Perspectives of Hospital‐Based Nurses on Breastfeeding Initiation Best Practices

ObjectiveTo assess the variation in breastfeeding knowledge and practices of registered nurses in hospital women and family‐care units and the informal and formal hospital policies related to the initiation and support of breastfeeding.DesignThis qualitative study employed a focus group approach to solicit perceptions of hospital‐based nurses regarding breastfeeding best practices.SettingEight state hospitals stratified by socioeconomic status (SES) and size served as settings to recruit participants for this study.ParticipantsForty female registered nurses from labor and delivery (n=9), postpartum (n=13), labor and delivery/recovery/postpartum care (LDRP) (n=12) and neonatal intensive care unit (NICU) (n=6) constituted eight focus groups.ResultsThe majority of nurses reported being knowledgeable of evidence‐based best practices related to breastfeeding initiation. However, in non‐Baby Friendly/Baby Friendly Intent (non‐BF/BFI) settings, nurses' knowledge often was not in accordance with current best practices in breastfeeding initiation, and reported hospital policies were not based upon evidence‐based practices. Barriers to best practices in breastfeeding initiation included hospital lactation policies (formal and informal), nurses' limited education in breastfeeding initiation best practices, high rates of surgical delivery, and lack of continuity of care with the transition of responsibility from one nurse to another from labor and delivery to transition care to postpartum care.ConclusionsA significant disparity between nurses' intention to support breastfeeding and their knowledge suggests a need for education based on the World Health Organization Baby Friendly standards for nurses at non‐BF/BFI hospitals. A significant barrier to supporting breastfeeding is lack of hospital policy and inappropriate or outdated policy.     

Success of an Educational Intervention on Maternal/Newborn Nurses' Breastfeeding Knowledge and Attitudes

Objective:o test the effect of a breastfeeding educational program for improving breastfeeding knowledge, attitudes, and beliefs of maternal/newborn nurses, and to improve their intentions to provide breastfeeding support to new mothers.Design:Quasi‐experimental, pretest/posttest design.Setting:Maternity units of 13 hospitals located in midwestern and east coast states.Participants:Nine experimental and three control hospital sites resulted in a convenience sample size of 240 registered nurses (RNs); 206 RNs in the experimental sites and 34 RNs in the control sites.Methods:Participation in the experimental groups involved the completion of two questionnaires upon study entry and then again after completion of a self‐study module. Participants in the control groups completed the two questionnaires twice with a 4‐ to 6‐week interval between them without access to the self‐study module.Main Outcome Measures:Nurses' breastfeeding knowledge, attitudes, beliefs, and intentions to support postpartum mothers who are breastfeeding.Results:Findings suggest that this educational strategy was effective in improving maternal/newborn nurses' breastfeeding knowledge, attitudes, and beliefs, and intentions to support breastfeeding mothers.Conclusion:This self‐paced, study module, which is guided by an on‐site, trained staff member, may be a cost‐effective strategy for improving nurses' breastfeeding knowledge and support to new breastfeeding mothers. Nurses may find this type of teaching modality to be less intimidating than a structured classroom setting, and more desirable for their busy schedules.     

