology, 42, 316–321. doi: 10.1007/s00127-007-0168-1 Sheeder, J., Kabir, K., & Stafford, B. (2009). Screening for postpartum depression at well-child visits: Is once enough during the first 6 months of life? Pediatrics, 123, e 982–e988. Retrieved from http://pediatrics.aappublications. org/content/123/6/e982.full.pdf+html doi: 10.1542/peds.2008-1160 Smith, M. V., Rosenheck, R. A., Cavaleri, M. A., Howell, H. B., Poschman, K., & Yonkers, K. A. (2004). Screening for and detection of depression, panic disorder, and PTSD in public-sector obstetric clinics. Psychiatric Services, 55, 407–414. doi: 10.1176/appi.ps.55.4.407 Sofronas, M., Feeley, N., Zelkowitz, P., & Sabbagh, M. (2011). Obstetric and neonatology nurses’ attitidues, beliefs, and practices related to the management of symptoms of maternal depression. Issues in Mental Health Nursing, 32, 735–744. doi: 10.3109/01612840.2011.609635 Teiss`edre, F., & Charbrol, H. (2004). Detecting women at risk for postnatal depression using the Edinburgh Postnatal Depression Scale at 2 to 3 days postpartum. Canadian Journal of Psychiatry, 49, 51–54. Tripp-Reimer, T., & Doebbeling, B. (2004). Qualitative perspectives in translational research. Worldviews on Evidence-Based Nursing, 1, S65–S72. doi: 10.1111/j.1524-475X.2004.04041.x US Preventive Services Task Force. (2009). Screening for depression in adults: US Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 151, 784–792. World Health Organization. (2001). Mental health: New understanding, new hope. Geneva, Switzerland: Author.

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