Improving breastfeeding education among hospital nurses

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Graduate Dissertations and Theses Dissertations, Theses and Capstones

2018

Improving breastfeeding education among hospital nurses Improving breastfeeding education among hospital nurses

Kara R. Connelly

Binghamton University--SUNY

, [email protected]

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Improving Breastfeeding Education Among Hospital Nurses

KARA RAE CONNELLY FNP-C

BSN, Binghamton University, 2009

MSN in Family Health, Binghamton University, 2013

DNP CAPSTONE

Submitted in partial fulfillment of the requirements for

the degree of Doctor of Nursing Practice

in the Graduate School of

Binghamton University

State University of New York

2018

iii

Accepted in partial fulfillment of the requirements for

the degree of Doctor of Nursing Practice

in the Graduate School of

Binghamton University

State University of New York

2018

April 30, 2018

Nicole Rouhana, Chair

Department of Nursing, Binghamton University

Kathleen Fitzgerald, Member

Department of Nursing, Binghamton University

Susan Terwilliger, Member

Department of Nursing, Binghamton University

Abstract

Breastfeeding is well-documented as the most beneficial method of infant feeding

worldwide. There are numerous national initiatives present to improve breastfeeding

outcomes. Despite knowledge and health care organization efforts, the recommendations

of exclusive breastfeeding through six months of life with continued breastfeeding

through one year of age are not being met. The purpose of this DNP project is to

determine if a structured self-study educational program on breastfeeding

recommendations, the 4

Edition of the Lactation Management Self-Study Modules

created by Wellstart International™, provided to hospital nurses on a maternity unit in

Central, New York with a Level One nursery, will improve nursing knowledge of

appropriate breastfeeding practices, decrease variations in breastfeeding education

provided to patients, and improve breastfeeding outcomes for the facility. The research

study used a quasi-experimental design to determine how an educational program

provided to hospital nurses impacts both their knowledge of breastfeeding as well as the

breastfeeding outcomes for the hospital. This DNP project, along with the growing body

of literature, supports the need for continued provision of education related to

breastfeeding among nurses in direct care of breastfeeding mothers, and expresses a need

for further research on this topic to optimize breastfeeding outcomes worldwide.

This DNP capstone project is dedicated to my husband Richard who provided his love,

support and guidance throughout this journey. It is additionally dedicated to my son

Joseph and dog Gracie who also provided their love and support.

Acknowledgements

Thank you to Dr. Rouhana for guiding me throughout this journey as my

Committee Chair. Thank you additionally to Dr. Fitzgerald and Dr. Terwilliger for your

time and commitment to this DNP project.

vii

Table of Contents

Page

Chapter 1: Problem Statement 1

Introduction 1

Background 3

Significance 7

Problem Statement 14

Purpose Statement 14

Theoretical Framework 15

Chapter 2: Review of Literature 19

Introduction 19

Inclusion Criteria 19

Impact of Nursing Knowledge and Practice 20

Educational Program Design 22

Impact of Educational Program on Breastfeeding

Knowledge

Impact of Education on Breastfeeding Outcomes 25

Summary 27

Chapter 3: Plan for Resolution 29

Methods 29

viii

Target Population 33

Setting 33

Budget 34

Chapter 4: Outcome / Evaluation 35

Purpose 35

PICOT Question 35

Data Collection 35

Statistical Analysis 37

Summary of Findings 40

Chapter 5: Summary 42

Introduction 42

Summary of Findings 43

Implications for Practice 44

Limitations 46

Recommendations for Research 46

Conclusion 47

Appendix A 50

Appendix B 60

Appendix C 61

References 62

Improving Breastfeeding Education Among Hospital Nurses

Chapter 1: Problem Statement

Introduction

Breastfeeding is widely supported as the optimal form of nutrition among infants.

There is significant documentation of the countless health benefits of exclusively

breastfeeding infants during the first six months of life and the continued presence of

breastfeeding throughout the first year of life (American Academy of Pediatrics [AAP],

2012; Centers for Disease Control and Prevention [CDC], 2013; DiGirolamo, Grummer-

Strawn, & Fein, 2008; Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward, 2011;

World Health Organization [WHO], 2013). Despite these recommendations there is a

significant deficit in breastfeeding practices among American mothers. According to

breastfeeding statistics, an estimated 75% of women initiate exclusive breastfeeding

practices at the birth of the infant, yet this percentage drastically decreases to 15% by the

time infants reach six months of age (Centers for Disease Control and Prevention [CDC],

2011). The Surgeon General’s Call to Action to Support Breastfeeding (2011) discusses

the importance of the role of the health care worker as related to improving breastfeeding

outcomes. The document emphasizes the importance of improving practices of

postpartum nurses to ensure the receipt of consistent, evidence-based maternity care to

improve breastfeeding among patients.

There are numerous national initiatives, including the Baby Friendly Hospital

Initiative (BFHI) and Healthy People 2020, aimed at improving breastfeeding practices

among American mothers (Healthy People 2020, 2013; WHO, 2013). Recommendations

of these initiatives include the provision of breastfeeding education and training to

nursing staff directly working with breastfeeding women and infants. Although this

suggested method of improving breastfeeding practices is well-documented, the majority

of hospitals remain without a baby-friendly hospital designation. This has resulted in a

wide variation of breastfeeding knowledge among hospital nurses who are essential to

promoting successful breastfeeding. This disparity is largely due to the lack time,

resources and finances required to provide the appropriate education and policy changes

required to meet baby friendly standards.

There has been extensive research performed that focuses on evaluating the

breastfeeding knowledge of hospital staff of various disciplines (Crowder, 2006;

DiGirolamo, Grummer-Strawn, & Fein, 2008; Owoaje, Oyamade, & Kolude, 2002;

Patton, Beaman, Csar, & Lewinski, 1996; Wallace, Kosmala-Anderson, 2007). This

research has widely yielded results displaying the variance in level of knowledge of

breastfeeding among health care workers in direct contact with breastfeeding couplets.

Much of this research reveals a lack of knowledge regarding appropriate breastfeeding

practices, as well as a lack of consistency in education provided to patients, among these

staff members. Despite a lack of standardized breastfeeding education there has been

limited research performed on developing effective educational programs for hospital

nursing staff and their resultant efficacy. This lack of training has the potential to

negatively influence long term breastfeeding rates among mothers in the United States.

Background

Breastfeeding is well-documented as the most beneficial method of infant feeding

worldwide. The literature widely supports the positive effects of breastfeeding on an

infant’s neurological development, as well as a significant preventative measure in

protecting the health of an infant (American Academy of Pediatrics [AAP], 2012; Centers

for Disease Control and Prevention [CDC], 2013; DiGirolamo, Grummer-Strawn, &

Fein, 2008; Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward, 2011; World

Health Organization [WHO], 2013). According to the World Health Organization

(WHO) (World Health Organization [WHO], 2013), “If every child was breastfed within

an hour of birth, given only breast milk for their first six months of life, and continued

breastfeeding up to the age of two years, about 220,000 child lives would be saved every

year (WHO, 2013, para. 2).” Current guidelines from the American Academy of

Pediatrics (AAP) (American Academy of Pediatrics [AAP], 2012) recommend exclusive

breastfeeding of an infant until six months of life, with introduction of complementary

feedings and continued breastfeeding until at least one year of age.

According to the Centers for Disease Control and Prevention (CDC) (Centers for

Disease Control and Prevention [CDC], 2011), in the United States (US) approximately

75% of infants are exclusively breastfed at birth; however current statistics show that by

six months of age this national average drastically decreases to 15%. At the state level

approximately 80.5% of new mothers initiate breastfeeding in New York State. This

statistic represents any infant who has ever been breastfed in any capacity in 2013 (CDC,

2016). This figure drops to 55.8% and 31.3% for those continuing to breastfeed at six

months and 12 months respectively (CDC, 2016). Statistics for infants who are

exclusively breastfed account for 37.1% a three months of age and 16.9% at six months

of age. Within Broome County, NY, the population of focus for this DNP project, 79.3%

of mothers initiate any form of breastfeeding during the hospital stay in 2014. This

statistic decreased to 69.5% by the time of hospital discharge (Mothers and Babies,

2017).

The policy statement entitled Breastfeeding and the Use of Human Milk

published by the AAP (2012) provides evidence of the decreased incidence of common

infections and diseases of infancy and childhood, in newborns who are exclusively

breastfed. These common infections include, but are not limited to, otitis media, celiac

disease, gastrointestinal infections, Sudden Infant Death Syndrome (SIDS), and obesity.

In addition, there are improved neurodevelopmental outcomes related to exclusive

breastfeeding, resulting in higher intelligence scores among those infants breastfed longer

than three months. This study provides evidence regarding the unique health benefits

observed when an infant is exclusively breastfed during the first six months of life (AAP,

2012).

Current research supports breastfeeding guidelines, as discussed by both the CDC

(2013) and AAP (2012); however national statistics suggest that these feeding goals are

not met by the vast majority. Although there are high levels of breastfeeding initiation,

there is a significant decrease in exclusive breastfeeding by six months of age (AAP,

2012, CDC, 2013, WHO, 2013). Due to this deficit, and the knowledge of breastfeeding

benefits, there are numerous national initiatives aimed at improving breastfeeding

outcomes. Healthy People 2020 (2013) is one national initiative which has focused on

improving breastfeeding rates. Among the Healthy People 2020 goals for infant care are

numerous objectives which directly refer to infant feeding practices. These objectives are

as follows:

• Increase the proportion of infants who are ever breastfed

• Increase the proportion of infants who are breastfed at six months

• Increase the proportion of infants who are breastfed at one year

• Increase the proportion of infants who are breastfed exclusively through

three months

• Increase the proportion of infants who are breastfed exclusively through

six months

Although national goals are in place, programs are needed to help meet these proposed

objectives.

