Highly Selective Phosgene-Free Carbamoylation of Aniline by

Research in Nursing & Health

Effects of the Implementation of a Breastfeeding Best Practice Guideline in a Canadian Public Health Agency Lynn A. Rempel,* Lynn McCleary*

Department of Nursing, Brock University, 500 Glenridge Ave., St. Catharines, ON, Canada L2S 3A1 Accepted 28 May 2012

Abstract: Several strategies were used to implement a breastfeeding best practice guideline (BPG) in a Canadian public health agency. Nurses surveyed before and 1 year after implementation reported increased BPG-related knowledge and stronger beliefs regarding breastfeeding duration beyond 1 year. Telephone surveys also were conducted with mothers; 90 before BPG implementation and another cohort of 141 mothers following implementation. Post-implementation mothers were more knowledgeable about sources of breastfeeding help, obtained more help from public health nurses, and reported more breastfeeding-related discussion with healthcare providers. Compared to the pre-implementation cohort, mothers in the post-implementation cohort who were still breastfeeding at 6 months intended to continue breastfeeding longer. Implementing a breastfeeding BPG can affect breastfeeding-related experiences at a population level.ß 2012 Wiley Periodicals, Inc. Res Nurs Health Keywords: attitude of health personnel; breast feeding; health promotion; diffusion of innovation; evaluation studies; nursing; evidence-based

Clinical best practice guidelines (BPG) are becoming widely available as tools that assist nurses to translate research and evidence into practice. However, successfully implementing innovations such as BPGs within organizations is a complex process, involving change within the organization and adaptation of the BPG to fit the organizational context (Rogers, 2005). The ‘‘knowledge to action process’’ model (Graham et al., 2006) provides a framework for

the process of implementing BPGs. Potential knowledge users begin the action cycle of the process by identifying either a practice problem or new knowledge (Graham et al., 2006). Potential users vet and tailor the knowledge to their context and identify barriers and facilitators to knowledge use and practice change (Graham et al., 2006). Users identify and implement strategies to increase new knowledge use and then monitor and assess

This research was supported in part by a grant from the Registered Nurses’ Association of Ontario. The authors recognize the contributions of Kathy Bell, RN, MScN, Coleen Flynn, RN, BScN, Catherine Lowes, RN, BScN, and Gloria Morris, RN, MScN, from Niagara Region Public Health who collaborated on aspects of study design, support for data collection, and dissemination of the methods and outcomes at professional conferences. We also acknowledge the valuable work of our research assistants, Nathan Kelly, Kim Pavli, Julianne Sciascia, Julianne Rockingham, and Danielle Ricketson. Correspondence to Lynn A. Rempel *Associate Professor. Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/nur.21495

ß 2012 Wiley Periodicals, Inc.

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RESEARCH IN NURSING & HEALTH

changes in practitioners’ knowledge or attitudes, their practice, and the influence of practice change on health outcomes (Graham et al., 2006). The action cycle concludes with sustained knowledge use (Graham et al., 2006) involving routinization (Rogers, 2005) of new practices that are fully incorporated into regular activities. The Registered Nurses Association of Ontario (RNAO) develops evidence-based BPGs and supports BPG use by recognizing agencies that implement and evaluate RNAO guidelines as BPG Spotlight Organizations. A public health agency in Ontario, Canada, used the knowledge to action process (Graham et al., 2006) to implement the RNAO (2003) Breastfeeding Best Practice Guidelines for Nurses (Breastfeeding BPG). In this article, we report the outcomes of this process. Background Nurses’ breastfeeding knowledge, beliefs, and behaviors can significantly affect mothers’ breastfeeding success (Clifford & McIntyre, 2008). However, health professionals often feel unprepared to provide breastfeeding support (Smale, Renfrew, Marshall, & Spilby, 2006; Wambach et al., 2005), and mothers sometimes obtain conflicting information or lack desired support from health professionals (Bramhagen, Axelsson, & Hallstro¨m, 2006; Smale et al., 2006). Training nurses and other health professionals can affect breastfeeding practices and breastfeeding rates (Watkins & Dodgson, 2010), but it is unclear which method of educating health professionals consistently increases breastfeeding duration (Spilby et al., 2009). Actively involving nurses in breastfeeding training and policy development was shown by Ekstro¨m, Widstro¨m, and Nissen (2005) to improve nurses’ breastfeeding attitudes. The World Health Organization/United Nations International Children’s Emergency Fund (WHO/UNICEF, 2009) Baby-Friendly Hospital Initiative (BFHI) delineates a process of policy and practice change to ensure that all maternity facilities are centers of breastfeeding support (WHO/UNICEF, 2009). The initiative involves implementation of the Ten Steps to Successful Breastfeeding (WHO, 1998) and has been shown to improve breastfeeding initiation, duration, and exclusivity (Hannula, Kaunonen, & Tarkka, 2008; Spilby et al., 2009). Thus, the Research in Nursing & Health

RNAO breastfeeding BPG incorporates BFHI recommendations. Previously researchers focused primarily on hospital-based breastfeeding support (Spilby et al., 2009). Public health nurses (PHN) also provide prenatal and postpartum education and support to breastfeeding mothers (RNAO, 2003). Additionally, these nurses engage in health promotion at a population level (Community Health Nurses Association of Canada, 2008) through social marketing, collaboration with hospitals, social services, businesses and other agencies, and advocacy for breastfeedingfriendly environments. The effects of improving breastfeeding knowledge and behavior among nurses who have both an individual and a population health focus are unknown. In this study, we addressed these gaps by testing the implementation of the RNAO (2003) Breastfeeding BPG in the Healthy Babies/Healthy Children program of a regional public health agency that serves a population of over 400,000 in southern Ontario. Breastfeeding BPG Implementation A panel of nurses developed the breastfeeding BPG practice recommendations for nurses and healthcare organizations following a comprehensive literature review (RNAO, 2003). A summary of the recommendations is provided in Table 1. A companion self-learning package (RNAO, 2006) details supporting evidence and resources. The public health agency used multiple strategies that have evidence of effectiveness either individually or in combination (Prior, Guerin, & Grimmer-Sommers, 2008; RNAO, 2003) to achieve practice change and improved outcomes. A committee of 12 nurses, including a lactation consultant known as an opinion-leader (Flodgren et al., 2011), used a consensus process (Siddiqi, Newell, & Robinson, 2005) to tailor the BPG to their context. Information derived from a survey administered prior to implementing the BPG was used to identify gaps in nurses’ knowledge and confidence related to breastfeeding. The committee determined the optimal order and pace for implementing BPG recommendations and planned the implementation strategies. The BPG implementation was initiated with an event attended by all 36 PHNs assigned to the Healthy Babies/Healthy Children program from four district offices. The BPG and BFHI