Use of a Web‐based Education Program Improves Nurses’ Knowledge of Breastfeeding

ObjectiveTo evaluate the baseline knowledge and knowledge gained of nurses, nursing students, midwives, and nurse practitioners who completed Breastfeeding Basics, an online educational program.DesignThis study reports on an anonymous evaluation of an online breastfeeding education program developed and maintained to promote evidence‐based breastfeeding practice.ParticipantsIncluded in the study were 3736 nurses, 728 nurse practitioners/midwives, and 3106 nursing students from the United States who completed ≥ one pretest or posttest on the Breastfeeding Basics website between April 1999 and December 31, 2011.MethodsBaseline scores were analyzed to determine if nurses’ baseline knowledge varied by selected demographic variables such as age, gender, professional level, personal or partner breastfeeding experience, and whether they were required to complete the website for a job or school requirement and to determine knowledge gaps. Pretest and posttest scores on all modules and in specific questions with low pretest scores were compared as a measure of knowledge gained.ResultsLower median pretest scores were found in student nurses (71%), males (71%), those required to take the course (75%), and those without personal breastfeeding experience (72%). The modules with the lowest median pretest scores were Anatomy/Physiology (67%), Growth and Development of the Breastfed Infant (67%), the Breastfeeding Couple (73%), and the Term Infant with Problems (60%). Posttest scores in all modules increased significantly (p < .001).ConclusionBreastfeeding Basics was used by a large number of nurses and nursing students. Gaps exist in nurses’ breastfeeding knowledge. Knowledge improved in all areas based on comparison of pretest and posttest scores.     

Hospital Education in Lactation Practices (Project HELP): Does Clinician Education Affect Breastfeeding Initiation and Exclusivity in the Hospital?

ABSTRACT: Background: A woman’s decision to breastfeed may be influenced by her health care practitioners, but breastfeeding knowledge among clinicians is often lacking. Project HELP (Hospital Education in Lactation Practices) was an intensive education program designed to increase breastfeeding knowledge among health care practitioners. The purpose of this study was to determine whether educating practitioners affected breastfeeding initiation and exclusivity rates at hospitals with low breastfeeding rates. Methods: Between March 31, 2005, and April 24, 2006, we taught courses at four Massachusetts hospitals with low breastfeeding rates. Each course consisted of three, 4‐hour teaching sessions and was offered nine times. The training, taught by public health professionals, perinatal clinicians, and peer counselors, covered a broad range of breastfeeding‐related topics, from managing hyperbilirubinemia to providing culturally competent care. Medical records of infants born before and after the intervention were reviewed to determine demographics and infant feeding patterns. Results: Combining data from all hospitals, breastfeeding initiation increased postintervention from 58.5 to 64.7 percent (p = 0.02). An overall increase in exclusive breastfeeding rates was not statistically significant. In multivariate logistic regression for all hospitals combined, infants born postintervention were significantly more likely to initiate breastfeeding than infants born preintervention (adjusted OR 1.32, 95% CI 1.03–1.69). Conclusions: Intensive breastfeeding education for health care practitioners can increase breastfeeding initiation rates. (BIRTH 36:1 March 2009)     

Estimated Breastfeeding to Support Breastfeeding in the Neonatal Intensive Care Unit

ObjectiveTo evaluate the effects of estimated breastfeeding on infant outcomes in comparison to test weighing and to describe staff members’ experiences of estimated breastfeeding as a method for supporting the transition from tube feeding to breastfeeding.DesignA mixed method evaluation.SettingNeonatal Intensive Care Unit (NICU) in Sweden.ParticipantsThe study included 365 preterm (25^th–36^th gestational weeks) infants and 45 nurses or nurse assistants.MethodsA retrospective comparative medical record study was used to assess infant outcomes during a period of test weighing (196 infants) and again after the implementation of estimated breastfeeding (169 infants). A qualitative survey was conducted to explore the staff experiences of estimated breastfeeding.ResultsNo differences were found between groups regarding duration of tube feeding, length of hospital stay, gestational age, weight at discharge, and rate of any breastfeeding. Infants in the estimated breastfeeding group had a higher risk of not being exclusively breast milk fed than infants in the test‐weighing group (OR = 2.76, CI [1.5, 5.1]). Staff perceived estimated breastfeeding as a more facilitative and less stressful method for mothers than test weighing. Some staff had difficulty following guidelines while simultaneously providing person‐centered care.ConclusionsEstimated breastfeeding is a nonintrusive and feasible method for assessing and supporting the transition from tube feeding to breastfeeding among preterm infants in a NICU. However, the increased risk for not being exclusively breastfed is of concern. Additional research is needed to assess whether this method is appropriate and feasible in varying contexts and cultures.     