The literature widely supports the provision of educational programs to hospital

staff as a method of improving this disparity in breastfeeding statistics (AAP, 2012;

CDC, 2013; DiGirolamo, Grummer-Strawn, & Fein, 2008; Healthy People 2020, 2013;

Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward, 2011; WHO, 2013). Experts

recommend formal breastfeeding training for any healthcare worker in the direct care of

breastfeeding patients (AAP, 2012; CDC, 2013; WHO, 2013). Despite this knowledge,

development of educational programs for healthcare workers is not widely applied at the

hospital level. Creating a formal breastfeeding education program may help promote

recommended infant feeding practices among new mothers.

One structured program currently in existence is the 4

Edition of the Lactation

Management Self-Study Modules: Level One, created by Wellstart International™.

Wellstart International™ as an organization has had a strong focus on lactation

management education since 1983. Their initial Lactation Management Education

Program, which took place from 1983-1998 demonstrated positive outcomes related to

breastfeeding practices and policies among attendees. This initial program was four

weeks long and included a combination of educational components and policy

development. Long term outcomes of the program included increased breastfeeding

knowledge and skills for breastfeeding support, increased organization of breastfeeding

conferences and workshops and increased improvement of breastfeeding policies among

others. (Wellstart International™, n.d.)

The Lactation Management Self-Study Module: Level One is a program

developed by Wellstart International™ that provides appropriate education pertaining to

breastfeeding and is specifically created for those health care workers caring for breast

feeding mothers and infants. The self-study module, now in the 4

edition incorporates

education related to breastfeeding benefits, how to counsel breastfeeding mothers,

optimal infant feeding, as well as breastfeeding practices and identification of common

barriers. This program provides a standardized, comprehensive curriculum for basic

breastfeeding practices. This self-study design of the program additionally allows

participants to complete the educational tasks at their own pace in any setting they

choose. This model increases accessibility and ease of completion for all individuals.

The pre-test and post-test design additionally allows program participants to track

knowledge gained throughout the course. (Wellstart International™, 2013)

The 4

Edition of the Lactation Management Self-Study Modules: Level One by

Wellstart International™ is to be implemented among hospital nursing staff in order to

determine their impact on breastfeeding outcomes, with an ultimate goal of improving

infant health outcomes. The intent of this DNP project is to bridge the gap between the

vast knowledge of breastfeeding benefits and the implementation of an appropriate

educational program within a hospital in Central, NY with a Level One nursery. The

goal is to improve breastfeeding knowledge and provision of patient education among

hospital nurses to ultimately help meet national health objectives provided by Healthy

People 2020, thereby positively influencing long term breastfeeding success.

Significance

It is well documented in the literature that women who receive appropriate

support while breastfeeding have improved outcomes in exclusive breastfeeding during

the first six months of life (AAP, 2013; CDC, 2011; CDC, 2013; WHO, 2013). Based on

this knowledge, Healthy People 2020 (2013) list numerous national health objectives

aimed at increasing exclusive breastfeeding rates among newborn infants, as stated

above. The CDC (2013) identifies the importance of the intra-partum hospital course in

initiating breastfeeding successfully. Appropriate support and education from hospital

providers and nursing staff throughout the hospital course greatly impacts the

breastfeeding success of mother and infant. At this time, approximately one in three

mothers will discontinue breastfeeding without appropriate support in the hospital setting

(CDC, 2011).

This DNP project aims to assist in meeting national health objectives through

evaluating and improving knowledge of hospital nursing staff on breastfeeding, with the

implementation of an educational program for hospital nurses. The educational program

chosen for implementation in this DNP project is the 4

Edition of the Lactation

Management Self-Study Modules: Level One by Wellstart International™. Although

there is a growing body of literature supporting the education of hospital staff as a means

of improving breastfeeding outcomes, no specific educational program has been

identified as begin the most effective, indicating the need for future research on this topic.

Ward and Byrne (2011) performed a systematic review of 15 previously

implemented educational programs for healthcare workers. The results of this study

identified that programs which required a minimum of 18 hours of education had the

greatest impact on breastfeeding outcomes for the facility. The authors however state

that of the educational programs that were shorter than 18 hours in length, only one of

those studies evaluated breastfeeding outcomes. The authors discuss that a positive

impact of shorter breastfeeding programs cannot be ruled out based on the study. In

addition, the results also noted that any form of continuing breastfeeding education was

beneficial to staff members. It is important to note however that while this study

analyzed previously implemented programs, the researchers did not implement their own

program based on information learned from their analysis. The literature overwhelmingly

supports breastfeeding as the ideal method of infant nutrition (AAP, 2012; CDC, 2013;

DiGirolamo, Grummer-Strawn, & Fein, 2008; Semenic, Childerhose, Lauziere, &

Groleau, 2012; Ward, 2011; WHO, 2013). At this time further evaluation of programs

intending to improve breastfeeding outcomes is still needed to help increase national

statistics of infants receiving the recommended methods of feeding over the first year of

life. The objective of this DNP project is to add to the body of knowledge regarding

lactation education, with an ultimate goal of improving both nurses’ knowledge regarding

breastfeeding and breastfeeding outcomes. The study will employ the use of the 4

Edition of the Lactation Management Self-Study Modules created by Wellstart

International™ in a hospital in Central New York State with a Level One nursery. The

project will evaluate the effectiveness of a breastfeeding educational program by

measuring breastfeeding knowledge among participating nurses and breastfeeding

outcomes of the postpartum mothers they care for.

On the forefront of national breastfeeding initiatives is the Baby Friendly Hospital

Initiative (BFHI) proposed by WHO and the United National Children’s Fund (UNICEF).

The Baby Friendly Hospital Initiative is a worldwide initiative officially launched by the

WHO and UNICEF in 1991 in order to improve, promote and support breastfeeding

practices. The 10 Steps to Successful Breastfeeding was first published by the WHO and

UNICEF as a portion of the Baby Friendly Hospital Initiative in 1989 (WHO/UNICEF,

1999). This document entitled Protecting, Promoting and Supporting Breastfeeding: The

Special Role of Maternity services, outlines the 10 essential steps each hospital must

incorporate in order to appropriately support breastfeeding during the intra-partum

hospital stay. In The 10 Steps to Successful Breastfeeding WHO and UNICEF (1989)

state the following:

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to all

health care staff.

2. Train all health care staff in skills necessary to implement this policy.

3. Inform all pregnant women about the benefits and management of

breastfeeding.

4. Help mothers initiate breastfeeding within half an hour of birth.

5. Show mothers how to breastfeed, and how to maintain lactation even if

they should be separated from their infants.

6. Give newborn infants no food or drink other than breast milk, unless

medically indicated.

7. Practice rooming-in - that is, allow mothers and infants to remain together

- 24 hours a day.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to

breastfeeding infants.

10. Foster the establishment of breastfeeding support groups and refer mothers

to them on discharge from the hospital or clinic.

Of these 10 steps, the first two recommend creating a hospital breastfeeding

policy and training all healthcare workers with the necessary skills for successful

implementation (WHO, 2013). These first two steps indicate the importance of

standardized breastfeeding policy and education. In the US this initiative is implemented

by the accrediting body Baby-Friendly USA, Inc. (BFUSA) (Baby-Friendly USA

[BFUSA], 2012). The BFHI recognizes hospitals who have successfully implemented

both the 10 Steps to Successful Breastfeeding as well as the International Code of

Marketing of Breast-milk Substitutes and provides them the designation of a baby

friendly hospital. The International Code of Marketing of Breast-milk Substitutes (WHO,

1981) is a document delineating the appropriate use of breast-milk substitutes and further

discusses appropriate marketing and distribution of these substitutes. Currently adoption

of the 10 Steps to Successful Breastfeeding is the choice of each individual hospital.

There are financial incentives at both the state and federal levels for demonstrating

increased numbers of infants who are breastfed at birth; however the incentive simply

mandates that each hospital have a documented breastfeeding policy in place and does

not dictate the method institutions use to support increasing their breastfeeding rates.

The hospital chosen for participation of this DNP project is currently on their

journey towards earning Baby-Friendly designation. This hospital is located in Central

New York State and performs approximately 1200 births per year. Provision of the

educational program dually benefits the participating hospital by assisting them in

meeting the Baby-Friendly requirement of staff training and education. The hospital

currently employs the use of Baby-Friendly practices and has a Level One nursery.

In a study performed by DiGirolamo, Grummer-Strawn, and Fein (2008), a strong

link was discovered between mothers who were exposed to baby-friendly practices

during their hospital stay, and the length of time they exclusively breastfed their infant. In

this study, of the women included, approximately eight percent received all of the

recommended baby friendly practices. Additionally, those who had the advantage of

being exposed to the recommended baby-friendly breastfeeding practices were 13 times

more likely to continue breastfeeding past the first six weeks of life (DiGirolamo,

Grummer-Strawn & Fein, 2008). The CDC (2013) additionally discusses implementing

educational programs for health care workers as an effective measure of supporting

breastfeeding women, and improving outcomes for the maternal-infant dyad. Ward and

Byrne (2011) identified improved knowledge and patient education practices among

nurses and health care providers who have received structured education on the topic.