EFFECTS OF BREASTFEEDING BEST PRACTICE GUIDELINE/ REMPEL AND McCLEARY

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Table 1. Summary of Registered Nurses Association of Ontario (2003) Breastfeeding Best Practice Guideline Recommendations Practice recommendations 1. Nurses endorse the Baby-FriendlyTM Hospital Initiative (BFHI). The BFHI directs healthcare facilities to meet the ‘‘Ten Steps to Successful Breastfeeding’’. Nurses have a role in advocating for ‘‘breastfeeding friendly’’ environments 2. Nurses and healthcare practice settings endorse the WHO recommendation for exclusive breastfeeding for the first 6 months with introduction of complementary foods and continued breastfeeding up to 2 years and beyond thereafter 3. Nurses will perform a comprehensive breastfeeding assessment of mother/baby/family, both prenatally and postnatally, to facilitate intervention and the development of a breastfeeding plan 4. Nurses will provide education to couples during the childbearing age, expectant mothers/couples/ families and assist them in making informed decisions regarding breastfeeding 5. Small, informal group health education classes, delivered in the antenatal period, have a better impact on breastfeeding initiation rates than breastfeeding literature alone or combined with formal, non-interactive methods of teaching 6. Nurses will perform a comprehensive breastfeeding assessment of mother/baby prior to hospital discharge. If a mother and baby are discharged within 48 hours of birth, there must be a face-to-face follow-up assessment conducted within 48 hours of discharge by a qualified healthcare professional. Discharge of mother and baby after 48 hours should be followed by a telephone call within 48 hours of discharge 7. Nurses with experience and expertise in breastfeeding should provide support to mothers. Organizations should consider establishing and supporting peer support programs, alone or in combination with one-to-one education from health professionals, in the antenatal and postnatal periods Education recommendations 8. Nurses providing breastfeeding support should receive mandatory education in breastfeeding in order to develop the knowledge, skill, and attitudes to implement breastfeeding policy and to support breastfeeding mothers Organization and policy recommendations 9. Practice settings need to review their breastfeeding education programs for the public, and, where appropriate, make the necessary changes based on recommendations in this best practice guideline 10. Practice settings/organizations should work towards being accredited by the Baby-FriendlyTM Hospital Initiative 11. Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation Note: Recommendations abbreviated from Registered Nurses Association of Ontario (2003), pp. 10–13. The full BPG is available to download at no cost at rnao.org.

recommendations were presented in a lecture, and nurses engaged in interactive education (Forsetlund et al., 2009) by dividing into groups to discuss how well the agency was meeting the BPG recommendations and how the agency could improve. A breastfeeding checklist for home visits, telephone breastfeeding assessments, and a new ‘‘Choose Breastfeeding’’ pamphlet were introduced. These new resources supported integration of the BPG recommendations into the process of nursing care (Gross & Pujat, 2001; Richens, Rycroft-Malone, & Morrell, 2004). Additional resources were developed throughout the 16 months of BPG implementation (see Table 2). During the implementation period, any nurses new to the Healthy Babies/Healthy Children program received orientation to the Breastfeeding BPG and relevant resources. Electronic Research in Nursing & Health

mail reminders (Prior et al., 2008) about BPGrelated information and processes were sent weekly over 6 weeks to all nurses near the end of the implementation year. Feedback regarding the results of pre-implementation surveys—a type of practice audit (Jamtvedt, Young, Kristoffersen, O’Brien, & Oxman, 2006)—was presented at a staff meeting. To enhance continuity across health sectors, nurses offered optional breastfeeding lectures to hospital maternal child nurses. Finally, a committee of nurses and managers joined with local hospitals and other agencies to begin work towards achieving hospital and community services Baby-Friendly Initiative designations (Breastfeeding Committee for Canada, 2002). Consistent with the knowledge to action process, research was conducted to evaluate this multi-faceted breastfeeding BPG

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Table 2. Resources and Activities for Integrating the Breastfeeding Best Practice Guidelines Recommendations Into the Process of Care Breastfeeding checklist developed for prenatal home visits, postnatal home visits, and telephone breastfeeding assessments Revised breastfeeding handouts and information resources and developed new ‘‘Choose Breastfeeding’’ pamphlet Breastfeeding Passport developed to help mothers record breastfeeding-related data and support mothers’ communication with various healthcare providers Postpartum visit assessment guideline card Electronic documentation flow-sheet Breastfeeding teaching kit (with teaching aides for work with individuals and community groups) Introduction of a prenatal breastfeeding workshop Supported an annual event that brings mothers together to breastfeed in a public venue

implementation. The researchers sought to address the following questions about the implementation of the breastfeeding BPG: (1) (2) (3)

What is the effect on PHNs’ knowledge, beliefs, and behavior regarding breastfeeding and breastfeeding promotion? What is the effect on mothers’ breastfeeding duration, exclusivity, and intentions to continue breastfeeding? What is the effect on the sources of help accessed by mothers and the amount of guidance obtained from health professionals?

