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2004 Support on Perinatal Units in Florida Hospitals Elisa H. Casey

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BREASTFEEDING SUPPORT ON PERINATAL UNITS IN FLORIDA HOSPITALS

By ELISA H. CASEY

A Thesis submitted to the School of Nursing in partial fulfillment of the requirements for the degree of Master of Science

Degree Awarded: Spring Semester, 2004 The members of the committee approve the thesis of Elisa. H. Casey defended on December 03, 2002.

______Deborah Frank Professor Directing Thesis

______Sandra Faria Committee Member

______Barbara Cottrell Committee Member

Approved:

______Jeanne Flannery, Director, School of Nursing Graduate Program

______Katherine P. Mason, Dean, School of Nursing

The Office of Graduate Studies has verified and approved the above named committee members.

ii This work is dedicated to the nurses who are doing their best to make sure that and babies get breastfeeding off to a successful start.

iii ACKNOWLEDGMENTS There are many people whose time and efforts have been instrumental in making this study a success. First and foremost, to my husband, Travis... thank you for being there through the entire process. Thanks also for the computer technical assistance, editing, and reference matching. To my daughter, Rhianna... thank you for being patient and for reminding me what truly matters... and for being my inspiration through this effort. To my committee, thank you for all of the support and guidance throughout the whole process. To Betty Brown at ACNS, thank you for the assistance with the finer details of SPSS. To Donald R. Workman, thank you for the hours of assistance working out the research problems and the assistance with analyzing and interpreting the data. To Jeanne Flannery, thank you for all of the support and for believing in me. Finally, thank you to every director of nursing, unit manager, and staff nurse throughout Florida whose responses made this research successful. It would have never happened without all of you.

iv TABLE OF CONTENTS LIST OF TABLES ...... ix ABSTRACT ...... x CHAPTER ONE ...... 1 Problem Statement ...... 2 Significance of Problem ...... 2 Purpose ...... 2 Assumptions ...... 3 Limitations ...... 3 Research Questions ...... 3 Hypotheses ...... 4 Operational definitions ...... 4 Summary ...... 5 CHAPTER TWO ...... 7 Conceptual Model ...... 7 King’s Dynamic Interacting Systems ...... 7 Review of Literature ...... 10 Breastfeeding ...... 10 Physiology 10 Benefits 10 Hospital Policies and Practices 12 Attitude Toward Breastfeeding ...... 21 Supporting Breastfeeding ...... 21 Summary ...... 22 CHAPTER THREE ...... 23 Design ...... 23

v Sample ...... 23 Variables ...... 23 Instruments ...... 24 Informed Consent ...... 25 Procedure ...... 25 Data Analysis ...... 27 Summary ...... 30 CHAPTER FOUR ...... 31 Participant Demographics ...... 32 Unit Manager Demographics ...... 32 Staff Nurse Demographics ...... 32 Policies & Practices ...... 34 Unit Manager Results ...... 34 Staff Nurse Results ...... 39 Practices 39 Education & Support 41 Compliance of Policies with Research ...... 43 Compliance of Practices with Policy and Research ...... 44 Statistical Comparisons ...... 49 Nurse Attitude Toward Breastfeeding ...... 51 Relationship of Attitude to Compliance ...... 53 Current Results Compared to Churchill’s Results ...... 53 Demographics ...... 54 Unit Manager 54 Staff Nurse 54 Policies & Practices ...... 57 Policies 57 Practices 59 Attitude 60

vi Summary ...... 60 CHAPTER FIVE ...... 62 Participant Demographics ...... 62 Return Rate ...... 62 Facility Demographics ...... 63 Staff Nurse Demographics ...... 64 Policies & Practices ...... 65 Unit Manager Results ...... 65 Practices 65 Teaching & Support 66 Breastfeeding Interruption 67 Staff Nurse Results ...... 70 Practices 70 Teaching & Support 72 Policy & Practice Compliance with Research ...... 73 Attitude Toward Breastfeeding ...... 74 Current Findings vs. Churchill’s Findings ...... 75 Conceptual Framework ...... 76 Limitations ...... 76 Assumptions ...... 78 Implications for Practice ...... 78 Nursing Practice ...... 78 Advanced Nursing Practice ...... 79 Administration ...... 80 Education ...... 81 Continuing Education 81 Nursing Schools 81 Recommendations for Future Research ...... 82 Summary ...... 83

vii APPENDIX A Permission to Utilize Houston & Field Tool ...... 85 APPENDIX B Permission to Use Churchill Modifications ...... 88 APPENDIX C Permission to Use Cusson’s Attitude Toward Breastfeeding Scale ...... 90 APPENDIX D Florida State University IRB Approval Letter ...... 92 APPENDIX E Director of Nursing Cover Letter ...... 94 APPENDIX F Unit Manager Cover Letter ...... 97 APPENDIX G Unit Manager Questionnaire ...... 100 APPENDIX H Staff Nurse Cover Letter ...... 105 APPENDIX I Staff Nurse Questionnaire ...... 107 APPENDIX J Facility Approval from Baptist Hospital Miami ...... 114 REFERENCES ...... 120 BIOGRAPHICAL SKETCH ...... 125

viii LIST OF TABLES Table 1 Hospital Demographics by Unit Manager Report ...... 33 Table 2 Staff Nurse Demographics by Staff Nurse Report ...... 35 Table 3 Unit Policies and Regulators ...... 36 Table 4 Descriptive Statistics for Analysis of Covariance: Policy Compliance .....44 with Level of Perinatal Unit and Deliveries (Covariate) Table 5 Tests of Between Subjects Effects ...... 44 Table 6 Agreement Between Staff Nurse (SN) Data and Unit Manager (UM) Data . 45 Table 7 Descriptive Statistics for Analysis of Covariance: Practice Compliance ...50 with Level of Perinatal Unit and Deliveries (Covariate) Table 8 Tests of Between Subjects Effects ...... 50 Table 9 Correlation of Practice Compliance with ...... 51 Selected Demographic Characteristics Table 10 Attitude Scores for Select Individual Questions ...... 52 Table 11 Correlation of Attitude Score with ...... 53 Selected Demographic Characteristics Table 12 Changes in Hospital Demographics by Unit Manager Report ...... 55 Table 13 Changes in Staff Nurse Demographics by Staff Nurse Report ...... 56 Table 14 Changes in Unsupportive Unit Policies and Regulators ...... 58

ix ABSTRACT Breastfeeding has documented benefits for mothers and babies. A Healthy People 2010 goal is to increase breastfeeding rates to 75% initiation, 50% at 6 months, and 25% at 1 year. Nurses a key role in meeting the goals by influencing policy and practices. Purpose: 1) examine breastfeeding-related policies/practices on perinatal units of Florida hospitals, 2) describe nurse attitudes toward breastfeeding, 3) examine the extent to which policies and practices are supportive of breastfeeding, and 4) compare findings with those of Churchill from 1992. Methodology: Non-experimental cross-sectional survey using modified Houston & Field Hospital Practices Questionnaire and Cusson’s Attitudes Toward Breastfeeding Scale. Subjects: Perinatal unit managers and 4 nurses from each Florida hospital providing obstetric services. Results : 75 of 119 unit managers and 268 of 476 staff nurses responded. Twenty-six managers (34.7%) reported that greater than 75% of mothers initiated breastfeeding; 24 (32.4%) reported that greater than 75% were discharged breastfeeding. Policies mostly supported breastfeeding: no routine supplements (98.7%), unrestricted suckling time (94.6%), demand feeding (92%), and no complements (87.7%); however, 53.3% of facilities restricted distribution of formula discharge packs. Nearly all managers reported one-on-one teaching is done, yet only 58.1% of units had a teaching protocol. Staff nurses reported the following practices: demand feeding (73.3%), unrestricted suckling time (80.1%), no routine supplements (22.3%), and no routine complements (29.6%); 32.3% reported restricted distribution of formula discharge packs. Most nurses had positive attitude scores (89.5%); none had negative scores. There was insufficient evidence to conclude that perinatal unit level had an effect on policy compliance. There was a substantial discrepancy between policy and practice. Small improvements in policy and practice occurred since 1992. Conclusions: Most policies are up to date; however, practices at many facilities are not in line with those recommended by research.

x CHAPTER ONE INTRODUCTION Breastfeeding has multiple benefits for both mothers and their babies. Breastfeeding increases the rate at which the uterus returns to normal size following (Labbok, 1999). Women who breastfeed have a reduced risk of premenopausal cancer (Kennedy, 1994; Labbok, 1999). The delayed return of menses experienced by many women reduces blood loss and promotes spacing of pregnancies (Kennedy, 1994; Labbok, 1999). Bone remineralization is improved postpartum thereby offering protection against osteoporosis (Kennedy, 1994; Labbok, 1999). Breastfeeding mothers often have increased confidence in their skills (Kennedy, 1994). Babies also reap multiple benefits from being breastfed. Breastfed babies have decreased risk of gastrointestinal and respiratory infections (Orlando, 1995; Raisler, Alexander, & O’Campo, 1999). Breastmilk is easy to digest and nutrients are in a bioavailable form that promotes absorption (American Dietetic Association, 1997). A meta-analysis of studies which evaluated a possible correlation between breastfeeding and cognitive development found that breastfeeding is associated with higher cognitive development scores than formula feeding (Anderson, Johnstone, & Remley, 1999). The American Academy of [AAP] (1997), the American Dietetic Association (1997), and the American College of Obstetricians & Gynecologists (2000) indicated that breastfeeding is beneficial for both mothers and babies; a minimum of four to six months of exclusive breastfeeding is recommended by all three organizations. The AAP recommended a minimum of one year of breastfeeding (AAP, 1997). The United States Surgeon General has set a goal of 75% of mothers initiating breastfeeding and 50% of mothers breastfeeding at 6 months as part of Healthy People 2010 (Centers for Disease Control [CDC] & Health Resources and Services Administration [HRSA], 2000).