Although education of hospital staff demonstrates positive impacts on

breastfeeding outcomes, there are still only five percent of infants born in “Baby-

Friendly” designated hospitals (CDC, 2011). Semenic and colleagues (2012) identified

barriers to implementing the Baby-Friendly Hospital Initiative, with a primary factor of

insufficient training of health care workers as one of the obstacles. A document published

by Baby-Friendly USA in 2004 entitled Overcoming Barriers to Implementing the 10

Steps to Successful Breastfeeding discusses multiple barriers hospitals face when

attempting to implement breastfeeding training among their staff (Baby-Friendly USA,

2004). These barriers include lack of time, lack of an expert trainer, lack of monetary

resources, and high turn-over in staff members. This document suggests numerous

solutions to overcome these barriers, including: assessing prior knowledge of

breastfeeding, incorporating training at staff meetings, self-study modules and web-based

training in order to meet the recommended 18 hours of breastfeeding education. The 4

Edition of the Lactation Management Self-Study Modules created by Wellstart

International™ chosen for this DNP project addresses many of the aforementioned

barriers hospitals face when providing staff education.

Although the current WHO breastfeeding course for healthcare workers is 18

hours in length, this amount of time is not feasible for many facilities due to many of the

above mentioned reasons. Additional barriers present for the local hospital utilized in

this DNP project include staffing issues related to an insufficient number of nurses. These

barriers have impacted the successful implementation of the 10 Steps to Successful

Breastfeeding in many hospitals. Although the research supports that educating nurses

about breastfeeding in any capacity is beneficial, as noted by Ward and Byrne (2011),

further research is needed on educational programs which are shorter in length, as well as

self-study programs which can be performed individually by employees. These programs

are less burdensome for facilities due to the amount of time they take to implement, the

flexible nature of implementation, as well as economic feasibility. The literature

overwhelmingly supports that increased implementation of formal educational programs

for nursing staff is needed to improve support of the maternal-infant dyad during the

intra-partum hospital stay and assist in meeting the national health objectives discussed in

Healthy People 2020 (AAP, 2012; CDC, 2013; DiGirolamo, Grummer-Strawn, & Fein,

2008; Healthy People 2020, 2013; Semenic, Childerhose, Lauziere, & Groleau, 2012;

Ward, 2011; WHO, 2013). Despite this knowledge, hospitals are not abiding by these

recommendations due to multiple previously identified barriers. At this time there has

been comparatively less research performed on the impact of educational programs,

which employ a self-study model, on both the breastfeeding knowledge of hospital nurses

as well as the breastfeeding outcomes for the facility. The chosen educational program

for this study meets the self-study criteria and program length is less than 18 hours.

Implementation of this program will aid in bridging the gap of knowledge related to

efficacy of these types of educational interventions.

Many studies have discussed a need for further education of hospital staff;

however, more knowledge is needed regarding the most effective educational program

for improved outcomes (AAP, 2012; CDC, 2013; DiGirolamo, Grummer-Strawn, & Fein,

2008; Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward, 2011; WHO, 2013).

Specifically, literary resources support the development of a formal educational program

to be uniformly implemented among nursing staff to improve outcomes and streamline

patient education among hospitals (AAP, 2012; CDC, 2013; DiGirolamo, Grummer-

Strawn, & Fein, 2008; Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward, 2011;

WHO, 2013). There continues to be a growing body of literature dedicated to improving

breastfeeding outcomes, but at this time there continue to be gaps in knowledge regarding

efficient methods of educating hospital nursing staff.

Problem Statement

Current research on breastfeeding evaluates the improvement in breastfeeding

knowledge among nurses who have received some form of breastfeeding education.

Despite this knowledge, the research does not focus on the type of educational program

that is most effective at improving knowledge of nurses and breastfeeding outcomes (Li,

Li, Ashley, Smiley, Cohen, & Dee, 2013; Owoaje, Oyemade, & Kolude, 2002; Ward, &

Byrne, 2011). Furthermore, a frequent barrier hospitals face when attempting to

implement the 10 Steps to Successful Breastfeeding is lack of time and resources for the

implementation of the WHO recommended 18 hour educational program. Further

research is needed to determine an effective educational program for nursing staff, which

employs the use of a self-study model, in order to streamline the education provided to

patients and improve national breastfeeding outcomes.

Purpose statement

The purpose of this DNP project is to determine if a structured self-study

educational program on breastfeeding recommendations, the 4

Edition of the Lactation

Management Self-Study Modules created by Wellstart International™, provided to

hospital nurses on a maternity unit in Central, New York with a Level One nursery, will

improve nursing knowledge of appropriate breastfeeding practices, decrease variations in

breastfeeding education provided to patients, and improve breastfeeding outcomes for the

facility.

Theoretical Framework

This study aimed to implement an educational innovation, guided by the use of

the Diffusion of Innovations theory, as discussed by Rogers (2005). The process

involved adoption, implementation, and ideally maintenance of the innovation over time.

The model of the study involved a pre-test and post-test design to evaluate knowledge

before and after the intervention, in an effort to demonstrate program effectiveness. The

educational program entailed nurses completing the 4th Edition of Wellstart

International™ Lactation Management Self-Study Modules, Level One. The Diffusion

of Innovations Theory guided implementation and assessment strategies to achieve

optimal results.

The Diffusion of Innovations is a theoretical model originally published by

Everett Rogers in 1962 (Rogers, 1962). In his book, Diffusion of Innovations, Rogers

(2005) discusses innovation, communication channels, time, and social system as the four

main elements that directly impact any new idea. Diffusion itself is a process which

involves communication of the innovation. The innovation is then introduced to the

social system over a period of time. Rogers (2005) discusses the five stages of diffusion

as knowledge, persuasion, decision, implementation, and confirmation. Knowledge

involves the process of the individual acquiring initial knowledge of the innovation. The

concept persuasion refers to the acquisition of further knowledge of the innovation. The

decision process involves the individual determining whether or not to implement the

innovation. Implementation refers to the individual actively applying the innovation.

The final stage of confirmation involves the individual determining the benefits of the

innovation and deciding to continue its application.

The innovation for this particular study involved introduction of a structured

educational program among the nursing staff on a perinatal unit in Central New York

State. For this study, the communication occurred through offering participation in the

study to all nurses working on the hospital unit. Nurses were asked to complete The 4th

Edition Lactation Management Self-Study Modules, Level One by Wellstart

International™.

The self-study module employs the use of a pre-test and posttest design.

Nurses were directed to www.wellstart.org and asked to complete the Lactation

Management Self-Study Modules. The course required nurses to complete the pre-test,

followed by three modules, followed by the completion of the post-test. Nurses then

signed into the website and complete the final exam online. Nurses who received a score

of 80% or higher were be eligible for a certificate of completion for the course.

An additional impact of the educational program will be evaluated through the use

of a telephone interview survey of mothers at six weeks postpartum. Mothers were

interviewed in three waves, with one interview group completed prior to implementation

and two interview groups completed after the implementation of the 4th Edition Lactation

Management Self-Study Modules, Level One by Wellstart International™. Interviews

were conducted by the primary researcher, Kara Connelly FNP-C. The two post

implementation groups were interviewed exactly six weeks after implementation and then

a second group 10 weeks after implementation. From implementation to evaluation the

time frame of the study occurred over a three month period.

Rogers (2005) additionally discusses five categories of individuals who

are involved in adopting the intervention. These five categories include innovators, early

adopters, early majority, late majority and laggards. These individuals range from those

who are actively contributing towards diffusion and those who are protesting.

Description of the five categories of individuals predicted possible obstacles or

opposition to the proposed educational program. Through the application of the Diffusion

of Innovations framework nurses included in the study were classified within these five

categories. Nurses were categorized initially when the educational program was

implemented, through the use of self-report. The theoretical framework guided the

assessment of nurses to determine willingness to make changes and potential impact on

influencing breastfeeding rates.

Finally, Rogers (2005) discusses five factors which impact how the individual

perceives the intervention. These factors include relative advantage, compatibility,

complexity / simplicity, ability to trial, and ability to observe. The factors relate to an

innovation’s benefits to the individual, how well it conforms to their needs, ease of

implementation, ease of experimentation, and how visible it is to the majority. These

concepts guided the development of the educational program to improve efficacy. Each

of these factors directly impacts the success of diffusion. The local hospital participating

in the DNP Project faced numerous barriers related to staffing and time. The largest

barrier to increasing breastfeeding among this population was time. Nurses required an

educational program that could be done in the home setting and did not require further

hours in the hospital. The proposed study provided comprehensive, structured education

regarding updated breastfeeding practice. Educational concepts provided through the

program are directly applicable to daily patient care. The overall design allowed for

simple execution, and benefits of the program were evaluated by nurses participating.

The study design was guided by the theoretical framework in order to optimize program

success and adoption by nursing staff.