Methods Sample and Procedure Ethics approval was obtained from university, public health agency, and hospital ethics committees. We chose a pre- and post-design to evaluate the BPG implementation because funding restrictions limited the feasibility of data collection in more than one public health agency. Nurses in the Healthy Babies/Healthy Children program completed questionnaires at a regional staff meeting in 2007, prior to implementation of the BPG (pre-implementation). Post-implementation questionnaires were completed in 2009, at the end of the 16-month implementation period. Of the 46 nurses who completed questionnaires, 17 completed both pre- and post-implementation questionnaires (representing almost half of the program staff of 36 nurses), 14 completed only the first questionnaire, and 15 completed only the second questionnaire. Participants had been Research in Nursing & Health

registered nurses for 7–40 years (M ¼ 25) and had worked in a public health maternal child program for 1–30 years (M ¼ 9.5). Mothers who gave birth in one of the four regional hospitals in the study were recruited by Healthy Babies/Healthy Children hospital liaison nurses. The liaison nurses informed all mothers who gave birth in one of the four regional hospitals about the study, and obtained mothers’ contact information. Mothers who had home births attended by independent Registered Midwives were provided study information letters by their midwives. A cohort of 90 mothers was recruited over a 3-week period within 1 month of the BPG initiation in 2007. A total of 180 mothers was required to provide 80% power to detect a 15% increase in 6-month breastfeeding prevalence (assuming preimplementation prevalence at 0.40). Based on monthly birth rates, we expected to be able to recruit this number of mothers during the preimplementation recruitment period. Because participation was lower than expected, the 2008 post-implementation recruitment period was increased to 5 weeks, resulting in a second cohort of 141 mothers. Each cohort represented approximately one-third of the total births and the number of mothers asked to participate during the recruitment time periods. Demographic characteristics of the sample can be found in Table 3. The first author trained five undergraduate upper-level nursing students as research assistants (RAs). Training included review and practice of the study procedures (i.e., process of arranging telephone interviews, obtaining consent and adhering to ethical standards, administering the questionnaire, skip patterns in the questionnaire). Data were collected by telephone. RAs were observed conducting their first telephone contacts. The authors met


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Table 3. Maternal Cohort Demographic Characteristics Characteristic

Pre-BPG (n ¼ 90)

Post-BPG (n ¼ 141)

Age Completed High School Years of College or University Education Employed prior to birth of infant Intend to return to employment Anticipated infant age at return to work Married or living common-law Family income Primipara Breastfed previous child if multipara Duration of breastfeeding with last child

28.9 (4.9) 96% 2.8 (2.0) 91% 91% 12.6 months (9.0) 91% $60,000–$80,000 48% 96% 7.3 months (5.3)

30.5 (5.2) 95% 2.9 (2.3) 94% 87% 13.4 months (11.2) 97% $60,000–$80,0000 42% 91% 8.2 months (6.7)

Note: Family income is the median category. Other characteristics are reported using M (SD). p ¼ .01.

regularly with the RAs and were available during telephone interviews. At 2 weeks postpartum, RAs obtained informed consent and had mothers complete the first questionnaire. Mothers who were still breastfeeding at 2 weeks were surveyed at 2 months. Those breastfeeding at 2 months were also surveyed at 6 months postpartum. Survey time-points reflect breastfeeding periods assessed in other breastfeeding studies (Ip et al., 2007). Measures Public health nurse questionnaire. Research team members, including a lactation consultant from the BPG implementation committee, developed the nurse questionnaire for assessing both knowledge of the breastfeeding BPG recommendations and expected outcomes of the BPG implementation. Although not pilot tested, this questionnaire was edited for clarity and grammar based on feedback from the research ethics review and a RA. The paper and pencil questionnaire took about 20 minutes to complete. Breastfeeding BPG knowledge. The questionnaire was used to assess nurses’ familiarity with BPG content and knowledge of a core recommendation, endorsement of the BFHI. Familiarity was measured with six statements containing content that could plausibly be found in a breastfeeding guideline. Respondents circled yes, no, or unsure to indicate if that content was found in the breastfeeding BPG. A score of 2 was assigned for correct responses, 1 for unsure, and 0 for incorrect. A statement regarding the anatomy and physiology of breastfeeding that was not specified in the BPG Research in Nursing & Health

recommendations but was included in the selflearning package was assigned 1 if chosen as a recommendation. The total possible score for familiarity was 11. Knowledge of the BFHI was measured by asking respondents to list the WHO/UNICEF Ten Steps to Successful Breastfeeding on 10 numbered blank lines. The first author assigned a score of 2 for each statement including all the correct content for a step, 1 for each partially correct and 0 for an incorrect statement, for a total possible BFHI knowledge score of 20. Breastfeeding beliefs. The BPG indicates that to implement breastfeeding policy and support breastfeeding mothers, nurses must develop positive beliefs (RNAO, 2003). Beliefs were measured in three ways. Nurses’ overall belief about breastfeeding support was measured by an item asking nurses to rate the importance for them that the mothers they assist breastfeed successfully, on a 0 (not at all important) to 4 (extremely important) scale. Second, nurses used a 0 (no impact) to 4 (greatly significant impact) scale to rate their beliefs regarding the influence of nine BPGrecommended actions on overall breastfeeding success: prenatal breastfeeding education; support from partner, family, friends, healthcare professional, and educated peers; avoidance of bottles and artificial teats (also called pacifiers) in the first month; and consistent breastfeeding instruction from healthcare providers. Third, nurses rated their beliefs about the WHO breastfeeding duration recommendations using a breastfeeding duration beliefs scale. This scale was adapted from a scale measuring mothers’ breastfeeding intentions (Rempel, 2004) to breastfeed to various time points. The scale stem was revised to ask nurses how