An Institutional Ethnography of Nurses’ Support of Breastfeeding on the Night Shift

ObjectiveTo describe nurses’ support of breastfeeding on the night shift and to identify the interpersonal interactions and institutional structures that affect this support.DesignInstitutional ethnography.SettingThe mother/baby unit of a tertiary care hospital with 4200 births per year.ParticipantsRegistered nurses (N = 16) who provided care on the night shift to mother/infant dyads in the immediate postpartum period.MethodsData were collected using focus groups, individual and group interviews, and mother/baby unit observations. The focus groups were held before the night shift and had five participants. The nine individual and group interviews were conducted between 0100 and 0230 on the mother/baby unit. Three unit observations were conducted. Interviews were recorded, professionally transcribed, and analyzed using a content analysis method.ResultsData analysis yielded three themes that described these nurses’ support of breastfeeding on the night shift: competing priorities, incongruent expectations, and influential institutional structures. The need of visitors to see their new family members competed with the needs of mothers to rest and breastfeed their newborns. Helping breastfeeding dyads who experienced difficulties competed with providing care to other patients. Parents’ expectations regarding newborn behavior were incongruent with the reality of newborn feeding and sleeping patterns. Institutional structures that affected the provision of breastfeeding support by nurses included hospital breastfeeding practices, staffing, and policies.ConclusionNurses’ support of breastfeeding on the night shift encompasses a complex interplay of interpersonal interactions with new families and visitors regarding priorities and expectations and negotiating institutional structures such as feeding policies and staffing.     

Integrative Review of Breastfeeding Support and Related Practices in Child Care Centers

ObjectiveTo synthesize the extant research on the support of breastfeeding and breast milk feeding and related practices in child care centers (i.e., daycare centers) in the United States and globally.Data SourcesWe used key terms to search Ovid, CINAHL, and PubMed for articles that met eligibility criteria. When potentially relevant articles were identified in PubMed, we used the cited by and similar articles features to identify additional articles. We also examined the reference lists of reviewed studies.Study SelectionWe included original research articles on breastfeeding or breast milk feeding in child care centers published in 2000 or after and available in English. We reviewed titles and/or abstracts of 1,984 articles and abstracted 37 for full-text review. Of these, 16 studies met eligibility criteria and were included in the review.Data ExtractionWe abstracted data from the 16 articles to facilitate comparison and identification of patterns related to support of breastfeeding/breast milk feeding and related practices in child care centers. These data included year of publication, setting, design/methodology (and methodologic limitations), type of respondent/sampling unit (e.g., directors and staff members of child care centers, mothers), sample size, outcome measures, and pertinent study findings.Data SynthesisWe categorized study findings into three themes: Knowledge, Attitudes, and Experiences of Staff Members in Child Care Centers; Implementation and Adherence to Policies, Practices, and Regulations in Child Care Centers; and Prevalence of Breastfeeding in Child Care Centers. Findings indicated staff members generally had positive attitudes toward breastfeeding but tended to remain neutral regarding encouragement and support of breastfeeding. Training and knowledge about breastfeeding among staff members in child care centers appears limited and focused mainly on the storage and preparation of breast milk; however, staff members indicated the desire to obtain additional education about breastfeeding. Few U.S. child care centers or states have comprehensive, evidence-based policies and regulations to address support for breast milk feeding and breastfeeding. The prevalence of breastfeeding in U.S. child care centers is less than that in other child care settings (home-based child care, etc.), child care centers in other developed countries, and national breastfeeding averages.ConclusionWe found a general lack of policies and practices to support breastfeeding in child care centers, particularly in the United States. The degree to which this policy/practice deficit contributes to suboptimal breastfeeding rates among women who use child care centers requires further study.     