For the purposes of this study the theoretical framework has provided detailed

methods of categorizing participants in order to determine potential obstacles and

measure program success. The various concepts discussed by Rogers aided in analyzing

data, and provided insight for best practices when diffusing an innovation in order to

obtain optimal results. Most significantly, the theoretical framework provided a

structured method of categorizing nurses in order to determine their willingness to

implement the program. Additionally the use of the Diffusion of Innovations Model

(Rogers, 2005), has guided program design to meet the needs of the participating

hospital, in order to meet the goal of improving breastfeeding outcomes.

Chapter 2: Review of Literature

Introduction

Currently there is a growing body of literature dedicated to improving

breastfeeding outcomes. It is well documented that improving healthcare workers’

knowledge of evidence-based breastfeeding recommendations has a positive impact on

breastfeeding outcomes. Given the national goal of increasing compliance with

breastfeeding recommendations, as well as current recommendations of the 10 steps to

successful breastfeeding, there is increased focus on improving breastfeeding education

for healthcare workers in direct care of breastfeeding mothers.

Inclusion Criteria

For this review of literature a total of 26 studies were selected. Search engines

used included MEDLINE, CINAHL, and Google Scholar. Search terms of breastfeeding,

education, and nurse were used to find articles. With a total initial yield of over 3,000

articles between the three search engines, articles were further excluded based on their

relevance, publishing date, availability in English, and availability in an online format.

Articles were peer-reviewed and chosen based on publication date within the past 15

years, with the exception of one study performed in 1996. Articles included in this DNP

project were both intervention and non-intervention studies. The final articles were

chosen based on their topics related to: the impact of educational breastfeeding programs

on the knowledge of the healthcare workers; need for further education related to

breastfeeding; and the impact of the intra-partum hospital stay on breastfeeding

outcomes.

Impact of Nursing Knowledge and Practices

Of the articles reviewed there is a common discussion of the impact of nursing

practices on successful initiation of breastfeeding (Cross-Barnet, Augustyn, Gross,

Resnik, & Paige; 2012; DiGirolamo, & Grummer-Strawn, 2008; Ellis & Hewat, 1983;

Patton, Beaman, Csar, & Lewinski, 1996). These studies suggest a direct correlation

between the implementation of recommended breastfeeding practices and overall success

in breastfeeding initiation. DiGirolamo & Grummer-Strawn (2006) discussed improved

breastfeeding outcomes with the implementation of baby-friendly practices. Despite this

knowledge, only 8.1% of mothers included in the study received all of the recommended

baby-friendly practices. Patton, Beaman, Csar, & Lewinski (1996) identified a positive

correlation between nurses’ education and knowledge of breastfeeding as well as their

attitude towards the practice. These articles determine a need for improvement in

breastfeeding knowledge among healthcare workers and discuss the impact that the intra-

partum hospital stay has on breastfeeding outcomes and successful initiation.

An additional five of the selected articles performed research evaluating the

current knowledge and amount of education provided to healthcare workers in order to

determine a need for further education (Brodribb, 2012; Osband, Altman, Patrick, &

Edwards, 2011; Smale, Renfrew, Marshall, & Spilby, 2006; Wallace, 2007; Weddig,

Bakers, & Auld, 2011). The majority of these articles additionally determined the

attitudes of healthcare workers related to breastfeeding (Smale, Renfrew, Marshall, &

Spilby, 2006; Wallace, 2007; Weddig, Bakers, & Auld, 2011). Attitudes related to

breastfeeding were often positively correlated with the level of education related to

breastfeeding and knowledge of breastfeeding best practices. As discussed by Rogers

(2006), prior to the implementation of an innovation it is necessary to acknowledge that

individuals possess baseline knowledge of the topic in order to determine areas for

improvement. The articles assessed this baseline knowledge in order to evaluate the need

for implementation of educational remediation (Brodribb, 2012; Osband, Altman,

Patrick, & Edwards, 2011; Smale, Renfrew, Marshall, & Spilby, 2006; Wallace, 2007;

Weddig, Bakers, & Auld, 2011). Instrumentation to assess baseline knowledge varied

among articles reviewed. Methods of assessing knowledge included use of interviews,

surveys, questionnaires and analysis of previous studies. Studies were largely qualitative

in design. The research uniformly supported a need for further education of nurses

directly related to breastfeeding. Smale, Renfrew, Marshall, & Spilby (2006) discussed

that practitioners interviewed acknowledged feeling unprepared to provide education to

breastfeeding women. Furthermore, breastfeeding women interviewed felt unsupported

and additionally felt that healthcare workers did not possess the knowledge to answer

their questions.

Wallace (2007) performed an assessment of 549 practitioners, predominantly

nurse midwives, to evaluate their knowledge of breastfeeding recommendations and

hospital policy. Of the practitioners interviewed 9.8 % were unaware of the current

WHO breastfeeding recommendations. Similarly, Weddig, Baker, & Auld (2011)

assessed breastfeeding knowledge of healthcare workers and determined there was a

significant deficit among nursing knowledge of best breastfeeding practices. This study

specifically documented a disparity in breastfeeding knowledge among non-baby-friendly

hospitals.

A common weakness among these articles was the use of small sample size.

Small sample size creates less reliable results due to increased potential of bias. With the

exception of Wallace (2007), these studies involved sample sizes of less than 100

healthcare workers. This weakness hinders generalizability to the entire population. An

additional weakness is the use of self-report as a means of collecting data. In these

studies, all data were collected through verbal interviews, and therefore relied solely on

self-report. Authors also discussed that documented attitudes related to breastfeeding are

likely skewed in a falsely positive direction, as those who agreed to participate in the

study were more dedicated to improving breastfeeding outcomes. Finally, none of the

above mentioned research studies performed an educational program to determine if

implementation improved attitudes, knowledge and breastfeeding outcomes.

Educational Program Design

Five additional articles used a pre-test and post-test design to determine the

impact of an educational program on nursing knowledge and attitudes related to

breastfeeding practices (Bernaix, Beaman, Schmidt, Harris, & Miller, 2010; Davis,

Stichler, & Poelter, 2012; Ekstrom, Widstrom, &Nissen, 2005; Mellin, Poplawski, Gole

& Mass, 2011; Weddig, Baker, Auld, & Hordynski, 2011). Common topics covered in

these educational programs included, but were not limited to, current breastfeeding

recommendations, importance of breastfeeding, skin-to-skin contact, the baby-friendly

hospital initiative and strategies for supporting the breastfeeding dyad. These studies

diffusely documented an improvement in breastfeeding knowledge among intervention

groups. An additional study performed by Dodgson & Tarrant (2007) employed the use

of a control and intervention group to determine the effectiveness of an educational

intervention related to breastfeeding. This particular program was provided to

baccalaureate nursing students.

Among these studies, educational programs varied from online self-study, face-to-

face lectures and a combination of both methods. With the exception of Davis, Stichler,

& Poelter (2012) and Mellin, Poplawski, Gole & Mass (2011) study designs involved

control and intervention groups, and additionally evaluated multiple hospital and clinic

sites. Davis, Stichler, & Poelter (2012) executed a unique educational program by

mandating all of the maternal / newborn nurses in one hospital to participate in a two

hour educational program. Two of the research studies (Davis, Stichler, & Poelter, 2012;

Weddig, Baker, Auld, & Hordynski, 2011) quantitatively evaluated participants initially

post-education and at another interval afterwards. Researchers differed in their methods

of post-educational program evaluation with the use of a second quantitative post-test at a

three month interval (Davis, Stichler, & Poelter, 2012), and the use of an interview of

nurses at a 12 month interview (Weddig, Baker, Auld, & Hordynski, 2011). One study

evaluated both healthcare professionals as well as breastfeeding mothers pre and post

intervention (Mellin, Poplawski, Gole & Mass, 2011). Researchers noted increased

comfort among healthcare professionals related to breastfeeding however, no statistically

significant improvement in breastfeeding satisfaction was noted among mothers. Each of

the studies determined a need for the provision of further breastfeeding education given

at regular intervals.

A major weakness seen in each of these studies is the use of small sample size of

less than 300 participants. An additional weakness for Davis, Stichler, & Poelter (2012)

was the use of only one hospital setting. Although these studies generally documented an

improvement in breastfeeding knowledge and attitudes, they failed to compare findings

with other breastfeeding educational programs. Moreover, the research studies did not

discuss the impact improved education had on breastfeeding outcomes within their

facility.

Four studies (Bernaix, Beaman, Schmidt, Harris, & Miller, 2010; Davis, Stichler,

& Poelter, 2012; Ekstrom, Widstrom, &Nissen, 2005; Weddig, Baker, Auld, &

Hordynski, 2011) support the use of the Diffusion of Innovations model through their

methods of implementation. The educational programs use Rogers’ (2006) stated steps

of diffusion. The steps of knowledge, persuasion, decision, implementation, and

confirmation were outlined in the research studies when detailing the implementation of

educational programs. Each of the educational programs built on the baseline

breastfeeding knowledge of the participants. Prior to inclusion in the research study

participants were informed of the requirements and therefore able to make an informed

decision to accept or decline the invitation to participate. Researchers determined

success of the educational intervention with a post-test and further follow up to assess the

participants’ confirmation to continue applying acquired knowledge. Research programs

were made visible to potential participants either through requesting participation or

mandating participation within the facility. The process of educational implementation

within each of the research studies mirrors the concepts with in the Diffusions of

Innovations model and therefore supports the theoretical framework.