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strongly, on a scale from 0 (definitely should not) to 10 (definitely should), they believed a woman should breastfeed a baby at various ages. Target ages were revised to 1, 3, 6, and 9 months, and to 1, 1.5, 2, 2.5, and 3 years to better assess beliefs about extended breastfeeding. Use of BPG implementation resources. The first author and the public health agency BPG coordinator developed a list of breastfeeding BPG implementation activities and resources for the post-implementation survey. The BPG coordinator, implementation committee members, and the second author checked the items for clarity. Nurses were asked if they participated in the activity or accessed the resource, and, if so, how useful each item had been to their practice. Response options were 0 ¼ not at all useful to 4 ¼ extremely useful. Breastfeeding promotion confidence. The BPG indicates that nurses should develop skills for breastfeeding promotion. Because it was not feasible to directly assess the nurses’ breastfeeding support skills, confidence regarding provision of breastfeeding information was used as a proxy for skill. Items measured nurses’ confidence in their ability to provide current evidence-based information about eight topics related to breastfeeding BPG recommendations from 0 (not at all confident) to 4 (extremely confident). Breastfeeding promotion behavior. Two forms of breastfeeding promotion were measured—breastfeeding advocacy and providing prenatal breastfeeding information. Advocacy was measured by how often nurses engaged in advocacy recommended by the implementation committee. Types of advocacy included: informing families about breastfeeding support groups, breastfeeding benefits, and exclusive breastfeeding to 6 months; informing employers about breastfeedingconducive work environments; informing school officials regarding discussion of breastfeeding in primary schools; and informing other professionals and the public regarding their responsibilities related to the WHO code on marketing of infant formula. Possible responses on the breastfeeding advocacy scale ranged from 0 (never) to 4 (routinely). Prenatal information provision was measured by how often nurses discussed breastfeeding intentions, confidence, physical factors that might affect breastfeeding, support, and the effects of medications with prenatal clients. Research in Nursing & Health

Response options ranged from 0 (never) to 4 (always). Maternal breastfeeding survey. The maternal breastfeeding survey was developed for this study by the research team lactation consultant and the first author. The survey was designed to measure breastfeeding outcomes at 2 weeks, 2 months, and 6 months. In addition, the survey measured the extent to which mothers obtained information and help that was consistent with the BPG recommendations. The maternal breastfeeding questionnaire was predominantly based on scales that had been used in previous studies (e.g., Rempel, 2004; Rempel & Moore, 2012). The questionnaires, administered by the RAs conducting the telephone interviews, were formatted to indicate when to skip non-applicable items. The questionnaires took 20–30 minutes to complete. Breastfeeding status. Breastfeeding status was measured using items designed for use by other provincial health departments to measure outcomes for community Baby-Friendly Initiative designation (Breastfeeding Committee for Canada, 2002). Mothers were asked if they were still breastfeeding. Breastfeeding mothers were asked if they had fed anything to their infants other than breast milk in the previous 7 days to determine current breastfeeding exclusivity. Mothers who had discontinued breastfeeding were asked the baby’s age, in weeks, when breastfeeding was stopped. Intention to continue breastfeeding. Breastfeeding mothers were asked how long they planned to breastfeed in months. Breastfeeding intention strength was measured using a scale developed by Rempel (2004). RAs asked mothers to choose a number from 0 (definitely do not intend) to 10 (definitely do intend) to indicate how strongly they intended to breastfeed based on the baby’s age in months when their baby was 2, 4, 6, 9, 12, 15, 18, 24, and >24 months old. Perceived problems with breastfeeding. Breastfeeding problems were assessed by asking mothers to rate 19 common breastfeedingrelevant problems (Rempel & Moore, 2012). The interviewer told mothers the range of response options from 0 (no problem) to 5 (a very serious problem), and asked how problematic each item had been. Sources of information and help with breastfeeding. Using a measure of breastfeeding support (Rempel & Moore, 2012), RAs provided mothers with a list of local professional sources of postpartum breastfeeding help. The


mothers were asked how frequently they had used each source of help with the timeframe reflective of when the list was administered (e.g., since hospital discharge, 2 weeks, or 2 months). A new scale was developed for this study to assess the extent to which mothers had been exposed to conversations with health professionals regarding breastfeeding-related topics. The list of topics included content that the implementation committee had disseminated to health professionals in the community. Mothers indicated whether a healthcare provider had talked to them about each topic. Statistical Analyses Data were analyzed using SPSS 17 (Chicago, IL). Differences between mean scores for nurses who completed both pre- and postimplementation questionnaires were analyzed with paired-samples t-test. Differences between nurses’ responses on items within scales were analyzed with repeated measures ANOVA. Differences in proportions of nurses and mothers were analyzed using x2 and mean differences between maternal cohorts were analyzed using independent-samples t-test.

Results Effect on Public Health Nurses’ Knowledge, Beliefs, and Behavior BPG implementation evaluation. The implementation resources most commonly used by the 32 post-implementation nurses were the revised parenting resource guide and breastfeeding handouts (94%), the home visit and telephone checklists (91%), the breastfeeding passport (84%), and the electronic documentation flow sheet (81%). The breastfeeding passport was rated as moderately useful, with a mean score of 2.3 (SD ¼ 1.0). Other resources were considered very or extremely useful, with mean ratings greater than 3.0. Breastfeeding BPG knowledge. The 15 nurses who completed both surveys increased their mean BPG familiarity score from 7.1 to 8.1, t(14) ¼ 2.48, p ¼ .03, 95% CI [0.1, 1.9]. Twenty-three pre-BPG implementation and 27 post-implementation nurses were able to list at least one of the Ten Steps for Successful Research in Nursing & Health

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Breastfeeding. The overall mean BFHI knowledge score increased from 3.9 out of 20 (range: 0–14) to 6.7 (range: 0–20). Nurses who completed both surveys increased their mean score from 4.2 (SD 4.4) to 10.3 (SD 6.3), t(16) ¼ 3.82, p ¼ .001, 95% CI [2.7, 9.4], and the mean number of steps listed from 2.3 (SD 2.3) to 5.8 (SD 3.3), t(16) ¼ 3.94, p ¼ .001, 95% CI [1.5, 4.9]. The response frequencies for each of the 10 steps are presented in Table 4. Pre-BPG implementation, nurses listed precautions against supplementing with infant formula and use of artificial teats and pacifiers more often than any other steps. Post-implementation, more nurses listed provision of prenatal breastfeeding information and fostering support groups more than they had pre-implementation. Breastfeeding beliefs. Most nurses reported that the breastfeeding success of the mothers they assist was extremely important to them (nPre-BPG ¼ 19, 68%; nPost-BPG ¼ 24, 75%). Most nurses also indicated that support from family, friends, and healthcare professionals would have a significant to greatly significant influence on breastfeeding success. Nurses who completed both surveys showed a statistically significant increase in their belief that avoiding pacifiers in the first 3–4 weeks following birth positively influences breastfeeding success, MPre-BPG ¼ 2.5, SD ¼ 1.2; MPost-BPG ¼ 3.4, SD ¼ 0.9; t(16) ¼ 2.75, p ¼ .01, 95% CI [0.1, 1.5]. The average strength of nurses’ beliefs about whether a woman should breastfeed a baby at ages from 1 month to 3 years is displayed in Figure 1. Nurses strongly supported breastfeeding to 6 months but were less supportive of BPG-recommended continued breastfeeding for 2 years or longer. As shown in Table 5, the nurses who completed both surveys increased the strength of their beliefs for breastfeeding to a year and beyond. Breastfeeding promotion confidence. Results regarding nurses’ confidence in providing breastfeeding information are presented in Table 6. There were no significant changes in nurses’ confidence over time. However, nurses were significantly more confident with some topics than others before BPG implementation, repeated measures F(7, 20) ¼ 8.08, p < .001 and post-implementation, repeated measures F(7, 23) ¼ 6.64, p < .001. Pre-implementation, nurses were significantly more confident in providing current evidence-based information to mothers about community resources, benefits of