Evaluation of the Supportive Needs of Adolescents during Childbirth Intrapartum Nursing Intervention on Adolescents’ Childbirth Satisfaction and Breastfeeding Rates

ObjectiveTo evaluate the effect of the Supportive Needs of Adolescents during Childbirth (SNAC) intrapartum nursing intervention on adolescents’ childbirth satisfaction and breastfeeding rates.DesignSeparate sample posttest quasi‐experimental.SettingA tertiary hospital intrapartum unit.ParticipantsA convenience sample of 106 parturient adolescents.MethodsDuring Phase 1 the control group received current standard of intrapartum care.During Phase 2, the interventionist nurses provided the SNAC intervention and standard of care to the intervention group.ResultsThe t test indicated higher childbirth satisfaction in the intervention group.Chi‐square analysis indicated that the intervention group was more likely to breastfeed within the first hour after birth. There was no significant relationship between childbirth satisfaction and breastfeeding at three months and no differences between the groups in breastfeeding rates at hospital discharge and three months.ConclusionsThese results suggest that learning the SNAC intervention may help nurses positively influence adolescents’ childbirth experience and timing of breastfeeding initiation. Replication of the study is needed to further explore whether the intervention can significantly influence breastfeeding duration.     

Hospital‐Based Perinatal Nurses Identify the Need to Improve Nursing Care of Adolescent Mothers

ObjectiveTo determine whether hospital‐based perinatal nurses with expertise in adolescent mother‐friendly care identify a need to improve inpatient nursing care of adolescent mothers and how well perinatal units support nurses’ capacity to provide adolescent mother‐friendly care. Design/Setting/Participants: A key informant survey of nurses from eight perinatal units at three hospitals (four separate sites) in a Canadian city.MethodsPerinatal nurses expert in the care of adolescent mothers were identified by their managers and colleagues. These nurses and all perinatal clinical educators were invited to participate. Twenty‐seven of 34 potential key informants completed the survey.ResultsKey informants rated their own skill in caring for adolescent mothers higher (median 8.0) than they rated the skill of other nurses (median 6.0) on their units. They attributed their expertise working with adolescent mothers to their clinical and life experiences and their ability to develop rapport with adolescents. A common reason for the assigned lower peer‐group ratings was the judgmental manner in which some nurses care for adolescent mothers. Key informants also identified that hospital‐based perinatal nurses lack adequate knowledge of community‐based resources for adolescent mothers, educational programs related to adolescent mother‐friendly care were insufficient, and policies to inform the nursing care of adolescent mothers were not available or known to them.ConclusionA minority of perinatal nurses have expertise in adolescent mother‐friendly care. There is a need for perinatal unit‐level interventions to support the development of nurses’ skills in caring for adolescent mothers and their knowledge of community‐based resources. Peer mentoring and self‐reflective practice are promising strategies.     

Scoping Review of Postpartum Discharge Education Provided by Nurses

ObjectiveTo determine what is known about postpartum education provided by nurses to women before discharge from the hospital after birth and whether current nursing practices are effective to prepare women to identify warning signs of complications, perform self-care (physical and emotional), prepare for parenting a newborn, and establish infant feeding.Data SourcesWe conducted a systematic search of CINAHL Plus and MEDLINE for relevant sources, including peer-reviewed articles, conference presentations, and guidelines from professional organizations, that were published in English from January 2010 through November 30, 2020.Study SelectionWe included sources if participants were women who had given birth to a healthy, liveborn, term infant and were receiving education in whole or in part by a nurse during the maternity hospitalization. We excluded sources with samples of high-risk women or those who gave birth to high-risk infants (preterm, congenital anomalies, neonatal abstinence syndrome). Forty-six of the sources met the inclusion criteria.Data ExtractionWe extracted citation, type of document, country of origin, context (prenatal/postpartum or both and inpatient/outpatient or both), aim, participants (mother/father or both, sample characteristics), content of education and who provided it, outcomes or key themes, and main results.Data SynthesisInfant topics included breastfeeding and safe sleep, and maternal topics included breastfeeding, postpartum mood, and self-care after birth. Nurses prioritized safety, including safe sleep; preventing infant falls; decreasing infection; screening for postpartum depression; and avoiding adverse outcomes after discharge. Women focused on self-care, pain management, infant care, and parenting. Women and nurses prioritized breastfeeding. Authors of the included sources measured effectiveness by patient satisfaction, chart audit, pre- and posttests of nurses’ knowledge, and breastfeeding duration. Women reported barriers to postpartum education such as limited nursing time or conflicting information.ConclusionPostpartum education is a priority, but its effectiveness is not well studied. Few maternal or infant health–centered outcomes have been measured beyond breastfeeding duration. Nursing care and nurse expertise are not easily quantified or measured. Research is needed to inform best practices for postpartum education.     