1 Problem Statement Despite the known benefits of breastfeeding, only 64% of women in the United States were breastfeeding during the early postpartum period, only 29% were breastfeeding at six months, and only 16% were breastfeeding at 1 year according to the 1998 Abbott Laboratories Mothers’ Survey (as cited in CDC & HRSA, 2000). La Leche League International [LLLI] stated that hospital policies and practices such as delayed -baby contact, frequent mother-baby separation, routine supplementation, and scheduled feedings can interfere with getting breastfeeding off to a good start (LLLI, 1997). Several studies have confirmed the detrimental effect of mother/baby separation, routine supplementation, scheduled feedings, and formula-containing discharge packs on successful initiation of (Auerbach, 2000; Neifert, 1998; Wright, Rice, & Wells, 1996). A study that examined the experiences of mothers for whom breastfeeding was unsuccessful identified inadequate/inappropriate assistance and supplementation as contributing factors (Mozingo, Davis, Droppleman & Merideth, 2000). The problem which this study will address is that the degree to which Florida hospitals are complying with practices identified in the research as promoting successful initiation of breastfeeding has not been re-examined since Churchill’s 1992 study. Significance of Problem Hospital policies and practices influence the success of breastfeeding. Mothers rely on nurses for breastfeeding information and care. Breastfeeding is beneficial for the majority of mother/baby couples. Hospitals which follow practices that are contrary to current research can be open to litigation if breastfeeding is unsuccessful for a mother (Bornmann & Ross, 2000). It is crucial that unit managers on perinatal units and nurses who provide care to mothers and babies understand what policies and practices support and/or inhibit successful initiation of breastfeeding. Purpose The purposes of this study are: a) to investigate current policies and practices on perinatal units in hospitals licensed to provide perinatal care in the state of Florida, b) to describe nurse attitudes toward breastfeeding, c) to examine the extent to which current

2 policies and practices are consistent with those identified in the literature as supportive of breastfeeding and d) to compare current policies and practices with those identified by Churchill in order to determine what changes have been made since 1992. Conceptual Model Imogene King’s Dynamic interacting systems is the nursing conceptual model upon which this study will be based. The interacting systems consist of three components: personal systems (individuals), interpersonal systems (groups), and social systems (society) (King, 1981). In this study, the mother/baby dyad is the personal system, the nursing staff caring for the mother/baby dyad along with the practices and nurse attitudes is the interpersonal system, and the perinatal unit, with its policies, is the social system. Assumptions It is assumed that the unit managers will answer questions honestly and that they will not attempt to hand-select staff nurses who will answer surveys in a manner that would make the unit look better. It is also assumed that participants will answer questions honestly and freely instead of providing the answers that they think the investigator is seeking. Limitations The most significant limitation is that the facility and staff nurse samples are both convenience samples. The hospitals include those who provide perinatal services in Florida; the staff nurses include a sampling of nurses from within those perinatal units. The second significant limitation is that it is impossible to guarantee that the unit manager uses the requested procedure for randomly selecting staff nurses. Research Questions The following questions will be addressed by this study: 1. What are the demographic characteristics of the facility and participant sample selected for this investigation? 2. What are current policies and practices on perinatal units in hospitals licensed to provide perinatal care in the state of Florida?

3 3. To what extent are the existing policies and practices referred to in Research Question 2, consistent with those identified by current research as supporting successful initiation of breastfeeding? 4. What are perinatal nurses’ attitudes toward breastfeeding? 5. What is the relationship between attitudes and compliance as well as other demographic and practice variables? 6. To what extent are the results of the present investigation consistent with those reported by Churchill in 1992? Hypotheses Research Questions One, Two, Four, and Six are descriptive in nature and, therefore will not have hypotheses to be tested. The hypotheses to be tested for Research Question 3 are:

H0: There is no difference between existing policies and practices and those identified in the research as promoting successful initiation of breastfeeding.

Ha: There will be a difference between current policies and practices and policies and practices identified by research as supportive of successful initiation of breastfeeding. The hypotheses to be tested for Research Question 5 are:

H0: There is no relationship between nurse attitude and other demographic variables on compliance.

Ha: There is a relationship between nurse attitude and other demographic variables on compliance. Operational definitions Attitudes is defined as the mean score on Part 3 of the Staff Nurse Questionnaire which examines views on breastfeeding and will be reported as a score between 1 and 5. Bottle-feeding is a form of nutrition in which fluids including formula, water, juice, or breast are provided via an artificial and bottle. Breastfeeding is a form of in which breastmilk is taken directly from the mother’s breast by the infant.

4 A breastfeeding counselor is an individual with advanced education, training, or knowledge related to breastfeeding. Complement feedings are given to an infant along with breastfeeding at the time of feeding and may be sterile water, glucose water, or formula. Compliance is defined as following research-based policies and practices. A dyad is the mother/infant couple. A has formal education and hands-on breastfeeding training and holds certification. Perinatal nurses are those who work on mother/baby units and are responsible for providing nursing care including but not limited to breastfeeding assistance and education. The perinatal unit within the hospital provides care to mothers and babies following birth. Research-based practices have been identified in the literature as being supportive of breastfeeding and include unrestricted suckling time, limited use of supplementary and complementary feedings, and no routine distribution of formula-containing gift packs. Routine practices are those that are done across the board without a specific medical justification. Supplement feedings are given to instead of breastfeeding sessions and may include sterile water, glucose water, or formula. The unit manager, who may or may not be a nurse, oversees the day to day operations of a given hospital unit. Unit policies are the practices that are either ordered by a physician or are in manuals located on the units. Unit practices are the actual practices on hospital units; these may or may not be in compliance with unit policies. Summary Breastfeeding is beneficial to both mothers and babies. Mothers rely on nurses for education and assistance related to breastfeeding. Hospital policies and practices may

5 promote or hinder the initiation of successful lactation. The purpose of this study is to determine whether hospitals in Florida are using policies and practices that are supportive of breastfeeding, to examine nurse attitude toward breastfeeding, and to compare current practices with those identified by Churchill in 1992. Imogene King’s Dynamic Interacting Systems, the conceptual framework upon which the study is based, was introduced. The research questions and operational definitions were discussed.

6 CHAPTER TWO LITERATURE REVIEW The purpose of this chapter is to discuss the conceptual model to which this study is linked and its relation to the study. In addition, the purpose is to discuss literature pertinent to the research in order to lay out the importance of this study to nursing practice. Conceptual Model King’s Dynamic Interacting Systems Imogene King’s Dynamic Interacting Systems is the conceptual model upon which the study is based. The Dynamic Interacting System consists of three parts. The personal system, which is located at the center, consists of individuals. The interpersonal system, which consists of groups, wraps around the personal system. The social system, which consists of society, wraps around the outside. The systems interact in both directions (King, 1981). Within the personal system, the patient is a complete system. For the purposes of this research, the mother/baby dyad as a unit is the personal system and the patient. While a dyad is typically classed as an interpersonal system due to the interaction between the individual members, the mother/baby dyad is the entity who is being cared for when nursing care is provided in the context of breastfeeding. The interpersonal realm includes “role ..., interaction, communication, transaction, and stress” (King, 1981, p. 10). The nurse-patient relationship is an integral part of the system. For the purposes of this study, the nursing staff on the perinatal unit forms the interpersonal system. The interpersonal system also includes the actual practices on the unit as these are what are actually being done when caring for the breastfeeding dyad within the context of the nurse-patient relationship. Finally, the interpersonal system

7 includes nurse attitudes toward breastfeeding due to the potential influence on the nurse- patient relationship and on the provision of breastfeeding care. The social system includes the “moving forces in nursing” (King, 1981, p. 11). The health care system is a social system that influences both the nursing staff and the mother/baby dyad. For the purposes of this research, the perinatal unit with its policies serves as the social system. Several concepts stand out as pertinent. First, role conflict and stress are present for nurses in the interpersonal role. King explicitly stated that it is expected that nurses reduce stress in the hospital for both patients and their families but at the same time, little is done to reduce stress for nurses (King, 1981). For example, a hospital system that is not supportive of breastfeeding causes stress to the mother/baby dyad that is trying to establish breastfeeding. It also causes stress for a nurse who, although knowledgeable and wishing to support breastfeeding, is bound by policies that are both outmoded and not supportive of breastfeeding. Second, King listed six facets of organizational structure, two of which were especially pertinent to this research: constraints of the organization and who is responsible for decision-making at each level (King, 1981). Constraints would include unit policies and procedures and physician orders. The decision-making chain of command would include administration, physicians, and advanced practice nurses including nurse practitioners, certified nurse midwives, and nurse anesthetists. Third, the importance of communication and nurse attitude was discussed. If a new mother perceives a negative attitude towards breastfeeding on the part of a nurse, not only will she be far less likely to turn to that nurse for support, she may not turn to other nurses for support either; this will impair communication and will prevent transactions from occurring. The three systems do indeed interact within the context of care of the breastfeeding dyad. Hospital policies influence the practices on the unit. The practices, which are carried out by the nurses, influence the outcomes for mothers and babies. Moving in the other direction, mothers have the right to receive evidence-based care and have the responsibility to make their wishes regarding care of their babies known to the

