Factors Affecting Delivery of Evidence-Based Procedural Pain Care in Hospitalized Neonates

Objective: To examine the effects of nurse, infant, and organizational factors on delivery of collaborative and evidence-based pain care by nurses.
Design: Cross sectional.
Setting: Two Level III neonatal intensive care units in 2 large tertiary care centers in Canada.
Participants: A convenience sample of 93 nurses completed survey data on procedures they performed on ill neonates. The 93 nurses performed a total of 170 pain producing procedures on 2 different shifts.
Main Outcome: Nurse use of evidence-based protocols to manage procedure related pain using a scorecard of nurses' assessment, management, and documentation.
Results: Procedural pain care was more likely to meet evidence-based criteria when nurse participants rated nurse-physician collaboration higher (odds ratio, 1.44; 95% confidence intervals 1.05-1.98), cared for higher care intensity infants (odds ratio, 1.21; 95% confidence intervals, 1.06-1.39), and experienced unexpected increases in work assignments (odds ratio, 1.55; 95% confidence intervals, 1.04-2.30). Nurses' knowledge about the protocols, educational preparation and experience were not significant predictors of evidence-based care for the most common procedures: heel lance and intravenous initiation.
Conclusion: Nurse-physician collaboration and nurses' work assignments were more predictive of evidence-based care than infant and nurse factors. Nurses' knowledge regarding evidence-based care was not a predictor of implementation of protocols. In the final statistical modeling, collaboration with physicians, a variable amenable to intervention and further study, emerged as a strong predictor. The results highlight the complex issue of translating knowledge to practice, however, specific findings related to pain assessment and collaboration provide some direction for future practice and research initiatives.     

Breastfeeding Care in Ohio Hospitals: A Gap Between Research and Practice

Objective: To assess current breastfeeding care in Ohio hospitals and compare that care to research-based principles.
Design: Survey.
Setting: Ohio hospitals that provide maternity care.
Participants: All 141 Ohio hospitals that provide maternity care were invited to participate. One-hundred sixteen (83%) hospitals returned usable surveys completed by obstetric nurse managers.
Main Outcome Measure: A 38-item questionnaire provided data on hospital demographics and information regarding the care of breastfeeding mother-infant dyads.
Results: Research-based practices common in Ohio's hospitals include demand feeding, breastfeeding education, and breastfeeding as the initial neonatal feeding. Common non-research-based practices include supplemental fluid administration, postpartum nipple treatments, mandatory initial nursery stays, limited sucking time, restricted maternal-infant contact, distribution of formula packs, minimal follow-up care, and the suspension of breastfeeding for hyperbilirubinemia.
Conclusions: Despite positive changes in perinatal care, a number of non-research-based practices persist in Ohio hospitals for the care of the breastfeeding mother-infant dyad.     

Breastfeeding by Hispanic Women

Objective: To review the literature to describe Hispanic breastfeeding beliefs, attitudes, and practices in the United States.
Data Sources: Using the search terms "Hispanics" and "breastfeeding," both CINAHAL and MEDLINE (Ovid) databases were queried. Only research studies conducted in the United States from 1998 and 2008 were included in the review.
Study Selection: Fifty-five articles were located. Based on inclusion criteria, 38 research articles were included in this review.
Data Extraction: Each study was analyzed in relation to the purpose of the review.
Data Synthesis: Study findings were synthesized and organized into categories: acculturation status, breastfeeding intention, factors influencing initiation, breastfeeding barriers, breastfeeding support, and breastfeeding interventions.
Conclusions: Breastfeeding initiation rates are high among Hispanics living in the United States. Newly immigrated women initiate and continue to breastfeed longer than more acculturated women. Unfortunately, exclusive breastfeeding and duration rates fall well below the desired goals of Healthy People 2010 . Interventions aimed at encouraging and supporting women to maintain their cultural traditions, beliefs, and practices related to breastfeeding are needed.     

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.     

Comfort Measures in Breastfeeding, Primiparous Women

Objective: To examine various comfort measures and evaluate their effects in alleviating nipple soreness.
Design: Prospectively randomized, experimental study.
Setting: Postpartum unit of a community teaching hospital.
Patients: Seventy-three primiparous, postpartum, breastfeeding women.
Interventions: Subjects were randomly assigned to four groups, with all women receiving instruction about breastfeeding and using one of the following treatments: warm moist tea bag compress, warm water compress, expressed milk massaged into the nipple and areola and air dried, Instruction only (control group). The subjects completed a questionnaire each morning for 7 days regarding nipple soreness.
Main Outcome Measure: Effect of treatments on postpartum nipple pain.
Results: Subjects in the warm water compress group demonstrated significantly less pain on Day 3 than did the tea or breast milk group.
Conclusions: Anticipatory guidance by obstetric nurses may assist breastfeeding women in treating their pain nonpharmacologically.     