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Table 4. Nurses’ Identification of ‘‘Ten Steps to Successful Breastfeeding’’ Pre-BPG (n ¼ 23)

Step Have a written breastfeeding policy that is routinely communicated to all healthcare staff Train all healthcare staff in the skills necessary to implement this policy Inform all pregnant women about the benefits and management of breastfeeding Help mothers to initiate breastfeeding within a half-hour of birth Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants Give newborn infants no food or drink other than breast-milk, unless medically indicated Practice rooming-in, allow mothers and infants to remain together 24 hours a day Encourage breastfeeding on demand Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

breastfeeding, and breastfeeding duration and the introduction of solid foods than they were about providing information about other topics. They were also significantly less confident providing information about supplementation and management of breastfeeding difficulties than about prenatal breastfeeding education and mothers’ breastfeeding rights. Postimplementation, the nurses were more confident providing information about the rights of the breastfeeding mother and less confident

Post-BPG (n ¼ 27)

Correct n (%)

Partially Correct n (%)

Correct n (%)

Partially Correct n (%)

0

1 (4%)

3 (11%)

11 (41%)

1 (4%)

3 (13%)

15 (56%)

3 (11%)

5 (22%)

4 (17%)

19 (70%)

2 (7%)

9 (39%)

3 (13%)

11 (40%)

3 (11%)

8 (35%)

0

6 (25%)

0

5 (22%)

12 (52%)

13 (46%)

6 (27%)

8 (35%)

2 (8%)

16 (60%)

0

9 (39%) 11 (48%)

0 4 (17%)

6 (22%) 17 (73%)

0 2 (7%)

0

8 (35%)

6 (22%)

12 (44%)

providing information about the risks of formula feeding than they had been pre-implementation. Breastfeeding promotion behavior. The post-BPG implementation frequency of nurses’ discussion with prenatal mothers about influences on breastfeeding success is summarized in Table 7. Both pre- and postimplementation nurses provided significantly more information about breastfeeding intentions and support than about mothers’ breastfeeding confidence, medications or physical factors,

FIGURE 1. Public health nurses’ beliefs that a woman should breastfeed by child’s age and mothers’ 2-month breastfeeding intentions. Research in Nursing & Health


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Table 5. Changes in Nurse Beliefs Regarding Breastfeeding for 1 Year and Longer Pre-BPG

Post-BPG

95% CI

Infant Age (years)

M

SD

M

SD

t(14)

p-Value

LL

UL

1 1.5 2 2.5 3

7.2 6.2 4.9 3.6 3.5

2.5 2.2 2.7 3.1 3.0

8.4 7.5 6.7 5.5 5.0

1.8 1.4 1.4 2.1 2.3

2.36 2.43 4.10 3.50 3.29

.03 .03 .001 .004 .005

0.1 0.1 0.9 0.7 0.5

2.4 2.4 2.7 3.0 2.5

CI, confidence interval; LL, lower limit; UL, upper limit. Note: Sample size (n ¼ 15) limited to nurses who completed both surveys and all belief measures. Breastfeeding beliefs to each age measured on a scale from 0 (definitely should not) to 10 (definitely should).

repeated measures FPre-BPG(4, 26) ¼ 6.73, p ¼ .001; FPost-BPG(4, 28) ¼ 12.71, p < .001, respectively. Post-implementation they discussed mothers’ breastfeeding confidence more often than medications or physical factors. Both pre- and post-implementation, most nurses occasionally to routinely provided nursing mothers with information about mothers’ right to breastfeed in public (70%, 78%, respectively), but many never provided information to employers (67%, 62%), school officials (90%, 88%), or other professionals and the public (55%, 32%). Seventy-one percent and 66% of nurses, respectively, routinely provided factual information to families; 39% and 34% routinely provided information about peer supports. Before and after BPG implementation, most nurses reported being moderately or very helpful when assisting a mother with proper latching and positioning and breastfeeding difficulties (80%, 79%, respectively).

Effect on Mothers’ Breastfeeding Duration, Exclusivity, and Breastfeeding Intentions Breastfeeding Status Breastfeeding rates at each post-implementation follow-up assessment are summarized in Table 8. Ninety percent of pre-implementation and 88% of post-implementation mothers who were breastfeeding at 2 weeks were contacted at 2 months. Two-thirds of mothers in both cohorts were still breastfeeding. All pre-implementation and 92% of postimplementation mothers who were breastfeeding at 2 months were contacted at 6 months; 65% of the 60 pre-implementation mothers and 68% of the 84 post-implementation mothers reported still breastfeeding. There were no statistically significant changes in breastfeeding status from pre-implementation to post-BPG implementation.