8 nursing staff. Discussing their wishes with the nursing staff and administration has the potential to bring about changes when policies and practices are not in line with current research. The nursing staff have a responsibility to keep their knowledge up to date and to be aware of any biases they have which may interfere with the care they provide. Nurses further have a responsibility to make administration aware when policies are not evidence-based so that change can be brought about. Perinatal units have a responsibility to provide evidence-based care to mothers and to assure that written policies are enforced. No studies were found which specifically related Imogene King’s Dynamic Interacting Systems to care of the breastfeeding dyad within the hospital setting. Two studies were found, however, which are related. Killeen (1996) developed a tool to examine patient-consumer satisfaction with hospital care using King’s concepts of individuals, perception, role, decision-making, nursing situation, and past experiences. The tool was created to be useful for any hospital setting and was tested within the obstetric department of the study site. Patient satisfaction is one concern related to the care provided to mothers on perinatal units. Pfoutz (1990) developed a tool to measure patient satisfaction with care received during the perinatal period; King’s Interacting Systems was used as the conceptual framework. The personal system encompassed perception and Pfoutz indicated that “Perceptions are affected by awareness of past events, one’s values, needs, and future goals” (Pfoutz, 1990, p. 33.) It was further stated that satisfaction is a combination of “perception of the reality of care as well as valuation of that care” (Pfoutz, 1990, p. 33). The interpersonal system included goal-oriented communication. Both participants are valued. The social system included the power structure and the concept of authority. In summing up the relationship between King’s Interacting Systems and postpartum satisfaction with care, Pfoutz emphasized that the way a consumer perceives the care received and their satisfaction have an impact on how they interact with their care-givers. Neither the consumers nor providers operate alone; instead, they both operate within social systems which include providers, hospitals, and reimbursement systems. All are important in providing care.

9 Review of Literature Breastfeeding Physiology. Understanding the physiology of lactation is important when doing breastfeeding related research. During pregnancy, the ducts and lobules increase in number and size. Lactogenesis, or the ability of the mammary glands to produce milk, is initiated by the expulsion of the placenta. A sudden drop in the level of human placental lactogen (HPL) occurs. HPL competes with receptors in the . Nipple stimulation and removal of milk is essential in the process during the early phase. Nipple stimulation and milk removal stimulates the hypothalamus to inhibit dopamine secretion. The drop in dopamine level stimulates prolactin secretion and causes milk production. Suckling also stimulates release of , which is essential for milk production (Riordan, 1999). Benefits. It is also important to understand benefits of breastfeeding for the mother and baby. Benefits of breastfeeding are widely published in the nursing and medical literature. The American College of Obstetrics and Gynecology (2000) cited the following benefits to mothers in their 2000 educational bulletin: hastened involution of the uterus after birth which results in reduced blood loss; decreased incidence of ovarian and premenopausal breast cancer; delayed return of ovulation and menses which results in decreased blood loss and increased spacing between pregnancies; and improved re- mineralization of bones which results in decreased incidence of osteoporosis. The added benefit of nurturing and bonding was stated. The same set of maternal benefits were cited by the American Academy of Pediatrics in their 1997 policy statement on breastfeeding and use of human milk. Multiple benefits were cited for the baby. Human milk is species-specific for human babies. The American Academy of Pediatrics policy statement cited the following benefits in a paragraph which includes 39 references: “human milk feeding decreases the incidence and/or severity of diarrhea, lower respiratory infection, otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing enterocolitis;” (American Academy of Pediatrics, 1997) The American Dietetic Association (1997) reiterated that the unique composition of human

10 milk is tailored to the human species and also cited reduced incidence of diarrheal illnesses, respiratory illnesses, ear infections, and allergies. Breastmilk may have a protective effect against “sudden infant death syndrome, insulin-dependent diabetes mellitus, Crohn’s disease, ulcerative colitis, lymphoma, allergic diseases, and other chronic digestive diseases” and “breastfeeding has also been related to possible enhancement of cognitive development” (American Academy of Pediatrics, 1997). In 1999, Anderson, Johnstone & Remley performed a meta-analysis of 11 studies related to cognitive development and breastfeeding. Children who were breastfed had cognitive development scores that were 3.2 points (p < 0.001) higher than children who were formula fed and the benefit persisted into adolescence. An analysis was conducted of the live-birth cohort of babies (n = 7092) from the National Maternal and Infant Health Study which utilized the outcome measures of sick baby visits and number of months in which illnesses with “diarrhea, cough, wheeze, ear infection, runny nose or cold, fever, vomiting, or pneumonia” (Raisler, Alexander, & O’Campo, 1999, p. 26) occurred. The breastfeeding dose for the infants up through 6 months old was obtained and placed into one of five categories for each month: full breastfeeding, mostly breastfeeding, equal breastfeeding and formula-feeding, less breastfeeding than formula-feeding, and no breastfeeding. A dose-related response was identified. Infants who were in the minimal or no breastfeeding category had no reduction of odds for illness in the measured categories. Fully breastfed infants had decreased incidence of diarrhea, coughing/wheezing, and vomiting if they had older siblings and reduced incidence of ear infections, colds, and fever if they did not. Mostly breastfed infants had reduced incidence of diarrhea and coughing/wheezing if they had older siblings and reduced incidence of ear infections and colds if they did not. The equally breastfed/other-fed infants had reduced incidence of cough or wheeze if siblings were present and only lower odds of ear infections if siblings were not present. While fully breastfed and mostly breastfed babies had fewer sick visits (Mean Ratio 0.73 and 1.02), they were also more likely to have well visits (Mean Ratio 1.13 and 1.07). The

11 effects were not affected by socioeconomic standing. (Raisler, Alexander, & O’Campo, 1999). The United Kingdom National Case-Control Study Group attempted to determine whether breastfeeding offers protection against premenopausal breast cancer. The subjects were women who had been diagnosed with breast cancer before the age of 36 (n = 755); an age-matched control was assigned to each case (n = 755). The pairs were interviewed. Several outcome measures were identified including duration of breastfeeding for each live baby, at what point menstrual cycles returned, the use of hormonal contraceptives, and other risk factors for breast cancer. While breastfeeding was shown to reduce incidence of premenopausal breast cancer, breastfeeding duration of greater than three months per infant showed no increased benefit (United Kingdom National Case-Control Study Group, 1993). Hospital Policies and Practices Given the clear benefits of breastfeeding for the vast majority of mothers and babies, it would seem that breastfeeding would be promoted universally by health care providers; unfortunately, this is not always the case. As early as 1978, the American Academy of Pediatrics stated that hospital routines can make breastfeeding more difficult for mothers and suggested several changes: decrease sedation and/or anesthesia during labor to prevent impaired suckling; minimize separation of mother and baby during first 24 hours of life; breastfeed based on infant needs instead of on a rigid schedule; discourage routine supplementation with formula; and promote rooming-in. The statement was made that “apathy and lack of knowledge about infant nutrition by health professionals and the medical professions have been important problems.” (American Academy of Pediatrics, 1978, p. 598). In 1988, Houston and Field conducted a descriptive study of breastfeeding-related policies and practices in hospitals in Alberta, Canada. The authors developed a 39-item questionnaire which was used to interview unit managers (n = 97) and staff nurses (n = 46) in area hospitals that provided maternity services (n = 104). Most unit managers indicated that infants were placed to the breast within 2 hours of birth (n = 74) although a

12 large number of directors (n = 64) and nurses (n = 35) reported first feeds with other substances were common. While both unit managers (n = 81) and staff nurses (n = 32) reported that it was more common to feed infants on cue than on a fixed schedule, some categories of infants were placed on fixed schedules. Most respondents indicated that limited suckling time at the breast was recommended (n = 62 unit managers and n = 40 staff nurses). Supplement and complement feeds were routine. Provision of formula samples to breastfeeding mothers was common. Reasons for interruption or cessation of breastfeeding included jaundice, maternal antibiotics, fever in baby, , slow weight gain, sore , infant lethargy, or oxygen therapy for the newborn; however, pumping was recommended in those cases. The practices of early initiation of breastfeeding and feeding infants when they appear hungry were in accordance with research. The practices of routine supplementary/complementary feedings, restricted feeding time at the breast, and provision of formula-containing gift packs to mothers were not in accordance with research. In 1992, Churchill replicated the Houston and Field study in a southeastern state. Unit managers (n = 60) and staff nurses (n = 151) answered a survey regarding four specific policies and practices: suckling time, supplementary feedings, complementary feedings, and distribution of formula-containing discharge packs. Nurse attitudes toward breastfeeding were also examined. Policies regarding distribution of discharge packs containing formula was the only area that was contrary to research finding; distribution was restricted in just over 31% of facilities. The data on practices, however, indicated that with the exception of distribution of discharge packs, practices were not in accordance with set policies. Most nurses (n = 124) had positive attitudes toward breastfeeding. Personal breastfeeding experience had a strong correlation with a positive attitude toward breastfeeding (p = .000). In 1993, Rajan examined the effect of hospital practices on breastfeeding. A postal questionnaire was utilized to collect information from a selection of mothers (n = 1064) who were part of the National Birthday Trust Fund Pain Relief in Labor survey. While the survey mostly consisted of closed-ended questions, space for