Factors Associated With Breastfeeding Up To 6 Months Postpartum in Mothers With Diabetes

Objectives: To identify breastfeeding behavior in a group of women with diabetes and to determine factors that may influence breastfeeding rates in this population.
Design: A 2-year retrospective study.
Setting: Derby City General Hospital, Derby, UK.
Participants: Ninety-four women with diabetes.
Methods: Data were collected using questionnaire and maternal clinical records.
Results: Women with gestational diabetes mellitus intended to and breastfed more than women with type 1 and type 2 diabetes at 2 weeks postpartum ( p <.05). Logistic regression showed that the type of diabetes was the most significant predictor of breastfeeding at birth ( p <.05). At 1, 2, and 6 weeks and 4 months postpartum, maternal body mass index was negatively associated with breastfeeding ( p <.05). At 6 months, socioeconomic status predicted breastfeeding ( p <.05).
Conclusion: Type of diabetes is a significant predictor of breastfeeding initiation. At later stages of postpartum, maternal body mass index and socioeconomic status were significant predictors of infant feeding method. Identification of these factors can help in developing appropriate and timely interventions to more effectively promote breastfeeding.     

Excessive Weight Loss in Breastfed Infants During the Postpartum Hospitalization

Objective: To examine differences in breastfeeding frequency, voids, and stools in infants with weight losses < or ≥7% during the postpartum hospitalization.
Design: Secondary analysis of data from a primary psychometric study examining the Mother Infant Breastfeeding Progress Tool (MIBPT).
Setting: A midwestern community hospital in a multicultural racially diverse community.
Participants: Convenience sample of 53 breastfeeding women and infants hospitalized after birth.
Methods: Data were collected during a chart review; infants were divided into < or ≥7% weight loss groups at 2 days postpartum, and breastfeeding frequency, voiding, and stooling were examined between groups and used to predict a ≥7% weight loss at 2 days postpartum.
Results: Of the 53 infants, 20.8% lost ≥7% of their birth weight. Infants who lost ≥7% of their birth weight had significantly more total voids and a higher breastfeeding frequency on the day of birth than infants who lost <7% of their birth weight. A logistic regression analysis resulted in total voids being the only significant predictor of a ≥7% weight loss, with an odds ratio of 1.74 (95% CI=1.09, 2.75, p <; .05).
Conclusion: In the absence of other indicators of ineffective breastfeeding, breastfeeding infants who lose ≥7% of their birth weight during the first 2 days postpartum might be experiencing a physiologic diuresis after birth, unrelated to their breastfeeding behaviors. More research is necessary to determine the cause of a ≥7% weight loss in newborns during the first 48 hours after birth.     

Modified Delphi Study on Nursing Practice and Science in Fetal Care

ObjectiveTo identify essential structures, processes, outcomes, and challenges of nursing practice in fetal care and to identify research priorities for nurses in fetal care.DesignWe used a modified Delphi method to achieve consensus.SettingA secure online survey platform.ParticipantsThe expert panel included nurses from the Fetal Therapy Nurse Network. In addition, a multidisciplinary research jury included members of the North American Fetal Therapy Network (NAFTNet).MethodsWe collected data in three consecutive rounds with online questionnaires that were e-mailed to panelists. We used content analysis to generate statements from an initial round of open-ended questions. Statements met consensus if 75% of the panelists ranked it as greater than or equal to 6 on a 1-to-7 Likert scale.ResultsThe 48 nurse panelists and 11 multidisciplinary jury members described a range of nursing processes. Consensus was reached on 96 statements related to the structure, processes, outcomes, and research priorities of nurses in fetal care.ConclusionThe participants agreed that an expert fetal care nursing team is necessary to provide care to women and families during fetal diagnosis and treatment. Ideally, these nurses should coordinate care and provide direct clinical care (e.g., patient counseling) in outpatient prenatal settings and inpatient settings when fetal surgery is involved. Nurses should be supported to take on leadership roles in program development, research, quality improvement, and professional development with relevant professional organizations.     