Table 6. Nurses’ Confidence to Provide Current Evidence-Based Information Pre-BPG Topic Benefits of breastfeeding Breastfeeding duration and introduction of solid foods Community resources and supports Prenatal breastfeeding education Rights of the breastfeeding mother Guidance with supplementation Risks of formula feeding Management of breastfeeding difficulties

Post-BPG

M (SD)

95% CI

M (SD)

95% CI

3.6 (0.6)a 3.6 (0.6)a 3.5 (0.6)a 3.2 (0.8)b 3.0 (1.1)b 2.8 (0.8)c 2.7 (1.3)b, c 2.7 (0.8)c

[3.4, 3.8] [3.4, 3.8] [3.3, 3.8] [2.9, 3.5] [2.6, 3.4] [2.6, 3.1] [2.2, 3.2] [2.4, 3.0]

3.7 (0.5)a 3.7 (0.7)a 3.5 (0.6)a 3.2 (0.9)b 3.4 (0.7)a, b 2.9 (0.9)c 2.9 (1.1)c, d 2.6 (0.9)d

[3.5, 3.8] [3.4, 3.9] [3.3, 3.7] [2.9, 3.6] [3.2, 3.6] [2.6, 3.2] [2.5, 3.3] [2.3, 2.9]

Note: Confidence to provide each form of information measured on a scale from 0 (not at all confident) to 4 (extremely confident). CI ¼ confidence interval. Means within a column with different subscripts (e.g., ‘‘a’’ and ‘‘b’’) differ significantly, p < .05 in the Student–Newman–Keuls multiple comparison. Means within a column that share the same subscripts do not differ significantly. Items with two subscripts do not differ significantly from any item with which they share either subscript.


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Table 7. Nurse Discussion of Influences on Breastfeeding Success With Prenatal Mothers Pre-BPG (n ¼ 31) Topic Intent to breastfeed Availability of supports following delivery Confidence in being able to breastfeed Impact of medication on breastfeeding Physical considerations such as inverted nipples or past breast surgery

Post-BPG (n ¼ 29)

M (SD)

95% CI

M (SD)

95% CI

3.5 (1.0)a 3.5 (1.1)a 3.1 (1.2)b 2.8 (1.1)b 2.8 (1.2)b

[3.1, 3.8] [3.2, 3.9] [2.7, 3.6] [2.4, 3.2] [2.4, 3.3]

3.8 (0.5)a 3.8 (0.4)a 3.5 (0.6)b 2.9 (0.9)c 2.7 (1.2)c

[3.6, 3.9] [3.7, 3.9] [3.3, 3.7] [2.6, 3.2] [2.3, 3.1]

Note: Frequency of discussion of each topic measured on a scale from 0 (never) to 4 (always). CI ¼ confidence interval. Means within a column with different subscripts (e.g., ‘‘a’’ and ‘‘b’’) differ significantly, p < .05. Means within a column that share the same subscripts do not differ significantly.

Intentions to continue breastfeeding. The average planned breastfeeding duration at 2 weeks was 8.6 months pre-BPG implementation (SD ¼ 4.0) and 9.1 months (SD ¼ 4.7) post-implementation. Mothers’ 2-month breastfeeding intention strengths are shown in Figure 1. The pattern of change in intention strength is similar to that of the nurses’ breastfeeding beliefs. Post-implementation, mothers who continued breastfeeding to 2 months were slightly more comfortable with the possibility of breastfeeding for 24 months, M (SD)Pre-BPG ¼ 0.2 (1.0), M (SD)Post-BPG ¼ 0.7 (2.4), unequal variances t(130) ¼ 1.75, p ¼ .08, 95% CI [0.07, 1.0]. The same was found for intentions to breastfeed longer than 24 months, M (SD)Pre-BPG ¼ 0.2 (0.1), M (SD)Post-BPG ¼ 0.3 (1.5), unequal variances t(92) ¼ 1.86, p ¼ 0.7, 95% CI [0.02, 0.6]. At 6 months, post-implementation mothers intended to breastfeed somewhat longer, M (SD)Post-BPG ¼ 12.4 months (5.2), M (SD)Pre-BPG ¼ 11.0 months, (2.6), unequal variances t(86.8) ¼ 1.75, p ¼ 0.8 95% CI [0.2, 3.0]. Post-implementation strength of intention to breastfeed for 12 months was

significantly higher, M (SD)Pre-BPG ¼ 0.2 (1.0), M (SD)Post-BPG ¼ 1.3 (3.1), unequal variances t(94) ¼ 2.06, p ¼ 0.5, 95% CI [0.2, 1.9]. The post-implementation variance in strength of intention to breastfeed to 15, 18, 24, and longer than 24 months was significantly higher than it had been pre-BPG, indicating greater willingness to consider breastfeeding to those time points. No pre-implementation mother at 6 months had any intention to breastfeed longer than 24 months. Perceived problems with breastfeeding. At 2 weeks, 99% of the mothers in each cohort reported having at least one breastfeeding problem. At 2 months, 95% and 96% of mothers, respectively, reported having had a breastfeeding problem since 2 weeks postpartum. At 6 months, significantly fewer post-implementation mothers reported having given formula since 2 months because a healthcare provider expressed concern about the baby’s weight (Pre-BPG: 26%; Post-BPG: 4%, x2 (2, n ¼ 93) ¼ 9.70, p ¼ .002), or because the mothers could not tell how much the baby was drinking (Pre-BPG: 26%; Post-BPG: 7%, x2 (2, n ¼ 93) ¼ 5.89, p ¼ .02).

Table 8. Breastfeeding Rates by Cohort Pre-BPG (n ¼ 90)

Post-BPG (n ¼ 141)

Breastfeeding Outcome

n

% of Full Cohort

n

% of Full Cohort

Still breastfeeding at 2 weeks Exclusive breastfeeding in 7 days previous to 2 weeks Introduced soother prior to 2 weeks Still breastfeeding at 2 months Exclusive breastfeeding at 2 months Still breastfeeding at 6 months No formula before 6 months