13 additional comments was provided at the end of the questionnaire. Several factors detrimental to initiation of successful breastfeeding were identified. First, “absence of adequate and appropriate help for such specific problems [engorgement, cracked nipples] associated with feeding led several women to suggest their own solutions” (Rajan, 1993, p. 201). Second, while 59% of women who stated that they did not need help were still breastfeeding at 6 weeks, the group of women who indicated that they needed help had a 41% breastfeeding rate at 6 weeks if they got help but only 27% if they got inadequate or no support or assistance. Third, contradictory advice was often given; this caused much confusion. Fourth, at times, incorrect advice was given. Fifth, supplementation was common and at times, policies “encouraged the offering of formula milk to babies whose mother was felt to be too tired, sore, or otherwise unable to breast feed” (Rajan, 1993, p. 205). Rajan stated that women needed “clearer information, non-conflicting advice, and practical support specifically aimed at overcoming the initial physical barriers to breast feeding” and that “the discontinuation of misinformation... and incorrect practices... is a major priority” (Rajan, 1993, pp. 206-207). A 1996 study by Wright, Rice, and Wells sought to determine the impact on successful initiation of breastfeeding of changing hospital policies in a university teaching hospital; the changes were to bring them into compliance with the Ten Steps to Successful Breastfeeding of the United Nations Children’s Fund and World Health Organization. Interviews of mothers on postpartum units were conducted in 1990 (n = 192) and in 1993 (n = 392); changes in policy and practice were made in the interim. The study cited hospital practices including delayed initiation of breastfeeding, routine mother/baby separation, and formula discharge packs as having a detrimental effect on breastfeeding. Prior to the changes, just under 25% of mothers nursed in the first hour of birth. Nearly half (46.7%) of infants whose mothers had planned to combine breast and bottle feeding were given formula and 23.8% of mothers who had expressed an intent to practice exclusive breastfeeding were given formula. Over 3 in 5 (61%) of mothers received breastfeeding assistance, and 65% had discussed breastfeeding prenatally with their health care providers. After the practice changes, 63.2% of mothers nursed within

14 an hour of birth, formula supplementation had dropped to 27.9% and 12.4% for combination and exclusive breastfeeding mothers, respectively, and 81.9% received assistance. No significant change was noticed in the percentage of mothers who had discussed breastfeeding prenatally. Some data was collected in 1993 that was not collected in 1990: 43.5% of babies got pacifiers, rooming-in for greater than 60% of the time occurred with 53.3 babies, referrals were made to breastfeeding support groups for 38.4% of mothers, and 57.9% of babies were fed on demand. The majority of mothers (85.6%) received formula samples or coupons during pregnancy or the postpartum period; most (65.9%) received the samples in discharge packs. Formula supplementation in the hospital had a significant effect on both partial and full breastfeeding rates at 1 and 4 months. At the 1 month mark, 77.3% of infants who received formula while in the hospital were breastfed at all compared to 89.6% of infants who received no formula (p < .01); only 37.3% of infants who received formula were fully breastfed compared to a rate of 68.2% when no formula was given (p < .0001). At 4 months, 34.7% of infants who received formula at the hospital were still breastfeeding at all compared to 51.7% of those who did not; 8.0% of infants who received formula were exclusively breastfed at 4 months compared to 22.1% of infants who did not receive formula (p < .01). If the mother received formula-containing discharge packs, the baby was much less likely to be breastfed at one month; 78.7% of mothers were breastfeeding at all at 1 month if they received formula-containing discharge packs compared to a rate of 90.8% when formula- containing discharge packs were not provided (p < .01). Mothers who received information about breastfeeding support groups were more likely to still be breastfeeding at four months; 50.0% versus 41.0% were breastfeeding at all and 22.3% versus 11.8% were still fully breastfeeding (p < .05). One stated weakness of this study was that many factors were not independent of each other; for example, infants who were given formula in the hospital were less likely to room-in. In addition, because the obstetrics department did not participate, it was not possible to make a stronger effort to increase prenatal education.

15 A before-after nonequivalent control group study published in 1996 by Aliperti and MacAvoy examined the effect of changing hospital practices on duration of breastfeeding. The study site had practices including routine supplementation with glucose water and/or formula, initiation of breastfeeding greater than 3 hours after birth, and no encouragement for frequent breastfeeding. Policies and practices were changed to include initiating breastfeeding within 1 hour of birth when possible, minimizing supplementation, and encouraging frequent breastfeeding. A tracking form was utilized. Both the control group (n = 32) and the study group (n = 34) were recruited from mothers who planned to breastfeed. The control group, for whom data was collected before the changes were made, had a 56% rate of exclusive breastfeeding at 2 weeks and 31% at 6 weeks. The experimental group had a 76% exclusive breastfeeding rate at 2 weeks and 47% at 6 weeks. This finding was not statistically significant so data was reclassified to include mothers who were primarily breastfeeding. In the control group, 81% and 53% were primarily breastfeeding at 2 and 6 weeks respectively; in the experimental group, 91% and 76% were primarily breastfeeding at 2 and 6 weeks respectively. These results were statistically significant (p < .05). The authors identified interrelated factors as a weakness. The impact of hospital practices on breastfeeding rates was examined by DiGirolamo, Grummer-Strawn, and Fein (2001). Data from the 1993/1994 Infant Feeding Practices Survey (IFPS) were utilized. Respondents who initiated breastfeeding, who had expressed intent prenatally to breastfeed for more than 2 months, and who had no missing data were included in the study (n = 1085). The outcome variable used was breastfeeding termination before 6 weeks postpartum. Of the mothers who had planned 2 months or more of breastfeeding, 17% had stopped by 6 weeks postpartum. Five of 10 Baby-Friendly hospital practices were examined: initiation of breastfeeding within 1 hour of birth, no supplements, rooming-in, breastfeeding on demand, and no pacifiers. When a practice was not observed, it was considered a risk factor for early termination. The following high-risk practices were reported by the mothers: not breastfeeding on demand, 34.8%; late initiation of breastfeeding, 47.1%; no rooming-in, 55.1%; use of supplements,

16 55.7%; and use of pacifiers, 68.6%. Late initiation of breastfeeding (OR 2.4, AOR 1.6), supplements (OR 2.6, AOR 2.3), and not breastfeeding on demand (OR 1.6, AOR 1.2) were all statistically significant risk factors for early termination; pacifiers and rooming-in were not. The number of practices reported by the mother was also counted and the impact of the number of practices that were experienced on early cessation was examined; the fewer the practices experienced, the greater the incidence of termination. The number of appropriate practices experienced was as follows: all five, 7.2%; four practices, 14.4%; three practices, 23.1%; two practices, 27.8%; one practice, 20.3%; none, 7.2%. Mothers who experienced 4 of 5 practices were 1.7 times more likely to stop breastfeeding prior to 6 weeks postpartum than those who experienced all five. Those who experienced 3 were 3.1 times more likely. The following were significant at p < .05: two practices, AOR = 4.0; one practice, AOR = 4.5; and no practices, AOR = 7. The researchers determined that the cumulative effect had a stronger impact on early breastfeeding cessation than individual practices. A regression analysis predicted that the cessation rate would have been one-third of the 17% actual rate (6%) at 6 weeks if the mothers had experienced all 5 Baby-Friendly practices. A stated weakness of the study was that only the practices as experienced by the mothers were examined and that policies to which facilities adhered were not evaluated. A contrasting view on reasons for early termination of breastfeeding was provided by Ertem, Votto, & Leventhal (2001). English-speaking mothers who were eligible for WIC, had delivered a healthy full-term singleton infant, were planning to use the hospital’s primary care center for well baby care, and initiated breastfeeding within 48 hours of birth were recruited. Interviews were conducted while in the hospital and information was collected on sociodemographic characteristics, breastfeeding knowledge, and breastfeeding attitudes. If a mother indicated that her probability of breastfeeding at 2 months postpartum was low, she was considered to be not confident. Telephone interviews were conducted at 1 week postpartum. An in-person interview was conducted at the 2-week infant check. Record reviews were conducted at 2 and 4 months postpartum. Discontinuation was defined as no longer breastfeeding at all; continuation

17 was defined as any other amount of breastfeeding. The Hawthorne effect was controlled for by comparing records from a nonparticipating group who met eligibility criteria. Of the 125 breastfeeding mothers included in the study, 64 were included in the study group and 61 were in the nonparticipating control group. No differences were found in discontinuation rates between the two groups. Results were only reported for the study group. Of the study group, 36 mothers were Black, 22 were Puerto Rican, and 6 were White; 48 were single. The median age was 22, median years of schooling was 12.1 years, and 58 women were enrolled in WIC before delivery. The primary source of information for the mothers was written materials/videotapes (49.2%), medical professionals (22.1%), or family/friends (16.9%); 11.9% could not name a source. The infant’s pediatrician was identified by 92.3% as the source from whom they would prefer to receive breastfeeding information and by 79.7% as the professional to whom they would turn if problems occurred with breastfeeding. While most mothers (90.2%) were knowledgeable about benefits of breastfeeding for the baby, far fewer (30%) were knowledgeable about the practice of breastfeeding. The benefits of breastfeeding for the baby were the most common reason (92.2%) for mothers to choose to breastfeed. Nearly 2/3 (32.8%) of mothers had made the decision to breastfeed before conception; almost half (46.9%) had decided by the end of the first trimester. Most mothers (70.3%) felt supported in their decision to breastfeed by people close to them. The majority of mothers did not consider breastfeeding inconvenient (81.3%) and wanted to breastfeed for up to 6 months (95.3%). Despite these findings, nearly half of mothers (45.3%) felt that the chances they would still be breastfeeding at 2 months were low. Two time periods in which weaning was common were identified: The first 7 days (26.6%) and between 2 weeks and 2 months (32.1%). By 2 months, 77.4% of moms had stopped breastfeeding and by 4 months, 88.2% of mothers had stopped breastfeeding. Exclusive breastfeeding rates dropped with time; rates were as follows: 1 week, 37.5%; 2 weeks, 26.6%; 2 months, 11.3%; and 4 months, 5.9%. While several factors showed an association with early cessation of breastfeeding, only maternal age of <20 and lack of confidence about continuing to breastfeed until the infant was 2 months old had a