Impact of Educational Programs on Breastfeeding Knowledge

An additional three studies reviewed the impact of breastfeeding educational

programs on overall knowledge related to the topic (Li, Li, Ashley, Smiley, Cohen, &

Dee, 2013; Owoaje, Oyemade, & Kolude, 2002; Ward, & Byrne, 2011). These studies

employed the use of qualitative methods of evaluation of knowledge including evaluating

national survey responses, interviewing nurses and analysis of prior research studies.

Each of these studies determined that healthcare workers with increased levels of

education related to breastfeeding possessed improved knowledge and overall improved

breastfeeding outcomes for their patients. Ward & Byrne (2011) evaluated 15 studies in

order to compare varying educational programs. Results of the study determined that

breastfeeding educational programs that are a minimum of 18 hours in length have

optimal impact on breastfeeding outcomes. This finding supports the current WHO

recommendations for breastfeeding education.

Despite this finding, authors discussed that the impact of shorter educational

programs cannot be ruled out at this time due to insufficient documentation. Of the

shorter length educational programs evaluated in by Ward & Byrne (2011), only one

documented its impact on breastfeeding outcomes. Authors additionally discussed that

lengthier programs are frequently not feasible for facilities due to cost, time and lack of

resources. Ward & Byrne (2011) demonstrated a need for further evaluation of

educational programs that are more feasible for institutions to implement, with a specific

focus on their impact on breastfeeding outcomes.

Impact of Education on Breastfeeding Outcomes

An additional study performed by Siggia & Rosenburg (2014) evaluated the

impact of breastfeeding education for nursing staff on overall breastfeeding rates for the

institution being studied. Researchers employed the use of a multidisciplinary approach

in order to provide a total of 20 hours of education related to breastfeeding for nursing

staff. Findings did show an increase in initiation of exclusive breastfeeding among

mothers who gave birth at their facility. Researchers employed both didactic and bedside

educational interventions in their study. This study was particularly strong with a sample

size of 500 nurses.

The current recommendation for initial breastfeeding training of staff members is

a minimum of 18 hours (WHO, 2012). Baby-Friendly USA (2004) discusses multiple

barriers that facilities face when implementing this amount of education for their staff

members. Among the stated barriers are time and cost. The author recommends

numerous methods of attaining the recommended 18 hours of training over time,

including assessing baseline knowledge of nursing staff and providing periodic research

updates. Semenic, Childerhose, Lauziere, & Groleau, (2012) discuss effective leadership

and hospital training as two of the major barriers to successful implementation of baby-

friendly practices within hospitals. Ward & Byrne (2011), identified the need for further

research of the impact of programs that are shorter than the recommended 18 hours to

help decrease barriers for educating healthcare workers. Despite documentation of the

proven success of baby-friendly practices, facilities are still not meeting the minimum

recommendations. Multiple literary sources discuss the barriers that hospitals face when

attempting to implement these practices (Baby-Friendly USA, 2004; Semenic,

Childerhose, Lauziere, & Groleau, 2012; Ward & Byrne, 2011). These research findings

suggest the importance of assisting facilities in overcoming the documented barriers with

a goal of improving breastfeeding outcomes.

Summary

The body of literature related to improving breastfeeding education for those

caring for breastfeeding mothers continues to grow. Educational programs reviewed

supported the theoretical framework through inclusion of methods detailed within its

concepts. Presently there are gaps in the literature related to determining educational

programs which are most effective. Although there is significant support for educational

programs, there is still debate as to which programs produce ideal results. There is

additionally increasing documentation of the barriers hospitals face when attempting to

meet the recommended breastfeeding education guidelines outlined by WHO (2012).

Moreover, Ward & Byrne (2011) discuss a distinct deficit in knowledge of the impact on

educational programs that are shorter in length and more flexible in their implementation,

have on breastfeeding outcomes. At this time further research is needed on these

programs due to their economic feasibility and ease of implementation. Although these

shorter educational programs do not match the current 18 hour educational

recommendation, they provide condensed education to nurses in facilities which are

currently unable to meet the 18 hour guideline. This project aims to bridge the gap in the

literature, through implementation of Wellstart International’s™ Lactation Management

Self Study Modules, and further documents impact on breastfeeding outcomes for the

participating facility. The study intends to provide further research on a condensed, self-

study educational program to assist facilities that are facing barriers towards

implementing breastfeeding education among their staff members. Wellstart

International’s™ Lactation Management Self-Study Modules, Level One, 4

Edition

limits many of these barriers while providing a comprehensive, standardized educational

program for nurses.

Chapter 3: Plan for Resolution

Methods

The research study used a quasi-experimental design to determine how an

educational program provided to hospital nurses impacts both their knowledge of

breastfeeding as well as the breastfeeding outcomes for the hospital. The program was

implemented on a group of nurses, working on a maternity unit in one hospital in Central

New York. Inclusion criteria for the selected hospital site were based on its location in

the city of Central, NY, provision of care to patients of varying demographics, the Labor,

Delivery, Recovery, Postpartum (LDRP) model of the maternity unit, Level One nursery

and willingness of the facility to participate in the study. The hospital involved in the

research study does not currently possess a Baby-Friendly designation. The facility is

however in the process of working diligently to obtain this prestigious designation in

order to meet the breastfeeding needs of the community. The sample of nurses was

chosen using convenience sampling methods. All nurses on the unit were offered the

opportunity to participate in the educational program, which was part of their annual

breastfeeding education. The final sample included all nurses who voluntarily complete

the Lactation Management Self-Study Modules and receive a certificate of completion.

Participation in the study was strictly on a volunteer basis, no incentives are in place for

participants.

The educational program consisted of instructing nurses to visit

www.wellstart.org and complete The 4th Edition of the Wellstart International™

Lactation Management Self-Study Modules, Level One. Written approval via email was

obtained for use of this program in the study (Appendix C). Prior to beginning the

educational modules all nurses completed a pre-test which measured their baseline

knowledge regarding breast feeding. After finishing the program the nurses then

completed the final exam on the website. Nurses were finally asked to display proof of

program completion by presenting their certificate of completion within two weeks of

program initiation. Final exam scores were reviewed, and compared to self-reported pre-

test scores. In this study, the participating hospital nurses already possessed an

undetermined baseline level of knowledge of breastfeeding practices. All nurses working

on the maternity unit were invited to participate in the study and those who agreed to

participate were enrolled in the educational program. To assess the initial Registered

Nurse (RN) knowledge base, nurses completed the pre-test evaluation in the form of a

written test through the use of Wellstart International’s™ online Lactation Management

Self-Study Modules. Upon completion they were instructed to begin the three Self-Study

Modules. Self-Study Modules were performed individually by each nurse at their own

pace, the completion of the program was verified through self-report. The final step

involved completing the post-test and receiving a certificate of completion through

Wellstart International™. The post-test evaluation assessed the stage of confirmation, by

evaluating whether or not the nurses attained the concepts taught in the modules, with an

ultimate goal that new knowledge will be incorporated into patient care (Rogers, 2005).

After program initiation, nurses were asked to complete all Self Study Modules and

present their certificate of completion within two weeks. Nurses were then asked to

implement knowledge learned from the course into their patient interaction and patient

education. Lastly, program efficacy and nursing implementation of new knowledge

gained was evaluated through interviewing postpartum mothers.

Effectiveness of the educational program was evaluated using three different

evaluative tools. Nurses’ knowledge regarding breastfeeding was measured prior to the

start of the three self-study modules through completion of the program’s 28 question

pre-test, and again after module completion with the 28 question post-test. Finally nurses

signed into the final examination on the Wellstart International™ website. Nurses were

restricted only with a two week time frame for completion of the educational program

and were allowed to complete all educational components at their own pace. After

achieving a score of 80% or higher, nurses were eligible to download and print their

certificate of completion. This tool has been validated strictly as an educational tool by

Wellstart International™. Its efficacy as a method of improving patient breastfeeding

outcomes has never been studied.

This project additionally evaluated the impact of the educational program on

breastfeeding outcomes for the unit. The Breastfeeding Telephone Interview Survey,

weeks after they returned home. Written consent was obtained for use of this evaluative

tool in the study. This survey is designed to evaluate mothers who are six weeks

postpartum. The tool employs a list of questions designed to evaluate whether the patient

is still breastfeeding, their perception of their breastfeeding experiences, factors they felt

their ability to successfully breastfeed, and factors that impacted their decision to

discontinue breastfeeding. The complete survey is included as Appendix A. The survey

has not been modified from its original form for the purposes of this study. Mothers were

contacted and interviewed once for the purposes of this DNP project. Telephone

interviews were made in three waves at program initiation, six weeks after program

initiation and 10 weeks after program initiation. These time frames were chosen to

evaluate potential differences of maternal responses in relation to the educational

program provided. Oral consent for mothers to participate was obtained before initiating

the telephone interview. The oral consent form used during the interviews was evaluated

and approved during the IRB process. A waiver of prior authorization by research

participant was submitted and approved as a component of the IRB approval process,

allowing access to protected patient information for the purpose of recruitment. A

convenience sampling of postpartum women who were patients on the unit prior to

program implementation were first evaluated. All women who were six weeks

postpartum at the time of program initiation were contacted during the first wave of

interviews. After the educational program was implemented two additional groups of

women were contacted. All women who were six weeks postpartum during the time

interviews took place were contacted to be part of the sample group. A first group was

contacted two weeks after program completion. A second group was contacted six weeks

after program completion to evaluate if breastfeeding outcomes differed at varying

intervals after program completion and a third group was contacted 10 weeks after

program completion. Results of the three waves of interviews were then compared to

evaluate the program’s impact on maternal breastfeeding outcomes of those women that

gave birth at the institution.