80 54 30 60 25 39 12

89 60 33 67 28 43 13

123 80 54 91 47 57 18

87 57 38 65 33 40 13


EFFECTS OF BREASTFEEDING BEST PRACTICE GUIDELINE/ REMPEL AND McCLEARY 11

Effect on Sources of Help and Professional Guidance for Mothers Mothers’ use of breastfeeding help differed following BPG implementation. At 2 weeks, significantly more post-BPG implementation than pre-implementation mothers indicated that they knew telephone numbers to use for breastfeeding help, 93% versus 98%, x2 (2, n ¼ 203) ¼ 4.42, p ¼ .04. The most commonly used sources of breastfeeding help in both cohorts were the PHN telephone call (PreBPG: 67%; Post-BPG: 79%), the PHN home visit (Pre-BPG: 32%; Post-BPG: 36%), and physicians (Pre-BPG: 27%; Post-BPG: 36%). At 2 months, significantly more post-BPG mothers reported receiving PHN help through a combination of Parent Talk Line contacts, home visits, and telephone contacts, 50% versus 33%, x2 (2, n ¼ 175) ¼ 5.60, p ¼ .02. Physicians remained common sources of help at 2 months (Pre-BPG: 33%; Post-BPG: 48%). Conversations with healthcare providers also differed following BPG implementation. At 2 weeks, post-implementation mothers reported discussing more of 10 possible breastfeedingrelated topics with their healthcare providers since discharge than pre-implementation mothers, M (SD) ¼ 5.8 (3.1) versus 4.9 (3.1), respectively, t(226) ¼ 2.14, p ¼ .03, 95% CI [0.1, 1.8]. Significantly more post-implementation mothers reported talking about ways to increase milk production, 50% versus 38%, x2 (2, n ¼ 227) ¼ 4.54, p ¼ .03, and the effects of medications on breastfeeding, 39% versus 21%, x2 (2, n ¼ 228) 8.21, p ¼ .004. At 2 months, more post-implementation than pre-implementation mothers discussed milk production, 53% versus 35%, x2 (2, n ¼ 178) ¼ 5.67, p ¼ .02, and where to find help with breastfeeding, 70% versus 50%, x2 (2, n ¼ 178) ¼ 4.86, p ¼ .03. However, at 6 months, more pre-implementation than postimplementation mothers discussed length of intended breastfeeding, 32% versus 16%, x2 (2, n ¼ 142) ¼ 5.40, p ¼ .02. Discussion With this study, we demonstrate that implementing the RNAO breastfeeding BPG and principles consistent with the BFHI can change PHNs’ knowledge and beliefs and affect mothers’ breastfeeding intentions and experiences. Nurses increased their familiarity with the Research in Nursing & Health

BPG recommendations and the BFHI, and strengthened their beliefs that mothers should breastfeed for 1 year and beyond. Mothers obtained more breastfeeding help from PHNs, discussed more breastfeeding topics with healthcare providers, and mothers who were still breastfeeding at 6 months increased their intended breastfeeding duration. Nurses increased their breastfeeding BPG knowledge with respect to breastfeeding beliefs and actions that were generally congruent with the breastfeeding BPG prior to BPG implementation. However, nurses’ confidence and self-reported provision of breastfeeding support did not change. This limited behavior change might be related to the complexity of the process of innovation and change within an organization (Rogers, 2005). It can take a long time for system changes such as the use of flow-sheets and checklists to become incorporated into routine practice (Rogers, 2005). Further changes in nurses’ beliefs and behaviors might be realized as organizational processes become more routinized and new implementation strategies based on evaluation are adopted (Graham et al., 2006). One area where nurses expressed consistently lower confidence was regarding management of breastfeeding difficulties and formula supplementation. Nurses were more likely to note precautions against supplementation and pacifier use prior to implementation than they were to note other steps to successful breastfeeding. Moreover, after BPG implementation, nurses believed that pacifiers had an even greater impact on breastfeeding than they believed before implementation. Despite this, maternal pacifier use and formula supplementation did not decrease. Supplementation and pacifier use are connected to social norms regarding management of infant crying and hunger and are signs of breastfeeding challenges. Indeed, it is stated in the BPG that supplementing and use of pacifiers may not cause breastfeeding cessation but rather be responses to the problems that lead to breastfeeding cessation (RNAO, 2003). Nurses should focus less on convincing mothers to avoid these practices and more on improving breastfeeding management. Lack of change in rates of breastfeeding at 1-week postpartum may be partly explained by the limited change in nurses’ beliefs and behaviors. However, early breastfeeding duration is highly influenced by hospital practices (RNAO, 2003)—which were indirectly

12


influenced by the PHNs as they collaborated with hospitals, provided education for hospital staff, and advocated for breastfeeding-friendly environments. The PHNs engaged in a protracted process of developing collaborations with hospital nurses and physicians regarding baby-friendly practices. This meant that important interventions, such as the decision to seek Baby Friendly Initiative designation and the inception of prenatal breastfeeding workshops, were developed near the end of the implementation period. Given the gradual nature of such population-based changes, it might take longer than the 1-year period evaluated in this study for the effect of the BPG intervention on early breastfeeding to become apparent. Breastfeeding Duration Beliefs Nurses’ beliefs regarding extended breastfeeding are relevant to promoting breastfeeding duration beyond 6 months. Initially, nurses’ beliefs were consistent with the WHO/UNICEF (1990) recommendation regarding exclusive breastfeeding to 6 months but less consistent with the recommendation that breastfeeding should continue to 2 years and beyond. There is growing evidence of the health benefits of breastfeeding beyond 1 year for mothers and infants in developed countries (Ip et al., 2007; Meyers, 2009). Throughout the BPG implementation, nurses were encouraged to endorse the WHO recommendations. As they learned more about the benefits of continued breastfeeding and communicated this to mothers, nurses increased their beliefs that children should be breastfed to 1 year and longer. The change in nurses’ beliefs may have led some mothers in the post-implementation cohort who were still breastfeeding at 2 and 6 months to consider breastfeeding for 12 months or longer, a choice that is not socially normative (Rempel, 2004). PHNs are credible experts who mothers may have used to gauge the acceptability of extended breastfeeding (Petty and Brinõl, 2008). Alternatively, some mothers might have provided the response they had learned from nurses without actually intending to continue breastfeeding. Because breastfeeding data collection from each cohort of mothers was limited to 6 months, actual breastfeeding rates at 12 months are unknown. However, most mothers did not expect to return to work for 12 months. Since 2001, Canadian Employment Research in Nursing & Health