18 statistically significant association at both 2 weeks and 2 months; in fact, mothers who lacked confidence that they would continue nursing up to 2 months had nearly a 12-fold increase in incidence of early weaning compared to mothers who were confident. Merewood and Phillipp (2001) chronicled Boston Medical Center’s journey to becoming a Baby-Friendly Hospital. Prior to implementation of the initiative, only 6% of women were breastfeeding exclusively and only 30% of mothers gave more breastmilk than formula while in the hospital. Factors contributing to the low breastfeeding rates included no lactation education staff or facilities and no lactation education program for staff or patients. Some of the required changes in implementing the Ten Steps to Successful Breastfeeding were identified as easy. A teaching framework for both staff and patients were created. Policies were re-written and practices were modified to incorporate the Ten Steps and to eliminate routine distribution of pacifiers. Physicians were educated and eventually brought on board because their support was essential in implementing baby-friendly practices. The most difficult aspect was having the hospital pay fair market value for formula but that barrier too was overcome. Baby-Friendly status was granted in December 1999. The authors state that “Clear vision, committed leadership, the involvement of many departments, and the support of senior hospital staff members are essential components for the project.” (Merewood & Philipp, 2001, p. 37) The impact of the new policies and practices on breastfeeding rates was not discussed in this article. The impact of implementation of Baby-Friendly Hospital Initiative (BFHI) practices on breastfeeding initiation rate at Boston Medical Center was documented by Philipp et al. (2001). Randomly selected medical records for 200 patients for each of 3 years (1995, 1998, and 1999) were reviewed. Infant feedings during the postpartum stay were tallied and infants were categorized into one of 4 different groups: exclusive , mostly breast milk, mostly formula, and exclusive formula. Exclusion criteria included missing feeding data, HIV+ or Hepatitis-C+ mother, Neonatal Intensive Care Unit (NICU) admission, maternal substance abuse, adoption, or maternal incarceration. The maternal and infant demographics were similar for each of the 3 years. In 1995, prior

19 to implementation of any portion of the BFHI, only 58% of infants received any breast milk; 28% received mostly formula, 24.5% received mostly breast milk, and a mere 5.5% of infants were exclusively breastfed. By 1998, at which point most BFHI practices were in place, the percentage of infants who received any breast milk increased to 77.5%; 18.5% received mostly formula but the percentages of infants receiving mostly breast milk and only breast milk increased to 30.5% and 28.5% respectively. By 1999, all BFHI practices were in place and the hospital received official BFHI designation. Some breast milk was received by 86.5% of infants. The percentage of infants receiving mostly formula dropped to 13.5% while the percentage of infants receiving mostly breast milk and only breast milk increased to 39.5% and 33.5% respectively. All increases from 1995 to 1999 showed statistical significance of at least P = .005; the rates for exclusive breast milk, any breast milk, and exclusive formula were significant to P <.001. It is notable that the study population included a substantial proportion of women with Medicaid or no health insurance (over 50% Medicaid and over 33% uninsured) and the increases still occurred. A stated limitation of the study is that improved documentation might have occurred which could have artificially inflated the rates. A rather striking article entitled “It wasn’t working” chronicled women’s experiences with very short-term breastfeeding. Women who stopped breastfeeding before the baby was 2 weeks old were interviewed in a phenomenologic study. Several factors were identified as contributing toward failure, although two are especially pertinent for this study: inadequate and/or inappropriate assistance and unwanted supplementation were detrimental. Breastfeeding failure was a source of heartbreak and emotional distress for the participants in this study. Several recommendations were made for provision of sensitive care to breastfeeding mothers including attempting to eliminate supplementation unless medically necessary, providing realistic education about potential problems and solutions, and respecting personal boundaries. (Mozingo, Davis, Droppleman, & Merideth, 2000). Bornmann and Ross (2000) published an article discussing the use of laws regarding battery to protect and support breastfeeding. The three necessary elements that

20 are required to prove battery were identified: intention of a provider to touch in a way that is harmful or offensive; actual touching either with the body or with an object connected to the person; and that consent for the touching was not given. Injury is not a necessary condition. While the one known suit in the United States at the time of the article was found in favor of the hospital, the risk of litigation in today’s society is worth the attention of health care providers and hospital administration. Attitude Toward Breastfeeding In 1996, Patton, Bearman, Csar, and Lewinski published a study related to nurse attitudes about breastfeeding. A questionnaire was developed from the literature to evaluate attitudes and behaviors, percentage of mothers breastfeeding upon discharge, and demographics from perinatal nurses. Nearly two-thirds of respondents were interested in helping women breastfeed and the same number would recommend or actively encourage breastfeeding. Time factors including brief hospital stays were identified as a barrier to providing hands-on support. Breastfeeding education was received from multiple sources; the most common were reading articles, observing other nurses, observing breastfeeding mothers, personal experience, and inservice education. In 1985, Cusson examined the attitudes toward breastfeeding of adolescent females. A tool was designed to evaluate attitudes toward breastfeeding. 68 adolescent females from a high school participated. The survey included a Likert-scale with a range of 1 to 5; a positive attitude was defined as a score of 3.5 or greater. While the mean score for the participants was 3.28, which did not meet the cut-off for a positive attitude, 49% of the subjects did have a positive attitude and 46% considered breast-feeding future children. In 1992, Churchill utilized the Attitude Toward Breastfeeding tool in examining the attitudes of nurses working on perinatal units of Florida hospitals. The range of scores in the replication was 2.28 to 4.89; the mean score was 4.003 and 124 respondents (84.4%) had a positive attitude score. Supporting Breastfeeding The World Health Organization and UNICEF combined forces to create the Baby- Friendly Hospital Initiative (BFHI) with the intended purpose of increasing rates of

21 breastfeeding. From the research, ten key points were identified as supportive of breastfeeding: 1. Have a written breast-feeding 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 breast- feeding. 4. Help mothers initiate breast-feeding within a half-hour of birth. 5. Show mothers how to breast-feed, 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 –– allow mothers and infants to remain together –– 24 hours a day. 8. Encourage breast-feeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breast-feeding infants. 10. Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic. (World Health Organization, 1991). Summary Breastfeeding has multiple benefits for both mothers and babies; many of these benefits have been recognized for decades. Hospital policies and practices can either aid or hinder initiation of successful breastfeeding. Even when policies are in place, practices may not be in accordance with them. Modifying hospital policies and practices can have a positive effect on initiation and maintenance of breastfeeding.

22 CHAPTER THREE METHODOLOGY This chapter is a discussion of the methodology used for this project. The project design is explained. The nature of the sample being utilized is described. The procedure for the study is discussed. Each research question is reiterated along with an explanation of the statistical procedures that are being used to analyze the data generated. Design A non-experimental cross-sectional survey design was used to identify policies and practices on perinatal units in Florida hospitals. Self-report questionnaires were used to collect demographic data and attitudinal data from the nurses working on perinatal units. Additionally, unit managers were surveyed for current policies within their respective perinatal units. This study replicated studies of hospital practices in Alberta, Canada (Houston & Field, 1988) and of hospital policies and practices in Florida (Churchill, 1992). Sample The known population of hospitals which provide perinatal services in Florida (N = 125) were the source for participants in the current study. The unit manager (UM) for the perinatal unit of each facility (n = 125) was surveyed. A random sample of four nurses from each facility (n = 500) were likewise surveyed. Variables The dependent variables for this study were as follows: a) existing policies regarding breastfeeding on perinatal units in Florida hospitals, b) existing practices regarding breastfeeding on perinatal units in Florida hospitals c) compliance of existing policies with those identified by research as optimal for successful initiation of breastfeeding, d) compliance of existing practices with those identified by research as

23 optimal for successful initiation of breastfeeding, and e) nurse attitudes toward breastfeeding. There were four independent variables for the study: the hospital, the perinatal staff, the perinatal unit classification, and the number of deliveries per year. Within the hospital independent variable, current breastfeeding policies on perinatal units and current policies practices on perinatal units were utilized. Within perinatal staff, five areas were used: age, level of formal education, breastfeeding-related continuing education, personal breastfeeding experience, and attitude toward breastfeeding. Instruments Permission was obtained to use a modification of the Houston and Field Hospital Practices (1988) questionnaire (Appendix A). This questionnaire was distributed to UMs on perinatal units to determine what the policies are for timing of first feeding, the utilization of supplementary or complementary feedings, whether rooming-in is available, whether feedings are routinely scheduled, whether suckling time is restricted, and whether lactation consultants are available for mothers who need or request assistance. Content validity was established in previous studies; however, it was not possible to compute reliability data due to the nature of the tool. Permission was obtained from Ella Churchill to utilize her revisions of the Houston & Field tool (Appendix B). A modification of the Houston and Field questionnaire was also distributed to staff nurses for the purpose of determining actual practices; in addition, demographic data was collected from the nursing staff. Permission was obtained to use Cusson’s Attitudes Toward Breastfeeding scale (Cusson, 1985); this is a Likert scale questionnaire with 18 questions that was designed to examine attitudes toward breastfeeding. (Appendix C) Content validity was established through previous testing with similar populations; Cusson’s utilization of the tool revealed a Spearman-Brown Corrected Split-Half (odd- even) Index of 0.83 with an " coefficient of 0.71. Informed Consent Consent for participation in the study was implied by returning the questionnaire. Each questionnaire was accompanied by a self-addressed stamped envelope. The surveys

24 bore a numerical identifier which allowed the researcher to group the data that was received. The list which contains the hospital codes was maintained separately from the returned surveys. Each participant was provided with the address of the researcher so that the participant could request a copy of the results under separate cover. Procedure A preliminary list of hospitals which provide perinatal services was obtained from the 2000-2001 report on C-sections in Florida (Agency for Health Care Administration [AHCA], 2001). The report identified 128 hospitals at which C-sections were performed during 1998; this was the most current list available. Addresses were obtained using AHCA’s on-line facility locator (http://www.floridahealthstat.com). One hospital listed in the C-section report could not be located and was presumed to have closed. Attempts were made to determine whether the remaining 127 facilities listed in the Cesarean section report were still providing obstetric services. Because AHCA’s facility list did not provide this information, the on-line American Hospital Directory (AHD, http://www.ahd.com) was used. Hospital web pages were checked for facilities that had no information in the AHD listing. As a result, it was determined that seven hospitals were no longer providing obstetric services including one that had become a mental health facility. The AHD listing included two Naval hospitals and three Air Force hospitals; these were added to the facility list as all were listed as providing obstetric services. This brought the final initial mailing list to 125 hospitals. The caveat is that it was possible that a few facilities that manage a small number of births each year but are not performing C-sections were missed. An attempt was made to obtain a list from the Florida Organization of Nurse Executives (FONE) with the names of the Director of Nursing (DON) for each Florida hospital; although FONE did not have this information, they suggested that the Directory of Hospitals published by the Florida Hospital Association (FHA) would have it. The 2001-2002 Directory of Hospitals (FHA, 2001) had a list of nurse executives which had names listed for most hospitals on the mailing list. A call was placed to facilities who did not have a nurse executive listed.