The program was implemented over the course of three months. The first set of

postpartum mothers was interviewed in the two weeks prior to program implementation.

Six weeks after the program was implemented a second round of randomly selected

mothers was interviewed using the same methods and then finally a third group 10 weeks

after program completion.

Target Population

The program is aimed to impact the education provided to Registered Nurses who

are offering direct care of breastfeeding mothers during their postpartum stay in a

hospital in Central New York State with a Level One nursery. Specifically, the program

is designed to improve breastfeeding outcomes through providing structured education

for postpartum nurses caring for patients during the critical postpartum hospital stay. All

nurses providing care to breastfeeding mothers within the maternity unit of the

participating hospital were offered the educational intervention as a component of the

institution’s annual breastfeeding education. All RNs who completed the modules and

received a certificate of completion were included in the study.

Setting

The hospital chosen is a small private hospital in Central, NY. The nursing unit

targeted employs a Labor, Delivery, Recovery, Postpartum (LDRP) Model. The hospital

was selected due to its current dedication to providing optimal circumstances for

successful breastfeeding and present adoption of many of the recommendations of the 10

steps to successful breastfeeding. The hospital does not have a current baby friendly

designation, but has a goal of obtaining this designation in the future. The unit currently

has two part-time lactation consultants who rotate during the day and evening shifts, as

well as some weekends. Current breastfeeding education for nursing staff includes an

initial breastfeeding education day upon hire to the unit, with one additional

breastfeeding education program annually in the month of August. The hospital does

hold magnet status for excellence in nursing care. The unit is an 18 bed nursing unit,

employing a total of 33 nurses at the time of the study. The unit participates in

approximately 1200 births per year.

Budget

This research project is not funded by a research grant. The cost to implement the

program was minimal and limited to photocopying evaluative tools to be presented to

program participants. The self-study modules used in the research study are provided free

of cost for all participants. All costs of the program were incurred by the DNP student

conducting the study.

Chapter 4: Outcome / Evaluation

Purpose

The purpose of this study was to determine the impact of breastfeeding education

provided to hospital nurses on the breastfeeding outcomes of postpartum mothers and

their infants. Although there is significant research present regarding the innumerable

benefits of breastfeeding for mother and infant, gaps still remain related to education

provided to nurses on this subject. A review of literature further exposed barriers for

hospitals attempting to provide sufficient breastfeeding education to their staff members,

including time, money and available educational resources (Baby-Friendly USA, 2004;

Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward & Byrne, 2011). The research

study specifically aimed to employ the use of a self-study module with a pre-test / post-

test design in order to increase compliance in completing educational activities related to

breastfeeding among RNs due to ease and convenience of completion.

PICOT Question

The goal of this study was to answer the following PICOT question:

What is the effect of a structured self-study breastfeeding educational program on

the breastfeeding knowledge of hospital nurses, and breastfeeding outcomes on a

maternity unit in Central New York?

Data Collection

This study was initiated through attaining Institutional Review Board (IRB)

approval through both Binghamton University and the participating hospital. After

receiving written consent for participation in the research study all Registered Nurses

employed in the birthing center of a hospital in Central, NY with a Level One nursery

were instructed to go online and complete the 4th Edition of Wellstart International’s™

Lactation Management Self-Study Modules, Level One. This educational program was

required of all birthing center nurses as a component of achieving Baby-friendly

designation. A total of 33 nurses participated in the study with a 100% completion rate

for the unit. All nurses succeeded in receipt of a certificate of completion from Wellstart

International™. This certificate of completion indicates successful scores of 80% or

greater on the final post-test. Nursing self-report indicated improved knowledge through

completion of the educational intervention, as well as improved scores between pre and

post-tests. Of nurses participating in the educational intervention a mean age of 41 was

identified with a range of 23 to 60 years of age. Years of nursing experience within the

maternal-child field of nursing among participants ranged from a minimum of less than

one year to a maximum of 25 years, with the greatest number of RNs possessing five-10

years of experience.

The impact of the enhanced breastfeeding education on breastfeeding practices

was evaluated through conducting three rounds of telephone interviews for mothers who

were six weeks postpartum. Interviews were conducted through use of the Breastfeeding

Telephone Interview Survey, designed by Pamela D. Hill. All mothers who delivered at

the participating hospital, initiated breastfeeding during their hospital stay and were six

weeks postpartum at the time telephone interviews commenced were contacted for

participation in the study. Round one of interviews was conducted at the time nurses

initiated the self-study module as a pre-intervention group. A total of 28 women met

inclusion criteria and were contacted via telephone to be interviewed. Of the 28

contacted a total of seven women participated in the study. Two subsequent rounds of

post-intervention telephone interviews were then completed. Round two of interviews

was conducted six weeks after nursing completion of the self-study module. A total of 33

mothers were contacted with a final participation group of seven women. Finally, round

three of interviews was performed 10 weeks after the educational intervention. During

this round 35 mothers were contacted, with a total of eight participating in the telephone

interview process. Incorrect telephone number provision, disconnected telephone

numbers, failure to answer the telephone and opting against participation in the study

accounted for the final sample size totaling 22 women who participated during the three

rounds of interviews. Contact attempts for those who did not answer the telephone were

made a total of three times on varying days and times. All individuals participating in the

telephone interview provided oral consent for participation in the research study.

Statistical Analysis

Results of telephone interview questions were evaluated through the use of IBM

SPSS Statistics – Version 23 (1989, 2015) software. Each participating mother was

provided an individual row within the data set and identified with a unique number

correlating with her interview number, numbers one through twenty-two. Participants

were further identified based on their telephone interview group number, numbers one,

two and three.

Descriptive statistics were generated for the data set, including minimum,

maximum, mean, and standard deviation. Among maternal research participants mean

maternal age was 30.0909, with a minimum age of 22 and maximum age of 42. Mean

gestational age of infant at birth was 39.4273, with a minimum gestational age of 37.5

and maximum gestational age of 41.4. Mothers participating in the study presented with

a mean of Para 1.909 with a minimum of Para 1 and a maximum of Para 4. Of the 22

participating mothers, a total of seven delivered via cesarean section and 15 delivered via

vaginal delivery. Racial variation among participants included 19 mothers identifying as

Caucasian, two mothers identifying as African American and one mother identifying as

Indian.

The data set identified that 100% of participants reported rooming in with their

infants during the hospital stay. Additionally, 100% of mothers identified that their

initial breastfeeding attempt was made within the first hour after birth and attained a

successful first latch within the first four hours after birth. Hospital initiation of Baby-

Friendly practices can account for these constant variable results. Of the 22 maternal

participants less than half reported participating in a breastfeeding class for this

pregnancy, although 95% reported feeling well informed of breastfeeding practices prior

to delivery.

Reports of maternal and infant health were included among the telephone

interview questions. Mothers who reported that their infants experienced health problems

were coded as 1.0 while mothers who reported their infants remained healthy since birth

were coded as 2.0. This was coding was selected to identify of newborn health issues

that may have potentially impacted length of breast feeding. Reported health issues

among infants included newborn jaundice, constipation, tongue tie and oral candidiasis.

Descriptive statistical analysis indicated a mean of 1.7727 among responses for overall

infant health since delivery. Responses related to maternal health were valued as 1.00 for

those indicated maternal health issues since delivery and 2.00 among those who reported

no postpartum health issues. Maternal report of health issues included mastitis, nipple

candidiasis, and upper respiratory infections. Responses indicated a mean of 1.6818

among responses for overall maternal health since delivery.

Interview responses indicated that on the whole mothers were feeding their

infants on demand, with an average of eight-12 feedings in 24 hours and approximately

two-three hours between feedings. A total of 10 mothers indicated their infants had to

receive some formula supplementation since delivery, with a total of four mothers

indicating that their infant was solely formula fed six weeks after delivery. In wave one

of telephone interviews one out of seven mothers was solely formula feeding. In wave

two, three out of eight mothers were solely formula feeding. Finally, all seven mothers in

wave three were still breastfeeding. Among the four mothers who reported solely

formula feeding two disclosed maternal upper respiratory illness and two disclosed low

breast milk supply as the reasons for discontinuing breastfeeding.

As a component of the breastfeeding telephone interview survey mothers were

asked the following question:

How important have the following persons or organizations been to

breastfeeding?

Your Mother Very Important Important Not Important

Male Partner Very Important Important Not Important

Female Friend Very Important Important Not Important

Nurse Very Important Important Not Important

Physician Very Important Important Not Important

La Leche League Very Important Important Not Important

Other Very Important Important Not Important

Responses from group one indicate that five out of seven mothers expressed that the

hospital lactation consultant was very important to their breastfeeding success. Within

group two, one mother reported the hospital lactation consultant was very important to

her breastfeeding success, while three out of eight mothers reported hospital nursing staff

as being very important. Group three responses included one mother indicating the

hospital lactation consultant was very important, with four out of seven mothers reporting

the hospital nursing staff as very important. Maternal response trends indicated that

mothers within the two post-intervention groups increasingly reported the importance of

hospital nursing staff in their breastfeeding experience.