Maternity Care Practices: Implications for Breastfeeding

Background: Many United States mothers never breastfeed their infants or do so for very short periods. The Baby‐Friendly Hospital Initiative was developed to help make breastfeeding the norm in birthing environments, and consists of specific recommendations for maternity care practices. The objective of the current study was to assess the impact of the type and number of Baby‐Friendly practices experienced on breastfeeding. Methods: A longitudinal mail survey (1993–1994) was administered to women prenatally through 12 months postpartum. The study focused on the 1085 women with prenatal intentions to breastfeed for more than 2 months who initiated breastfeeding, using data from the prenatal and neonatal periods. Predictor variables included indicators of the absence of specific Baby‐Friendly practices (late breastfeeding initiation, introduction of supplements, no rooming‐in, not breastfeeding on demand, use of pacifiers), and number of Baby‐Friendly practices experienced. The main outcome measure was breastfeeding termination before 6 weeks. Results: Only 7 percent of mothers experienced all five Baby‐Friendly practices. The strongest risk factors for early breastfeeding termination were late breastfeeding initiation and supplementing the infant. Compared with mothers experiencing all five Baby‐Friendly practices, mothers experiencing none were approximately eight times more likely to stop breastfeeding early. Additional practices decreased the risk for early termination. Conclusion: Increased Baby‐Friendly Hospital Initiative practices improve the chances of breastfeeding beyond 6 weeks. The need to work with hospitals to increase adoption of these practices is illustrated by the small proportion of mothers who experienced all five practices measured in this study.     

Psychometric Testing of the Modified Breastfeeding Self‐Efficacy Scale (Short Form) Among Mothers of Ill or Preterm Infants

ObjectiveTo psychometrically assess the modified Breastfeeding Self‐Efficacy Scale–Short Form (BSES‐SF) among mothers of ill or preterm infants.DesignMethodological study.SettingThree neonatal intensive care units (NICUs) located in two hospitals in a central Canadian city.ParticipantsOne hundred forty‐four (144) breastfeeding mothers of ill or preterm infants.MethodsMothers completed the BSES‐SF modified for mothers of ill or preterm infants, the Hill and Humenick (H&H) Lactation Scale, and demographic questions.ResultsThe Cronbach's alpha coefficient for internal consistency for the BSES‐SF revised for mothers of ill or preterm infants was 0.88. Construct validity was assessed using comparison of contrasted groups (mothers who continued to breastfeed and those who discontinued) and correlation with the construct of maternal perceptions of insufficient milk supply. Support for predictive validity was demonstrated through significant mean differences between mothers who were breastfeeding (M = 83.44, SD = 8.23) and those who discontinued breastfeeding and breast pumping (M = 75.51, SD = 10.08) at 6‐weeks post–infant hospital discharge.ConclusionDemographic response patterns suggest that the modified BSES‐SF is a unique tool to identify breastfeeding mothers of ill or preterm infants at risk of prematurely discontinuing. This study provides evidence that the modified BSES‐SF may be a valid and reliable measure of breastfeeding self‐efficacy among a sample of mothers of ill or preterm infants.     