25 After approval by the Florida State University Institutional Review Board (IRB) (Appendix D), a letter explaining the nature of the project was sent to the DON for each hospital licensed to provide obstetric services (Appendix E) along with the questionnaire packet. The packets contained: A cover/consent letter for the unit manager of the perinatal unit (Appendix F) A questionnaire for the unit manager (UM) (Appendix G) A cover/consent letter for 4 nurses (Appendix H) A questionnaire for 4 nurses (Appendix I) Five stamped window envelopes One month after the surveys were mailed, a follow-up call was placed to the DON for each facility from which no surveys had been returned to make sure the packet had been received and to answer any questions. If this follow-up call revealed that the materials were desired but not received, a second packet was mailed. One facility sought and obtained approval of the present investigation through their own IRB (Appendix J). Confidentiality was maintained by assigning a code number to each facility; a master list was maintained in a secure file cabinet which the researcher has access to. Although the surveys bore a code number to allow grouping of the data received from respondents, data will not be reported individually. Completed surveys were mailed directly to the investigator. Returned surveys were kept in a secure file cabinet and will be destroyed five years after completion of the study. Consent to participate in the study was implied by completing and mailing the surveys to the investigator; a subject could decline to participate by discarding the materials. A checklist which was organized by facility ID number was used to track surveys as they were returned. The UM received a cover/consent letter and a questionnaire entitled “Hospital Unit Policies” and a stamped window envelope marked with the hospital code. The UM also received a packet for one nurse on each shift. Each staff nurse packet contained a cover/consent letter, the staff nurse questionnaire, and a stamped window envelope. The staff nurses mailed the questionnaires directly to the researcher in order to promote honest answers without fear of consequences.

26 One component of this study was to describe the policies and practices on perinatal units in Florida hospitals. Data was primarily collected on suckling time, use of complementary and supplementary feedings, and distribution of formula-containing discharge packs; it was anticipated, however, that other information that may influence breastfeeding would be gathered. The other component was to compare the data from the present inquiry with that collected by Churchill in 1992 in order to determine if policies and practices are more consistent with those identified by current research as optimal for promoting breastfeeding. Data Analysis Research Question 1, which asks “What are the facility and participant demographic characteristics of the samples selected for this investigation?” was analyzed using descriptive statistics. Measures of central tendency (MCT), including mean and median, were used for interval-scaled data. The median was preferable when the data was not symmetric. The mode was provided when informative. When ordinal data was generated and use of interval scaling could not be defended, the median was used for the MCT. The mode was utilized as the MCT for categorical variables. Measures of score dispersion were also utilized. In the case of interval scaled data, variance and standard deviation, minimum/maximum, and range were utilized. Semi-interquartile range, range, and minimum/maximum were used as the measures of dispersion for ordinal scaled data. Finally, distributional properties of the data including skew, frequencies, relative frequencies, and cumulative frequencies are provided when doing so is informative. Research Question 2, “What are the current policies and practices on perinatal units in hospitals licensed to provide perinatal care in the state of Florida?” is descriptive in nature. The data for this question was obtained from perinatal UMs as well as participating nurses. The data was reported as frequencies, percents, and cumulative percents. Where inquiry was made of policies and practices related to continuous variables such as “time suckling at breast” or “length of stay in the nursery”, additional descriptive statistics were provided. The reader should note that although continuous variables were surveyed, they are grouped categorically; this required estimation of

27 traditional descriptive measures from grouped data presentations. Because there are occasionally discrepancies between policy and actual practice, data regarding current policies were obtained from the UM; data regarding current practices were acquired from staff nurses. Results were reported for the entire sample of hospitals as well as by perinatal unit classification and by groupings of the number of annual deliveries. Research Question 3, “To what extent are the existing policies and practices referred to in Research Question 2 consistent with those identified by current research as supporting successful initiation of breastfeeding?” is evaluative in nature. Inquiries were made as to the degree to which current hospital policies and practices were consistent with those identified in the current literature as supportive of successful initiation of breastfeeding. The reader should note that there are two questions subsumed within Research Question 3. The first is “To what extent are current hospital policies consistent with those identified in the research as supportive of breastfeeding?” This was referred to as Question 3a. The second is “To what extent are current hospital practices consistent with those identified in the literature as supportive of breastfeeding?” This question will be referred to as Question 3b. Survey instruments received from the UMs were used to calculate an agreement index using the policies recommended by current research for promoting successful initiation of breastfeeding. Both descriptive and inferential analyses were conducted using “compliance” as a dependent variable with “perinatal unit classification” as a categorical factor with three levels and “number of deliveries in the previous year” as an interval scaled covariate in a One-Way Analysis of Covariance (ANCOVA). The One-Way ANCOVA design was employed to control for the potential effect of “Number of deliveries in the previous year” on the compliance of hospitals with recommended policies for optimal breastfeeding across different classification levels. This analytical technique, in essence, treated each hospital as though they had the same number of births in the previous year when considering compliance for each of the three classification levels. The model thus became a One-Way ANOVA on adjusted mean compliances. The minimally adequate sample size requirement for the above model was determined by using Cohen (1988), for non-directional alpha (") = .05, power (1-$) = .80,

28 and a moderate effect size (ES) = .30F and model degrees of freedom (df) = 3. Using these criteria, n was determined to be 31 observations per cell or a total n = 93. The reader should note that for a fixed power equal to that specified above, the number of observations per cell should be equal and since it was unexpected that there would be equal numbers of hospitals classified as Level I, II, and III, it was anticipated that the power for this study would be slightly less than .80 as stated above.

The null hypothesis to be tested with this design is: H0: Hospital compliance with recommended policies for optimal breastfeeding is independent of classification level and number of deliveries in the previous year. In symbol form:

H0: adj:1 = adj:2 = adj:3

The alternate hypothesis (Ha) is nondirectional and states, Ha: Hospital compliance with recommended policies is not independent of classification and/or number of deliveries in the previous year.

Ha: at least two adj:i not equal where “i” = Classification Level 1, 2, or 3. Subsequent only to a significant result for the global null stated above, follow-up tests of pairs of means will be conducted for analysis of the source of variation in mean compliance between groups. Rather than blindly repeating the above analyses for sub-question 3b, the researcher will scrutinize the data for the degree to which hospital “practices” are consistent with hospital “policies”. Given that the agreement indices are sufficiently different for an in-depth analysis of the “practices” data, the above ANCOVA design will be applied and results reported. Should discrepancies between policies and practices not be sufficiently large to warrant inferential analyses, comparisons of mean compliance practices across classification levels (I, II, and III) will be made descriptively. Research Question 4, “What are perinatal nurses’ attitudes toward breastfeeding” is descriptive in nature and will be handled similarly to Research Questions 1 and 2. Research Question 5 is “What is the relationship between attitudes and compliance as well as other demographic variables?” To address this question, the attitudinal variable will be scored on an interval scale, and its correlation with the practice compliance

29 variable will be provided. Measures of association will be provided for this variable with all other relevant demographic and practice variables. Where such associations are of a great enough magnitude to justify inclusion in a regression analysis for predicting “practice compliance”, such an analysis will be conducted. Should this not be warranted based on the strength of the associations and/or violations of model assumptions, association results will be reported descriptively. Research Question 6, “To what extent are the results of the present investigation consistent with those reported by Churchill in 1992" will be addressed using frequencies, contingency tables, and measures of association.

Summary Hospitals that are licensed to provide obstetric services in the State of Florida were sent questionnaire packets. The packets were addressed to the Director of Nursing and contained questionnaires for the UM and for 4 nurses per hospital. The nurse manager questionnaire examined unit policies and the staff nurse questionnaires examined unit practices. The staff nurses were also be surveyed about their attitudes toward breastfeeding. A cover letter was provided for each questionnaire and consent was implied by return of the questionnaires. The methods to be utilized in analyzing data for each of the 6 research questions and rationale for selection were discussed.