Summary of Findings

In summation, statistical analysis of the research study does yield multiple

significant findings. The most significant finding indicated an increase in mothers

reporting the importance of hospital nursing staff in their breastfeeding success among

mothers in maternal intervention groups two and three (Group one = pre-educational

intervention, Groups two-three = post-educational intervention group). Additionally,

group three had the highest concentration of mothers breastfeeding at six weeks

postpartum while group two had the lowest concentration. The two reasons indicated for

breastfeeding discontinuation included maternal upper respiratory illness and low breast

milk supply. Although minimal significant data was present, results are limited due to

multiple contributing factors including small sample size, experienced nursing staff

therefore limiting effectiveness of educational intervention, hospital participation in

baby-friendly practices, high level of maternal knowledge of breastfeeding and prior

maternal breastfeeding success. Findings related to success of the educational

intervention in regards to improving nursing knowledge of breastfeeding practices are

additionally unreliable due to self-report of variance between pre-test and post-test scores

as well as self-report of perception of impact of the educational intervention. While the

study did yield multiple statistically significant findings, further evaluation with a larger

sample size of both nurses and breastfeeding mothers is needed to determine

effectiveness of the educational intervention on nursing knowledge of breastfeeding

practices and maternal breastfeeding outcomes.

Chapter 5: Summary

Introduction

Breastfeeding is widely supported as the optimal method of infant feeding

worldwide (AAP, 2012; CDC, 2013; CDC, 2016; DiGirolamo, Grummer-Strawn, & Fein,

2008; Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward, 2011; World Health

Organization [WHO], 2013). There are numerous national initiatives present to improve

breastfeeding outcomes. Despite knowledge and health care organization efforts, the

recommendations of exclusive breastfeeding through six months of life with continued

breastfeeding through one year of age are not being met (AAP, 2012; CDC, 2011; CDC,

2013; CDC 2016). According to the 2016 Breastfeeding Report Card for the United

States, published by the CDC, there are high levels of breastfeeding initiation nationwide

however these rates decrease significantly throughout the first year of life.

This DNP project aimed to focus on breastfeeding education provided to hospital

nurses in direct care of breastfeeding mothers as a means of improving breastfeeding

outcomes. Use of the Wellstart International™ Lactation Management Self-Study

Modules Level One, Fourth Edition 2014 guided nursing staff through a comprehensive

educational program related to breastfeeding. Outcomes were evaluated at the nurse and

patient level to determine the efficacy of a web-based, self-study module in improving

nursing knowledge of breastfeeding and ultimately improving breastfeeding outcomes

among their patients.

Summary of Findings

This DNP project included a total of 33 nurses and 22 mothers in the study.

Nurse participation accounted for 100% of the nurses working on the participating unit at

the time of initiation. Complete nurse participation was attained through inclusion of the

educational intervention in the annual breastfeeding education requirements for the unit

staff. Of the 33 participating nurses all were successful in achieving a final exam score

of 80% or higher and successfully received a certificate of completion from Wellstart

International™. Nursing self-report indicated that all nurses had increased post-test

scores and felt the educational intervention was helpful in improving their breastfeeding

knowledge.

As discussed above in the statistical analysis, the research did yield multiple

significant findings. Analysis displayed a statistically significant relationship between

maternal intervention group and importance of hospital nursing staff in maternal

breastfeeding success. Mothers reported that hospital nurses were very important in their

breastfeeding experience with increasing frequency among groups two and three.

Mothers in group one listed the hospital lactation consultant alone. Additionally the two

reasons reported for breastfeeding discontinuation included maternal upper respiratory

illness and low breast milk supply. Although significant findings were yielded through

the statistical analysis there was no indication that the educational intervention improved

breastfeeding outcomes among the mothers surveyed. Responses showed the highest

concentration of mothers still breastfeeding at six weeks postpartum in group three

however, group two indicated the lowest concentration of mothers still breastfeeding.

Improved breastfeeding success among mothers from group three cannot be attributed to

the educational intervention.

Findings from this study indicate a positive reported impact on nursing

educational outcomes with no apparent change in breastfeeding outcomes among

surveyed mothers. This lack of change in maternal outcomes may be accounted for due

to small sample size and experienced nursing staff causing minimal impact of the

educational intervention on existing knowledge. An additional factor impacting

outcomes includes the fact that mothers were only six weeks postpartum at the time of

interviews. Further contributing factors may include the participating hospital’s

dedication to Baby-friendly practices on their journey towards attain a Baby-friendly

hospital designation during the time of the study. Overall, study findings indicate a need

for further research related to this topic.

Implications for Practice

The growing body of literature supports breastfeeding as the optimal form of

infant nutrition and focuses on methods of improving breastfeeding outcomes. Among

these recommended methods of improvement is the provision of breastfeeding education

to nursing staff (AAP, 2012; CDC, 2013; DiGirolamo, Grummer-Strawn, & Fein, 2008;

Healthy People 2020, 2013; Semenic, Childerhose, Lauziere, & Groleau, 2012; Ward,

2011; WHO, 2013). The literature supports a need for increased education provided to

hospital nurses related to breastfeeding due to great disparities in knowledge of nursing

staff related to breastfeeding and best practices (Brodribb, 2012; Crowder, 2006;

Osmand, Altman, Patrick, & Edwards, 2011; Smale, Renfrew, Marshall, & Spilby, 2006;

Wallace, 2007; Weddig, Bakers, & Auld, 2011). The literature further divulged barriers

to educational provision including time, monetary resources and lack of teaching staff

and educational resources (Baby-Friendly USA, 2004; Semenic, Childerhose, Lauziere,

& Groleau, 2012; Ward & Byrne, 2011). This DNP project intended to add to the

current literature and research through implementing a web-based, self-study educational

intervention that was free of cost and less than 18 hours in length. The Wellstart

International™ Lactation Management Self-Study Module 4

Edition, Level1 met these

criteria and was implemented on the maternity unit of a hospital in Central New York

State with a Level One nursery.

Results as discussed above indicated self-reported improvements in knowledge of

nurses, with no apparent change in breastfeeding outcomes among their patient over a

three month period. Implications for practice include a need for continued education of

hospital nurses in direct care of breastfeeding mothers. Inclusion of web-based, self-

study educational programs is supported due to positive outcomes among nurses. This

method of providing education to nursing staff assisted in meeting their unit education

requirements for Baby-friendly designation and the 18 hours of initial breastfeeding

education recommended by WHO (2013). Participant responses additionally supported a

need for increased access to lactation consultants during the immediate postpartum

hospital stay. This response further supports continued education for nurses due to the

fact that lactation consultants are not always readily available for patients. This study,

along with the body of literature, supports a need for continued education provided to

nurses related to breastfeeding and best practices. The study further supports use of web-

based, self-study modules as a means of overcoming barriers hospitals often face when

attempting to meet the breastfeeding education recommendations as proposed by WHO,

UNICEF and Baby-Friendly USA.

Limitations

This study was limited due to a small sample of nurses at only one hospital, which

further limited the number of maternal participants. Use of a larger sample of nurses

through providing educational interventions at multiple hospitals would strengthen future

research studies. The DNP project was further limited due to use of self-report as a

means of obtaining impact of the educational intervention through pre-test and post-test

result comparisons. Future studies would employ use of a pre-test / post-test design;

however obtaining hard copies of completed tests would strengthen the study design.

Recommendations for Research

This study aimed to add to the body of research related to breastfeeding education

provided to hospital nurses. Findings support the current body of research by indicating a

need for further evaluation of available breastfeeding education programs (Li, Li, Ashley,

Smiley, Cohen, & Dee, 2013; Owoaje, Oyemade, & Kolude, 2002; Ward, & Byrne,

2011). Recommendations for future research include use of a larger sample size of both

nurses and postpartum mothers. Additional recommendations for future research include

tracking breastfeeding outcomes for participating mothers over the first year of life of

their infants. The design of this research project was limited due to short interval follow

up with mothers at six weeks postpartum. Current statistics indicate that breastfeeding

levels drop off significantly after three months of age (CDC, 2013). Future studies

would aim to track mothers and their infants over the entire first year of life to determine

impact on extended breastfeeding outcomes.

Furthermore, the level one modules used in this study are self-proposed as entry-

level, base knowledge related to breastfeeding and breastfeeding practices. Use of higher

level modules, such as level two and level three by Wellstart International™, may yield

more significant results and build on intrinsic knowledge nurses may already possess due

to field experience. This research study adds to the growing body of research related to

breastfeeding education programs provided to hospital nurses. Research design and

execution exposed multiple areas for improvement for future research studies. Findings

support a need for continued research related breastfeeding education provided to

hospital nurses as a means of improving breastfeeding outcomes for postpartum mothers

and their infants.

Conclusion

Breastfeeding and its innumerable benefits for both mother and infant are widely

documented in the literature. UNICEF (2005) states the following:

“ breastfeeding is a unique process that provides ideal nutrition for infants and

contributes to their healthy growth and development, reduces incidence and

severity of infectious diseases, thereby lowering infant morbidity and mortality,

contributes to women's health by reducing the risk of breast and ovarian cancer,

and by increasing the spacing between pregnancies, provides social and economic

benefits to the family and the nation, provides most women with a sense of

satisfaction when successfully carried out (UNICEF, 2005, p. viii).”

