The Nurse’s Role in Breastfeeding Education Diana Amaya Rodriguez PhD, MS, CNS, RN Azusa Pacific University Scientific Writing GNRS 507 Michaela fox

Background information Breastfeeding is the ideal source of nutrition for infants during the 1st year 2/3 of children under the age of 1 die because of undernourishment AAP recommends women exclusively breastfeed for the first 6 months Breastfeeding exclusivity: practice of feeding only breast milk 6 months of exclusive breastfeeding: decrease GI disease, otitis media, lower respiratory tract infection, SIDS, diabetes, and obesity $13 billion dollars could be saved on a national level if 90% of women followed breastfeeding recommendations While breast milk is well recognized among literature as the optimal form of nutrition for infants, breastfeeding exclusivity remains a public health issue According to the Centers for Disease Control (CDC), breastfeeding is the ideal source of nutrition for infants during the first year of life, yet rates still fall below the goal set by Healthy People 2020, which aims to increase breastfeeding up to six months from 43.5% to 60.6%. Breastfeeding cessation is a maternal choice and may be due to the mother’s lack of knowledge on the benefits of breastfeeding. Due to this knowledge deficit, an array of research studies have been undertaken to evaluate the use of proper breastfeeding education. There is a significant link between the education nurses provide and breastfeeding outcomes Breastfeeding exclusivity is the practice of feeding only breast milk and excludes vitamins, minerals, or medicine Nurses are in an ideal position to assist postpartum women with the knowledge and skills needed to breastfeed. However, there is a discrepancy in the current breastfeeding information being taught to mothers

Picot Among postpartum women who have been assessed with the Breastfeeding Self Efficacy Scale-Short Form (BSES-SF) and received individualized education compared to those who have not, report a higher rate of commitment to exclusively breastfeed for six months prior to discharge?

Self-Efficacy theory Maternal self-efficacy (self confidence) Feasible & modifiable variability that influences breastfeeding initiation, duration, and exclusivity Learning takes place in a social context Much of what is retained is through observation 4 elements: personal accomplishment, vicarious experiences, verbal persuasion, and psychological and affective states Maternal self-efficacy, known as a mother’s confidence, is a feasible and modifiable variable that has been identified to influence breastfeeding initiation, duration, and exclusivity. A framework was generated to recognize the influence of self-efficacy on breastfeeding behaviors through Bandura’s Social Cognitive Theory, which emphasizes that learning takes place in a social context and much of what is retained is through observation. The theory of self-efficacy suggests that an individual’s degree of self-efficacy is based on four elements Personal accomplishments: is built on one’s experiences in which their self-efficacy increases with success and decreases with failure Vicarious experiences: suggests that we learn from watching others; if we observe someone else do something and succeed, then we believe we ourselves can do it Verbal persuasion: proposes that those who are persuaded that they have the skills to do something are more likely to put in the effort Psychological and affective states: created around the principle that our emotions are a guiding factor for our behaviors

Breastfeeding Self-Efficacy Scale-Short Form Screening tool to identify women who are at risk for early weaning Composed of 14 questions Scores range from 14-70 The greater the woman’s score, the greater level of self-efficacy Assesses the amount of assurance a woman has surrounding breastfeeding The BSES-SF is a screening tool used to identify women who are at risk for early weaning. In order for healthcare professionals to increase breastfeeding rates, high-risk mothers must be identified by modifiable variables that can be influenced through proper interventions. The BSES-SF is an instrument comprised of 14 questions with a series of scores ranging from 14-70 that assesses the amount of assurance a woman has surrounding breastfeeding. Mothers answer questions based on how content they are with their breastfeeding experience as well as the ability to determine if their baby received a sufficient amount of milk The greater the woman’s score the greater the level of breastfeeding self-efficacy. The more self-efficacy a woman has in her ability to breastfeed, the higher the probability that she will plan to exclusively breastfeed Women with more breastfeeding self-efficacy are more apt to start exclusive breastfeeding, continue when they face obstacles, develop reassuring thoughts, and are able to overcome struggles they experience.

Breastfeeding education given by nurses 86% of people in America turn to medical professionals as their main source of health information The knowledge level of nurses can impact not only a mother’s decision to breastfeed but also can give conflicting information to breastfeeding mothers There is an inconsistency in the education nurses are providing because many lack the correct education about breastfeeding initiation, exclusivity, and support. Lack of confidence among the nurses to deliver knowledgeable education and manage breastfeeding difficulties Without sufficient information, mothers are unable to appropriately evaluate the advantages of breastfeeding compared to artificial milk products and women who are well informed about the variety of breastfeeding health benefits have an increased likelihood to breastfeed Knowledge of the health benefits of breastfeeding is a critical element in deciding to breastfeed, but more importantly, knowing how to breastfeed is even more essential The knowledge level of nurses can impact not only a mother’s decision to breastfeed but also can give conflicting information to breastfeeding mothers. There is an inconsistency in the education nurses are providing because many lack the correct education about breastfeeding initiation, exclusivity, and support. There is a lack of confidence among the nurses to deliver knowledgeable education and manage breastfeeding difficulties and mothers also have indicated an increase in conflicting information they were receiving from nurses Nurses are in an ideal position to implement individualized education since they typically have the first and most consistent contact with expectant mothers