Adolescent Mothers' Breastfeeding Social Support Needs

Objective:To define aspects of social support that adolescents need from nurses when initiating breastfeeding in the early postpartum.Data Sources:MEDLINE and CINAHL databases for years 2000 to 2009.Data Extraction:Three searches were done using the following subject terms:adolescent mothers and breastfeeding (12 studies),adolescent mothers and breastfeeding and support (24 studies), andbreastfeeding and adolescent mothers and attitudes (15 studies). The 18 studies that were chosen for this synthesized review illuminated the dimensions of social support identified by House.Data Synthesis:The four types of supportive behavior categories identified by House were described in these studies (informational, instrumental, emotional, and appraisal). Esteem support as defined by Sarafino seemed to be synonymous with appraisal support. Many studies identified the importance of network support as a fifth category of supportive behavior in increased breastfeeding duration among adolescents; network support was included in this synthesis. These five types of social support provide a framework for defining supportive nurse behaviors.Conclusions:Nurses in the early postpartum can promote the long‐term health of adolescents and their children through the social support they offer adolescent mothers as they initiate breastfeeding. Network support appears to be essential to adolescents' breastfeeding experiences and needs to be included with informational, instrumental, emotional, and esteem/appraisal support when investigating support for this population. By integrating the five dimensions of social support into their care, nurses play an essential role in providing adolescents with the positive experiences that are so important to establishing breastfeeding.     

Interpretation of Biophysical Profiles by Nurses and Physicians

Objective: To determine the agreement between nurse and physician interpretation of biophysical profile scores.
Design: A prospective evaluation of videotaped biophysical profiles was independently scored by four nurse and four physician interpreters and compared to that of an expert physician.
Setting: The fetal assessment center of a large tertiary-care center; study included women from public and private practices.
Patients: Twenty-three women with high-risk pregnancies who were regularly scheduled for a biophysical profile. Women pregnant with multiple fetuses or whose fetuses were less than 28 weeks' gestational age or had severe fetal anomalies were excluded.
Main Outcome Measure: The proportion of agreement between the physicians and nurses and the physician expert was calculated for each biophysical profile criterion.
Results: The kappa statistic was used to evaluate the proportion of agreement with the "gold standard." When compared with the expert, physicians showed 60% moderate or substantial agreement, and the nurses showed 80% moderate or substantial agreement.
Conclusions: Nurses' interpretations of biophysical profiles were at least as reliable as physicians' when compared with an expert reviewer.     

Lifestyle Factors Related to Postpartum Weight Gain and Body Image in Bottle- and Breastfeeding Women

Objective: To explore the relationship of lifestyle variables to postpartum weight gain and body image attitudes of bottle- and breastfeeding women.
Design: Mail survey of new mothers at approximately 4 months postpartum.
Setting: Southwestern community.
Participants: One hundred one bottle-feeding women (69% white, 20% Hispanic, 11 % other) and 106 breastfeeding women [76% white, 19% Hispanic, 5% other) without diabetes. Bottle- and breastfeeding women did not differ on gestational weight gain or weight gain sustained postpartum.
Main outcome Measures: Postpartum weight gain (relative to prepregnancy weight) and body image attitudes.
Results: Feeding method (breast or bottle) was not associated with postpartum weight gain in the sample as a whole. Bottle-feeding mothers with higher postpartum gains exercised less, had higher fat intake habits, and were more dissatisfied with body image than mothers with lower gains. Breastfeeding mothers with higher and lower gains did not differ on any lifestyle factors. Overall lifestyle and psychologic skill in managing emotions were related negatively to postpartum body image dissatisfaction in both groups of women.
Conclusions: Breastfeeding women did not differ from bottle-feeding women in sustained postpartum weight gain. In bottle-feeding women, lifestyle factors were associated with levels of weight gain. Lifestyle-focused programs for weight management would potentially benefit these women.     

Variables Associated With Breastfeeding Duration

Objective: To identify the variables associated with breastfeeding duration.
Data Sources: The health science reference databases of CINAHL, PubMed, and the Cochrane Database of Systematic Reviews.
Study Selection: Meta-analyses, Cochrane reviews, literature reviews, and quantitative and qualitative studies published in English from 1998 through 2008.
Data Extraction: Data included all variables, both positive and negative, that were found to influence the outcome of breastfeeding duration.
Data Synthesis: Demographic factors that influence breastfeeding duration are race, age, marital status, education, socioeconomics, and Special Supplemental Nutrition Program for Women, Infants, and Children status. Biological variables consisted of insufficient milk supply, infant health problems, maternal obesity, and the physical challenges of breastfeeding, maternal smoking, parity, and method of delivery. Social variables included paid work, family support, and professional support. Maternal intention, interest, and confidence in breastfeeding were psychological variables.
Conclusion: Human lactation is a complex phenomena and the duration of breastfeeding is influenced by many demographic, physical, social, and psychological variables.     

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.     

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.     

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.