Effectiveness of an Obstetrics‐Based Advanced Cardiac Life Support Education Program

ObjectiveTo study the effectiveness of an obstetrics‐based advanced cardiac life support education (ACLS OB) program with pre‐ and postcourse maternal mock code drills and surveys evaluating satisfaction and self‐confidence in abilities of labor and delivery (L&D) nurses to perform ACLS algorithms.DesignQuasi‐experimental pretest/posttest study.SettingObstetric units in a community hospital system.ParticipantsLabor and delivery nurses (N = 96).MethodsNurses rotated through an ACLS OB course when their ACLS recertification was due. Two studies were done. Prior to the class, nurses participated in a maternal mock code drill during annual skills review, and performances were scored. One year later, nurses participated in maternal mock code drills. Results were compared with the previous year's scores. In the second study, pre‐ and postclass surveys were completed reflecting nurses’ satisfaction and self‐confidence with successfully completing elements of American Heart Association (AHA) algorithms following attendance at traditional ACLS classes versus ACLS OB.ResultsThe scores of nurses who completed the ACLS OB course were significantly greater overall when performing ACLS MegaCode algorithms (z = −6.08, p < .001) for 18 of 21 individual elements of the algorithm. Nurses reported statistically significant increases (p < .001) in all 13 elements of satisfaction and self‐confidence following completion of ACLS OB over traditional ACLS courses.ConclusionsEmphasizing changes in ACLS for obstetric patients during the precourse and using patient scenarios encountered in obstetric settings improved nurses’ performance in maternal MegaCode scenarios. The course also increased self‐satisfaction and self‐confidence of obstetric nurses in their ability to perform ACLS algorithms.     

Emergency Contraception Services for Adolescents: a National Survey of Children's Hospital Emergency Department Directors

Study ObjectiveTo assess emergency contraception (EC) counseling and prescribing practices of children's hospital emergency department (ED) directors and the use of EC protocols in these settings.DesignCross-sectional study of children's hospital ED directors responding to a 15-minute 44-item semi-structured survey during telephone interviews.Participants50 of 96 eligible directors of children's hospital EDs in the United States.Main Outcome MeasuresEC protocols, EC counseling processes, EC prescribing practices.ResultsMost (80%) ED directors reported always offering EC as part of sexual assault care; 66% were more likely to provide onsite EC in these situations. Only 52% identified the progestin-only regimen as the EC dispensed in their ED, and most (96%) limited provision to fewer than 120 hours after sex. Although 58% of ED directors reported ever prescribing ongoing contraception when providing EC, none had prescribed EC for future use. Written ED protocols for providing EC were more common for sexual assault care (76%) than for non-sexual assault care (14%). Directors who worked at hospitals with a sexual assault program were less likely to discuss all the recommended topics for EC counseling.ConclusionsThe recommended standard of care for providing EC to adolescents in children's hospital EDs is not being met. Although risk of pregnancy following sexual assault and consensual unprotected sex is identical, discrepant practices emerged from this survey of pediatric ED directors. Increased education and policy initiatives within children's hospital EDs are needed to standardize EC services for adolescents in this setting.     

Essential Competencies in Nursing Education for Prevention and Care Related to Unintended Pregnancy

ObjectivesTo identify the essential competencies for prevention and care related to unintended pregnancy to develop program outcomes for nursing curricula.DesignModified Delphi study.SettingNational.ParticipantsEighty‐five nurse experts, including academic faculty and advanced practice nurses providing sexual and reproductive health care in primary or specialty care settings.MethodsExpert panelists completed a three‐round Delphi study using an electronic survey.ResultsEighty‐five panelists completed the first round survey, and 72 panelists completed all three rounds. Twenty‐seven items achieved consensus of at least 75% of the experts by the third round to comprise the educational competencies.ConclusionThrough an iterative process, experts in prevention and care related to unintended pregnancy reached consensus on 27 core educational competencies for nursing education. The competencies provide a framework for curricular development in an important area of nursing education.