30 CHAPTER FOUR RESULTS This chapter contains a description of the data obtained from both Unit Manager (UM) and Staff Nurse (SN) questionnaires. The results from both the UM and SN questionnaires are presented by research question. Within each research question, UM data is presented before SN data; where appropriate, SN data will be compared with UM data. The specific policies and practices which will be examined are: use of supplement feedings, use of complement feedings, frequency of feedings, restricted suckling time at breast, and distribution of formula discharge packs to breastfeeding mothers. The samples of scores for this study were obtained from unit managers and staff nurses who work in the perinatal units of Florida hospitals which provide obstetric services. Of the 125 hospitals initially surveyed, six indicated that they were no longer providers of obstetric services, bringing the number of facilities to 119 and the possible number of staff nurse respondents to 476. The follow-up call placed to facilities from which no responses had been received by 4 weeks after the surveys were mailed revealed eight facilities that indicated that surveys were not received; duplicate survey packs were mailed to all eight facilities per their request. Surveys were received from 75 unit managers and 269 staff nurses from 89 facilities. UM responses were received from three facilities where no corresponding staff nurse response was received; staff nurse responses from 35 nurses at 14 facilities were received without corresponding response from the UM. Data received from facilities where only the unit manager or staff nurses responded will be included except where policies and practices are compared or when attempts are made to compare practices with hospital demographics. A significance level of " = .05 will be used for all inferences.

31 Participant Demographics Research Question 1 stated, “What are the facility and participant demographic characteristics of the sample selected for this investigation?” Information was collected from unit managers (UM) regarding hospital demographics and from staff nurses (SN) regarding participant demographics. Unit Manager Demographics Of 119 unit managers who received surveys, 63% returned their surveys (n = 75). Facility characteristics are reported in Table 1. The grouped data estimate of mean is ~1,505 births per year. This is larger than the grouped data estimate of median, which is ~1,250; therefore, the distribution is positively skewed. Over half of facilities are Level I perinatal units and over half of facilities are located in cities with populations of greater than 90,000 people. Demographic data were also collected on the percentage of mothers who initiated breastfeeding and the percentage of mothers that were breastfeeding when discharged; these data are also contained in Table 1. The grouped data estimate of mean is ~63.87% of mothers initiating breastfeeding is slightly higher than the grouped data estimate of median which is ~63%. Just over one-third of facilities reported initiation rates of over 75%; nearly three-quarters of facilities reported initiation rates of greater than 50%. Only 4% of facilities reported a breastfeeding initiation rate of less than 25%. While the grouped data estimate of median for breastfeeding rates at time of discharge remained the same at ~63%, the grouped data estimate of mean fell to 61.27%. Just under one-third of facilities reported breastfeeding rates at time of discharge as 76-100%. Slightly over two-thirds reported breastfeeding rates at time of discharge as greater than 50%. Nearly 10% of facilities reported that fewer than 25% of women were still breastfeeding at the time of discharge including a facility reporting that less than 10% of mothers were breastfeeding upon discharge. Staff Nurse Demographics A total of 269 staff nurse surveys were returned out of 476 for a rate of 56.5%. One survey was discarded because it was returned almost completely unanswered. This left a total of 268 surveys from which information was gathered. Complete demographics

32 TABLE 1 Hospital Demographics by Unit Manager Report Deliveries per year (n = 75) f % Cum % Under 250 [125] 1 1.3 1.3 251-500 [375] 6 8.0 9.3 501-1000 [750] 23 30.7 40.0 1001-1500 [1250] 11 14.7 54.7 1501-2000 [1750] 12 16.0 70.7 2001-2500 [2250] 4 5.3 76.0 Over 2500 [2750] 18 24.0 100.0 Perinatal Unit Level (n = 75) f % Cum % Level I 40 53.3 53.3 Level II 21 28.0 81.3 Level III 14 18.7 100.0 Community Size (n = 75) f % Cum % Under 15,000 1 1.3 1.3 15,001 - 30,000 1 1.3 2.6 30,001 - 45,000 4 5.3 7.9 45,001 - 60,000 9 12.0 19.9 60,001 - 90,000 8 10.7 30.6 90,001 - 150,000 14 18.7 49.3 Over 150,000 24 32.0 81.3 Didn’t know/ Blank 14 18.7 100.0 Breastfeeding Rate (Initiation) (n = 75) f % Cum% 76- 100% [88%] 26 34.7 34.7 51-75% [63%] 28 37.3 72.0 26-50% [38%] 18 24.0 96.0 11-25% [18%] 3 4.0 100.0 Less than 10% [5%] 0 0.0 100.0 Breastfeeding Rate (@Discharge) (n = 74) f % Cum% 76-100% [88%] 24 32.4 32.4 51-75% [63%] 27 36.5 68.9 26-50% [38%] 16 21.6 90.5 11-25% [18%] 6 8.1 98.6 Less than 10% [5%] 1 1.4 100.0 [ ] = Midpoint f = number of Unit Mangers reporting % = percent of Unit Managers reporting Cum% = cumulative percent of Unit Managers reporting

33 for staff nurses are reported in Table 2. The grouped data estimate of the mean for age of respondents was 41.17 years; the grouped data estimate of the median was 43 years. The distribution for age of respondents was negatively skewed. The age grouping with the largest number of respondents was 46 and older. The mode for educational preparation was Associate Degree (47.2%; n = 127). The grouped data estimate of the mean for years of nursing experience was 15.89 years; the grouped data estimate of the median was 18 years. The distribution for years of nursing experience was negatively skewed. The grouped data estimate of the mean for years of obstetric/neonatal nursing experience was 13.22 years; the grouped data estimate of the median was 13 years. The distribution for years of neonatal/obstetric nursing experience was more symmetric than any of the other continuous variables. The median for educational inservice attendance was between 2 and 5 years ago and the mode was within the past year (42.4%, n = 114). Most nurses felt like they always knew enough (36.6%; n = 98) or usually knew enough (60.4%; n = 162) to help breastfeeding mothers. Most nurses felt they always had time (8.6%; n = 23) or usually had enough time (65.3%; n = 175) to help breastfeeding mothers; nearly a quarter rarely have enough time (23.1%; n = 62) to help breastfeeding mothers and 2.2% (n = 6) felt they never had enough time. The majority of nurse respondents have breastfed at least one child (73.2%; n = 197), 11.2% did not breastfeed a child (n = 30), and 15.6% indicated the question was not applicable (n = 42). Policies & Practices Research Question 2 stated, “What are the current policies and practices on perinatal units in hospitals licensed to provide perinatal care in the state of Florida?” Policy-related information was collected from unit managers and practice-related information was collected from staff nurses. Unit Manager Results The Unit Managers were asked to classify whether several activities were common practices at their facility; the major practices examined were suckling time, frequency of feeds, complement and supplement feeds, and distribution of formula discharge packs. Managers were also asked to identify how these practices were

34 TABLE 2 Staff Nurse Demographics by Staff Nurse Report Age (n = 268) f % Cum % 20-25 [22] 15 5.6 5.6 26-30 [28] 17 6.3 11.9 31-35 [33] 31 11.6 23.5 36-40 [38] 37 13.8 37.3 41-45 [43] 53 19.8 57.1 46 and older [48] 115 42.9 100.0 Educational Preparation (n = 263) f % Cum % LPN 4 1.5 1.5 Diploma 51 19.4 20.9 Associate Degree 126 47.9 68.8 Bachelors Degree 78 29.7 98.5 Masters Degree 4 1.5 100.0 Nursing Experience ( in years) (n = 267) f % Cum % 0 - 1 [0.5] 7 2.6 2.6 2 - 5 [3.5] 30 11.2 13.8 6 - 10 [8] 31 11.6 25.4 11 - 15 [13] 45 16.9 42.3 16 - 20 [18] 48 18.0 60.3 Over 20 [23] 106 39.7 100.0 OB/Neonatal Experience (in years) (n = 267) f % Cum % 0 - 1 [0.5] 13 4.9 4.9 2 - 5 [3.5] 53 19.9 24.8 6 - 10 [8] 34 12.7 37.5 11 - 15 [13] 55 20.6 58.1 16 - 20 [18] 45 16.9 75.0 Over 20 [23] 67 25.1 100.1 Attended Breastfeeding Inservices (n = 268) f % Cum % Within Past Year 114 42.5 42.5 2 - 5 Years Ago 100 37.3 79.8 6 - 10 Years Ago 22 8.2 88.0 11 or More Years Ago 9 3.4 91.4 Have Never Attended 23 8.6 100.0 f = number of Staff Nurses reporting [ ]= Midpoint for calculating grouped data estimated means % = percent of Staff Nurses reporting Cum % = Cumulative percent of Staff Nurses reporting

35 regulated: unit policy, physician order, both, or neither. The goal was to identify how the policies were made and how those were communicated to staff members; the intent was to establish the standard of care for the unit. These results are reported in Table 3. Most policies examined were in line with research-based recommendations. Most unit managers reported (92%; n = 69) that feeding on a fixed schedule was not a common practice. Unrestricted suckling time was reported by 94.6% of participants (n = 70). While supplementary feedings to breastfed babies were not a common practice at 98.7% of facilities (n = 74), complement feedings were uncommon at a smaller percentage (87.7%; n = 64) of facilities. Distribution of discharge packs, which is contrary to research-based recommendations, was restricted in only 53.3% of facilities (n = 40). Unrestricted distribution of formula-containing discharge packs was least likely to be controlled by physician orders and/or policies followed by use of complement feeds.