In the Surgeon Generals Call to Action to Support Breastfeeding (2011) the US

Department of Health and Human Services lists health care, research and surveillance

among the areas to focus when attempting to increase national breastfeeding rates and

outcomes. This DNP project focused on the use of education provided to hospital nurses

as a means of improving both nursing education related to breastfeeding and overall

breastfeeding outcomes for mothers and their infants. Guided by Rogers (2003)

Diffusion of Innovations model, the study succeeded in implementing an educational

intervention to hospital nurses and further evaluated their educational growth and its

impact on the breastfeeding outcomes of patients in their care.

The research study was successful in implementing the Wellstart International™

Lactation Management Self-Study Modules Level One, Fourth Edition among nurses on

a maternity unit in Central New York State with a Level One nursery. While the study

yielded self-reported improvement in pre-test and post-test scores, no significant

improvement in breastfeeding outcomes among mothers at six weeks postpartum was

noted during three rounds of telephone interviews. Limitations of sample size, self-

report, experienced nursing staff, short interval follow up with postpartum mothers and

entry-level breastfeeding curriculum may have contributed to documented outcomes.

Recommendations for future research include the inclusion of multiple hospitals,

therefore increasing sample size, obtaining hard copies of nursing pre-test and post-test

scores, increasing difficulty of the educational program and continued surveillance of

participating postpartum mothers over the first year of life of their infant. In regards to

future practice, the study supports continued provision of breastfeeding education to

health care workers in direct care of breastfeeding mothers, as well as use of web-based,

self-study modules for providing such education.

The goal of this DNP project was to answer the following PICOT question:

What is the effect of a structured self-study breastfeeding educational program on

the breastfeeding knowledge of hospital nurses, and breastfeeding outcomes on a

maternity unit in Central New York?

The study succeeded in determining that the implemented educational program positively

impacted nursing knowledge while having no notable impact on breastfeeding outcomes

at six weeks postpartum. The research, along with the aforementioned proposed changes,

adds to the body of literature related to breastfeeding education and delineates areas of

need for future research and recommendations for current practice. This DNP project,

along with the growing body of literature, supports the need for continued provision of

education related to breastfeeding among nurses in direct care of breastfeeding mothers,

and expresses a need for further research on this topic to optimize breastfeeding

outcomes worldwide.

Appendix A

Breastfeeding Telephone Interview Survey

P. D. Hill

Primary Source

Hill, P. D. (1987). Effects of education on breastfeeding success. Maternal-Child Nursing

Journal, 16, 145-156.

Purpose Statement

Breastfeeding Telephone Interview Survey is designed to assess mothers’ current

method of infant feeding (e.g., schedules, frequency, and number of feedings per day),

and satisfaction with that method six weeks after delivery. Items (11) designed for

mothers who are currently bottle feeding their baby include questions regarding

whether the mothers are happy with bottle feeding and whether they wish they had

tried breastfeeding. Items (17) designed for mothers who are currently breastfeeding

include questions concerning how long they plan to breastfeed their baby, how soon

after the baby’s birth they began to breastfeed, perceptions of success at breastfeeding,

and how important specific persons and organizations have been to breastfeeding.

Finally, items (15) designed for mothers who tried breastfeeding and are currently

bottle feeding include questions regarding how long they breastfed their baby, how

soon after their baby’s birth they began to breastfeed, the reason they stopped

breastfeeding, feeding schedules followed when they were breastfeeding, and

perceived success at breastfeeding. Designed to be completed by mothers six weeks

after delivery, this questionnaire can be self-administered or administered by an

interviewer. It contains rating scales, yes/no and multiple-choice items, and open-

ended questions.

Reliability

Reliability statistics are not easily identified in the source.

Number of Questions

Vary from 11, 17, or 15 depending on infant feeding method adopted.

Directions for Scoring

Calculate percentages for rating scales, yes/no, and multiple-choice item responses.

Similarly, calculate percentages for open-ended questions, following development of a

coding scheme for reasons provided.

3699

Health and Psychosocial Instruments

(HaPI)

Breastfeeding Telephone Interview Survey

P. D. Hill

Breastfeeding Telephone Interview Survey

P. D. Hill

GENERAL INFORMATION

NAME ____________________________________________

1. Has your baby had any health problems since delivery?

YES…...1

NO…….2

If YES, please explain

________________________________________________________

2. What has been your general state of health since the birth of your baby?

EXCELLENT……………..1

GOOD……………………..2

FAIR………………………3

POOR……………………..4

3. Have you had any health problems since delivery?

YES…...1

NO….…2

If YES, please explain

________________________________________________________

4. How have things been going since you came home from the hospital?

VERY WELL……………..1

PRETTY WELL……….….2

FAIR………………………3

POOR……………………..4

5. Did you have any organized classes on breastfeeding or receive information on this

topic?

YES…...1

NO….…2

If YES, please explain

________________________________________________________

6. How well informed about breastfeeding did you feel?

VERY INFORMED……………..1

SOMEWHAT INFORMED……..2

POORLY INFORMED………….3

NOT INFORMED………………4

7. Did you attempt to breastfeed your baby?

YES…...1

NO….…2

If NO, go to page 3.

If YES, and you are still breastfeeding, go to page 4.

If YES, and you are now bottle feeding, go to page 6

FOR MOTHERS WHO ARE BOTTLE FEEDING THEIR BABY

1. While in the hospital, did you keep your baby in the room with you?

YES…...1

NO….…2

2. How many bottle feedings are you giving your baby each day? ________

How many ounces/feeding? ________

3. Are you completely happy with bottle feeding?

YES…...1

NO….…2

4. Do you wish you had tried breastfeeding?

YES…...1

NO….…2

If YES, explain

____________________________________________________________

If NO, explain

_____________________________________________________________

FOR MOTHERS WHO ARE NOW BREASTFEEDING

1. How long do you plan on breastfeeding your baby? __________ month(s)

2. How soon after the birth of your baby did you begin to breastfeed?

IMMEDIATELY AFTER DELIVERY……..1

WITHIN 4 HOURS………………………….2

WITHIN 5-8 HOURS………………………..3

WITHIN 9-12 HOURS………………………4

AFTER 12 HOURS……………………….…5

3. While in the hospital did you keep your baby in the room with you?

YES…...1

NO….…2

4. Do you breastfeed your baby at specific times of the day or whenever you think

he/she is hungry?

SPECIFIC TIMES………….1

WHEN HUNGRY………….2

5. On a typical day, how many times do you breastfeed your baby? _________

6. Have you been feeding your baby anything else besides breast milk?

YES…...1

NO….…2

7. Do you feel you have been successful in breastfeeding your baby?

YES…...1

NO….…2

If NO, explain

___________________________________________________________

8. How important have the following persons or organizations been to breastfeeding?

YOUR MOTHER VERY IMPORTANT IMPORTANT NOT

IMPORTANT

MALE PARTNER VERY IMPORTANT IMPORTANT NOT

IMPORTANT

FEMALE FRIEND VERY IMPORTANT IMPORTANT NOT

IMPORTANT

NURSE VERY IMPORTANT IMPORTANT NOT

IMPORTANT

PHYSICIAN VERY IMPORTANT IMPORTANT NOT

IMPORTANT

LA LECHE LEAGUE VERY IMPORTANT IMPORTANT NOT

IMPORTANT

OTHER VERY IMPORTANT IMPORTANT NOT

IMPORTANT

If OTHER, please explain

___________________________________________________

9. Does anyone specifically help you with the baby?

MOTHER YES NO

MALE PARTNER YES NO

FEMALE FRIEND YES NO

LA LECHE LEAGUE YES NO

OTHER YES NO

If OTHER, please explain

___________________________________________________

10. Are you satisfied with the feeding you are giving your baby?

YES…...1

NO…….2

If NO, explain

___________________________________________________________

FOR MOTHERS WHO TRIED BREASTFEEDING

AND ARE NOW BOTTLE FEEDING

1. How soon after the birth of your baby did you begin to breastfeed?

IMMEDIATELY AFTER DELIVERY…......1

WITHIN 4 HOURS………………………….2

WITHIN 5-8 HOURS………………………..3

WITHIN 9-12 HOURS………………………4

AFTER 12 HOURS……………………….…5

2. How long did you breastfeed your baby? ______ days

3. While in the hospital did you keep your baby in the room with you?

YES…...1

NO….…2

4. Could you tell me the most important reason why you stopped breastfeeding?

EMBARRASSED………………………..……1

NOT CONVENIENT……………………..…..2

SORE NIPPLES………….…………………...3

NOT ENOUGH MILK………………………..4

FATIGUE………………………………….….5

BECAUSE OF HUSBAND’S WISHES……...6

TO AVOID RESTRICTING SOCIAL LIFE…7

MILK WOULD NOT FLOW…………………8

IT WAS MESSY………………………………9

I WAS SICK…………………………………10

BABY WAS SICK…………………………..11

RETURNED TO WORK……………………12

RETURNED TO SCHOOL…………………13

FEAR OF LOSING FIGURE……………….14

OTHER……………………………………....15

If OTHER, please specify

____________________________________________________

5. Did you breastfeed your baby at specific times of the day or whenever you thought

the baby was hungry?

YES…...1

NO….…2

6. On a typical day, how many times did you breastfeed your baby? ________

times

7. Do you feel you were successful in breastfeeding your baby?

YES…...1

NO….…2

8. Are you satisfied with the feeding you are giving your baby?

YES…...1

NO….…2

If NO, explain

___________________________________________________________

Appendix B

Appendix C

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