Clinical implications Despite the known benefits and recommendations of exclusive breastfeeding, women still wean their infants earlier than the recommended six months Nurses have the most consistent relationship with their patients, placing them in an ideal position to provide personalized breastfeeding education The BSES-SF can be used during the postpartum phase to detect those in need of supplementary interventions to ensure breastfeeding continuation Despite the known benefits and recommendations of exclusive breastfeeding, women still wean their infants earlier than the recommended six months Within the hospital staff, nurses have the most consistent relationship with their patients, placing them in an ideal position to provide personalized breastfeeding education Nurses should be well versed in the most current research on the topic, and more importantly, willing to implement changes within their institutions that reflect this research. The problem lies in the fact that women receive mixed breastfeeding information from the nursing staff, which leads to inconsistencies in their breastfeeding practices The BSES-SF can be used during the postpartum phase to detect which women are more apt to succeed at breastfeeding compared to those in need of supplementary interventions to ensure breastfeeding continuation

Implementation of the plan Over 6 months First 3 months: Universal training among OB nurses Second 3 months: All antepartum patients assessed with BSES-SF ½ of patients will receive individualized education from nurses Providing individualized breastfeeding education to postpartum women, with the help of the BSES-SF, can be implemented into clinical practice within six months. The first step to delivering evidence-based breastfeeding education to patients is to implement universal training among OB nurses. Over a period of three months, lactation consultants will train all OB nurses on the implementation of the BSES-SF, how to interpret the results, as well as how to tailor the education they offer based on a woman’s self-efficacy score. Nurses must be proficient in their ability to screen and identify mothers at risk for premature weaning in order to assist in planning interventions For the following three months, all antepartum patients will be assessed with the BSES-SF Only half of the patients that were previously assessed with the BSES-SF will receive postpartum education based on their self-efficacy scores. From the data collected from the BSES-SF, nurses will modify their teaching strategies in relation to the patient’s discrepancies in self-efficacy.

Learning new practices Potential barriers Proper funding BUDGET Learning new practices STAFF Rural or teaching hospital ENVIRONMENT Implementing change does not come without barriers. A critical part of effectively implementing this change in practice involves addressing possible staff resistance, lack of supervision, institutional budget, and the environment in which these changes occur, whether it is at a rural or teaching hospital

Ethical considerations Justice: Fair, equitable, and appropriate treatment in light of what is due or owed to persons Justice allows all mothers the right to fair and equal breastfeeding education Keep in mind patient preferences, cultural practices, and religious beliefs Regardless of barriers that may surface, justice allows all mothers the right to fair and equal breastfeeding education. Regardless of breastfeeding recommendations it is important to keep in mind patient preferences, cultural practices, and religious beliefs. Breastfeeding practices vary among women and nurses can’t overlook the factors that determine a mother’s decision to exclusively breastfeed.

Expected outcomes Increase breastfeeding exclusivity rates among postpartum women Increase maternal breastfeeding education satisfaction Universal use of the BSES-SF among labor & delivery units Create nurses who are knowledgeable on breastfeeding best practices The goal is to increase breastfeeding exclusivity rates among postpartum women with the assistance of the BSES-SF and implementation of individualized nursing education. To decrease inconsistencies among breastfeeding education nurses give to mothers and increase their satisfaction with the in0hospital education they received. The BSES-SF is a universally applicable screening tool to increase breastfeeding exclusivity among postpartum women. Using a single universal screening tool will create consistency within each institution and throughout hospital organizations by deciphering the education and information nurses give to postpartum women concerning breastfeeding.

How will this be measured? Every postpartum mother will be asked a yes- or-no survey addressing her plan to exclusively breastfeed for 6months Survey will be paralleled to the patients self- efficacy score Multidisciplinary rounds weekly for 1st month BSES-SF oversight committee will shadow OB nurses to assure proper teaching is being given to women with low scores Upon discharge at the bedside, every postpartum mother will be asked a yes-or-no survey addressing her plan to exclusively breastfeed for six months. The survey will be administered regardless of whether the mother received individualized education contingent on a low self-efficacy score. This survey will be paralleled to the patients self-efficacy score and the subsequent education they received in order to determine if the BSES-SF screening tool was effective in improving their breastfeeding plans To ensure the BSES-SF is being used properly and nurses are providing sufficient education to postpartum women based on their level of self-efficacy, multidisciplinary rounds should take place weekly for the first month. A BSES-SF oversight committee composed of educated lactation consultants will shadow OB nurses to assure proper teaching is being given to women with low scores. After six months, the data should be analyzed, highlighting the patient surveys with no intent to exclusively breastfeed as well as those who propose to follow breastfeeding recommendations. For sustained change, data should be continuously evaluated and assessed annually, with comprehensive evaluations performed after five and 10 years

Conclusion Breast milk is the optimal form of nutrition for infants Breastfeeding exclusivity remains a public health issue Nurses are in an ideal position to assist postpartum women with breastfeeding based on their level of self-efficacy While breast milk is well recognized among literature as the optimal form of nutrition for infants, breastfeeding exclusivity remains a public health issue Nurses are in an ideal position to assist postpartum women with the knowledge and skills needed to breastfeed The BSES-SF is a screening tool that can be used by nurses to identify women at risk for early cessation in order to personalize the breastfeeding education they provide A change in clinical practice that utilizes the BSES-SF to increase a woman’s self-efficacy is needed to mend the gap between breastfeeding recommendations and actual feeding practices among mothers. Women with higher breastfeeding self-efficacy scores report a greater intention to exclusively breastfeed; therefore, with the use of the BSES-SF along with the proper support given by nurses, the goals set forth by the AAP and Healthy People 2020 to exclusively breastfeed within the first six months become more attainable.

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