Insurance maternity and parental benefits provide up to 50 weeks of paid leave. This has been associated with increased breastfeeding duration from 3 to 6 months (Baker & Milligan, 2008), and could contribute to increasing the prevalence of breastfeeding at 12 months. However, the benefit was available to both cohorts, so it does not explain the difference in intentions. There remains a notable difference between mothers’ and nurses’ beliefs about the continuation of breastfeeding longer than 6 months. Further research should be conducted to understand the reasons for that difference and guide development of creative strategies, such as ongoing professional or peer interaction with breastfeeding mothers, public sector advocacy to create welcoming places for breastfeeding toddlers, or social marketing campaigns that build on the gradually increasing acceptance of extended breastfeeding. Breastfeeding Support The process of BPG implementation appeared to improve the accessibility of professional breastfeeding support. Mothers were more aware of sources of telephone support and increased their use of PHN breastfeeding support. BPG implementation activities involving collaboration with other sectors (Community Health Nurses Association of Canada, 2008) strengthened communication with other health professionals regarding breastfeeding and baby-friendly practices and provided mothers with a resource to foster communication with healthcare providers. This combination of activities might have increased discussion of breastfeeding-related topics between mothers and their non-nursing healthcare providers. The only topic that was less commonly discussed after BPG implementation was intended length of breastfeeding. This potentially spurious finding appears somewhat inconsistent with the trend toward increased comfort with extended breastfeeding; it might be due to the individual, client-specific nature of breastfeeding support. Perhaps because of mothers’ greater use of PHN support, use of peer breastfeeding support did not increase. Nurses believed quite strongly that the support of an educated peer is important to breastfeeding success. Yet nurses did not routinely provide information about support groups to breastfeeding mothers. PHNs


are expected to empower individuals and groups to address their own health needs (Community Health Nurses Association of Canada, 2008). Thus, ongoing BPG implementation should include the development and support of peer breastfeeding support. Such support could be particularly effective at increasing exclusive breastfeeding in the first 6 months (Clifford & McIntyre, 2008; Sikorski, Renfrew, Pindoria, & Wade, 2003). Advocacy Advocacy is another expected community health competency. The BPG recommends that nurses advocate for breastfeeding-friendly environments. However, nurses infrequently reported breastfeeding promotion practices involving advocacy with employers, other professionals, and the public and developing peer support. Given that nurses more commonly provided mothers information about mothers’ rights to breastfeed in public, it might be that nurses were more comfortable with and committed to direct client action rather than advocating with public and corporate entities. Research is needed to understand nurses’ attitudes towards advocacy and determine ongoing implementation strategies aimed at enhancing advocacy competencies. A focused assessment of barriers to enacting new behaviors would be consistent with the knowledge to action process (Graham et al., 2006), resulting in the iterative development of new implementation strategies to sustain and build on initial BPG implementation success. Nurses would benefit from interactive, practical education (Prior et al., 2008), such as facilitated group problem-based learning sessions (Althabe et al., 2008), to address self-determined learning needs in areas of reduced breastfeedingrelated confidence. Nurses who are more confident managing breastfeeding challenges and arranging peer support could help mothers manage their early parenting challenges more effectively, and, in the process, reduce mothers’ use of artificial teats and supplementation and breastfeed more successfully in the first 6 months. Limitations Methodological challenges in clinical guideline implementation research are frequent, especially Research in Nursing & Health

when, as recommended by Graham et al. (2006), practitioners are actively involved in the process of determining their own unique strategies for guideline dissemination and utilization. Pre- and post-designs, such as the one used in this current study, are often the most feasible method for detecting changes expected from guideline implementation despite their inability to establish causality. Measures used in this study were predominantly developed by the investigators to connect knowledge, behavior, and outcomes directly to the BPG recommendations. Time constraints precluded preliminary psychometric testing of the study-specific measures. The limited number of significant results could be due to problems with the reliability or sensitivity of these new measures. The size of the maternal cohorts may have limited the number of statistically significant results. Ethical and privacy concerns prevented RAs from directly approaching new mothers in hospital regarding study participation and might have contributed to low participation rates. All new mothers were approached for the study but only one-third of the mothers participated, resulting in a non-representative sample. Caution should be taken in generalizing these results. The investigators did not assess mothers’ actual exposure to the new BPG-related resources or other BPG-informed PHN interventions. The changes in breastfeeding intentions reported by mothers were modest. However, the positive trend in intentions was an improvement over findings from a previous study of RNAO breastfeeding guideline implementation that found a reduction in exclusive breastfeeding in hospital (Davies, Edwards, Ploeg, & Virani, 2008). Furthermore, the modest changes are consistent with previous research indicating that guideline implementation can achieve effects sizes of about 10% (Grimshaw et al., 2004; Grol & Grimshaw, 2003). Even small effects can be important, especially when, as in the case of public health interventions, outcomes are difficult to influence (Prentice & Miller, 1992) and observed community-level impacts tend to be modest (Merzel & D’Afflitti, 2003). Consistent with recommendations for guideline implementation, the organization did not fully implement some BPG recommendations during this study. The process of integrating new knowledge into practice begins with adapting the knowledge to the local context (Graham et al., 2006) by prioritizing from the multiple

14


recommendations within a given BPG (RNAO, 2002). Limited attention was given to recommendations such as advocacy for breastfeedingfriendly communities and peer breastfeeding support. An added focus on these recommendations might increase the positive trends noted in this study. Continuing to partner with hospitals to foster multi-sector compliance with Baby-Friendly Initiative practices and increased advocacy for supportive community policies are community health strategies that could also further the gains realized by the BPG implementation. Research regarding the challenges faced by nurses who are expected to engage in a combination of direct-client, group, and population-level breastfeeding promotion is warranted to determine effective ways of supporting nursing practice. Conclusion Implementation of the breastfeeding BPG had a small effect on both the breastfeeding-related beliefs of PHNs and maternal breastfeeding intentions. Given the challenges of changing population health parameters, these preliminary results suggest that more consistent and pervasive implementation of the breastfeeding BPG by nurses could influence breastfeeding at a population level.

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