TABLE 3 Unit policies and regulators Written MD No Practice & Frequency Policy Order Both Neither Answer Suckling time (n = 74) Unrestricted (n = 70; 94.6%) 50.0 1.4 20.0 22.9 5.7 Restricted (n = 4; 5.4%) 50.0 0.0 0.0 25.0 25.0 Feeding frequency (n = 75) Fed on cue (n = 69; 92.0%) 42.0 2.9 34.8 14.5 5.8 Fed on schedule (n = 6; 8.0%) 33.3 16.7 50.0 0.0 0.0 Supplementation (n = 75) Uncommon (n = 74; 98.7%) 40.5 1.4 32.4 16.2 5.4 Common (n = 1; 1.3%) 0.0 0.0 100.0 0.0 0.0 Complementation (n = 73) Uncommon (n = 64; 87.7%) 40.6 3.1 40.6 9.4 6.3 Common (n = 9; 12.3%) 22.2 11.1 22.2 33.3 11.1 Discharge packs (n = 75) Restricted (n = 40; 53.3%) 37.5 0.0 20.0 25.0 17.5 Unrestricted (n = 35; 46.7%) 31.4 0.0 20.0 34.3 14.3 (Values reported as a percentage of unit managers responding)

36 Another important aspect of care of breastfeeding mothers is teaching them how to breastfeed. Of 75 facilities, all but one provide one-on-one teaching. Of the 74 facilities (98.7%) that do provide one-on-one teaching, 58.1% have a teaching protocol (n = 43) and 36.5% (n = 27) do not have a teaching protocol regarding the content to be provided to breastfeeding mothers; 5.4% of unit managers did not know whether a teaching protocol existed at their facility. The staff member responsible for providing teaching varied from facility to facility; because more than one staff member is responsible at many facilities, the numbers are not exclusive. The following staff members were listed as responsible for teaching: the postpartum nurse at 97.3% of facilities (n = 73), the delivery room nurse at 92% of facilities (n = 69), the nursery nurse at 88% of facilities (n = 66), a lactation consultant at 73% of facilities (n = 54), and a breastfeeding counselor at 40% of facilities (n = 30). Printed information regarding breastfeeding is distributed at 94.7% of facilities (n = 71). The practices of rooming-in and visiting hours were investigated. The majority of managers (84%; n = 63) indicated that 24 hour around-the-clock rooming-in is encouraged; 12% (n = 9) indicated that 12-23 hours of rooming-in is encouraged, and only 4% (n = 3) indicated that less than 12 hours a day of rooming-in is encouraged. Only one manager indicated that a physician order was required to allow rooming-in; this was at a facility where 24 hour rooming-in was encouraged. Visiting hours were unrestricted for immediate family of the mother in 86.7% of facilities (n = 65), for relatives at 54.7% of facilities (n = 41), and for friends at 44% of facilities (n = 33). Mothers sometimes encounter difficulty initiating breastfeeding; hence, unit managers were asked whether there was a staff member available to assist mothers who were having problems and, if so, who that professional was. Unit managers at 85.3% of facilities (n = 64) indicated that there was a staff member available to assist mothers experiencing difficulty. Of those 64 facilities, 82.8% had a lactation consultant on staff (n = 53), 23.4% had a breastfeeding counselor (n = 15), and 17.2% had a staff nurse responsible; some facilities had more than one type of professional who assisted mothers who were having problems. Unit managers were also asked whether there was a written

37 policy for referring mothers who were having breastfeeding related problems at the time of discharge to support services. Under half of managers (45.3%; n = 34) indicated that there is a policy for referral, 40% (n = 30) indicated that there was not a policy for referral, and 12% (n = 9) indicated that mothers are referred to support services although there is no policy to direct that it is done. Referrals were made to the following agencies or personnel (more than one answer was given by many unit managers; percentages are based upon the 43 facilities that make referrals): Lactation consultant, 90.1% (n = 39); La Leche League, 44.2% (n = 19); nursing mothers support group, 39.5% (n = 17); physician, 37.2% (n = 16); public health department, 11.6% (n = 5); nurse practitioner or midwife, 11.6% (n = 5); and other resources, 25.6% (n = 11). Other resources for referral included nursery staff, on-site lactation center, Women, Infants, & Children (WIC) program, the nursing staff, and an on-site parenting center. The final area examined was reasons that an infant might be removed from the breast. The most common reason for disruption of breastfeeding was low blood sugar, which was given as a cause at 52% of facilities (n = 39); of those, 4 provide supplements to breastfeeding, 3 supplement if breastfeeding did not bring the glucose levels up, 2 specified that they supplement if the baby is not latching on well, and 3 supplement until blood sugars stabilize. The next most frequently reported reason was jaundice, which was listed as a reason by 36% of facilities (n = 27); of those, 2 indicated this was not always done, 2 indicated that jaundiced babies were supplemented, 1 indicated that there might be a 24 hour interruption, and 1 indicated that mothers pumped and gave the baby expressed breastmilk (EBM). Managers at 34.7% of facilities indicated that babies were removed from the breast due to fever (n = 26) and another 2.7% specified maternal high fever of unknown origin as a cause (n = 2); 1 facility specified that babies with a fever were supplemented, 1 specified removal was for a temp of greater than 101, 1 specified that the baby was only removed if infectious, and 1 only discontinues breastfeeding if the mother is placed on medications incompatible with breastfeeding. Inadequate weight gain was given as a reason at 25.3% of facilities (n = 19); of those, 2 indicated that babies with inadequate weight gain were supplemented. Unit managers indicated that

38 breastfeeding was disrupted for “other reasons” at 18.7% of facilities (n = 14); these included infant tachypnea/respiratory distress (n = 5), neonatal sepsis or a newborn receiving antibiotics (n = 2), premature babies who were unable to suckle, in the NICU, or were receiving nothing by mouth, maternal complications (n = 4), and incompatible medications (n = 7). Finally, low was given as a reason by 10.7% of managers (n = 8); 1 facility indicated this was only done if the baby was in the Newborn Intensive Care Unit (NICU) and 1 indicated that low birth weight babies were supplemented. Only 3 facilities specifically stated that support and education to assist mothers to pump breastmilk was provided in cases where breastfeeding was interrupted. Staff Nurse Results Practices. The first portion of the staff nurse questionnaire examined multiple breastfeeding-related practices with normal healthy breastfed babies; the following practices were examined in this investigation: frequency of feeds, suckling time, use of supplements and complements, distribution of formula discharge packs, and breastfeeding education. Staff nurses were asked how frequently breastfed babies were fed; 73.3% indicated that babies are fed when they cry or appear hungry (n = 195), 18.4% indicated that babies are fed on a fixed schedule (n = 49), and 8.2% indicated that a combination of scheduled and demand feeding is used (n = 22). The schedule recommended by nurses who suggested scheduled feedings ranged from 2-3 hours to 4 hour spacing. The staff nurses were also asked whether they recommend restricted suckling time at the breast. Although 80.1% of staff nurses (n = 213) reported that they do not recommend restricted time, 0.8% recommend it on occasion (n = 2) and 19.2% (n = 51) routinely recommend restricted suckling time. The advice given for mothers who were told to restrict suckling time was wildly disparate; this was occasionally true even among nurses from the same facility. The advice ranged from starting with 5 minutes per side and increasing gradually from there; 10 to 15 minutes per side; 30 to 45 minutes per side; and over a dozen other recommendations in between. Several nurses reported advising mothers not to let the baby use the breast as a pacifier.

39 Another question asked was whether breastfed babies are normally given supplements between breastfeeding; the instructions indicated that survey questions were in reference to normal healthy breastfeeding infants. Of the 265 nurses who responded to this question, 22.3% (n = 59) indicated that babies are never given supplements, 77.4% (n = 205) indicated that supplements are occasionally given, and 0.4% (n = 1) indicated that supplements are always given. Multiple participants added comments regarding supplement use. Among the nurses who responded with “never,” comments included that supplementation might occur if medical problems with the baby including hypoglycemia occurred or if the mother requested supplementation. The nurses who responded with “occasionally” gave similar comments; maternal request for supplementation was the most common reason given. Participants were also asked what babies are given when supplementation occurs; more than one option could be marked. Formula was the most common substance used (78.4%; n = 210) followed by glucose water (20.5%; n = 55), sterile water (9%; n = 24), and other substances (5.6%; n = 15); “other” included expressed breastmilk (EBM; n = 6), (n = 1), and a 50/50 mix of glucose water and EBM or formula (n = 1). Finally, nurses were asked how supplements were given. Bottles by far were the most common means of administration used (73.5%; n = 197) followed by cup (24.6%; n = 66), nasogastric (NG)/orogastric (OG) tube (11.6%; n = 31), syringe (11.6%; n = 31), finger-feeding (10.1%, n = 27), supplemental nursing system (SNS; 7.1%; n = 19), spoon (6.7%; n = 18), and dropper (0.4%; n = 1). Nurses were asked whether breastfed babies are normally given complements with feeds; the same instruction that the question was in reference to normal healthy breastfeeding infants applied. Of 253 nurses who answered the question, 29.6% indicated that complements are never used (n = 75), 67.2% indicated that they are occasionally used (n = 170), and 3.2% indicated that complements are always used (n = 8). One of the nurses who responded with “never” indicated that complements are used if requested by the mother but that the practice is discouraged. Maternal request and MD request were the two most common reasons stated by nurses who responded with “occasionally”. One nurse indicated that she did not understand the question. Nurses were also asked what is

40 used for complement feeds. Again, formula was the most common substance used (64.2%; n = 172) followed by glucose water (17.2%; n = 46), sterile water (6.3%; n = 17), and other substances (4.9%; n = 13); EBM was the most common other substance used (n = 7). The staff nurses were asked whether formula discharge packs are routinely distributed to breastfeeding mothers. Of the 266 who answered, 66.9% (n = 178) indicated that discharge packs are routinely distributed, 32.3% (n = 86) indicated that they are not distributed, and 0.8% (n = 2) checked neither yes nor no but indicated that a breastfeeding bag is distributed. Among the participants who indicated that packs are distributed, 27 indicated that a breastfeeding formula bag is used; 8 indicated that they remove the formula from the discharge pack before distribution. Three nurses indicated that mothers request and expect the formula discharge bags. Two nurses from one facility indicated that they plan to stop distributing them. Of the nurses who answered that discharge packs are not routinely distributed, 2 indicated that they are distributed if requested, 2 indicated that formula is removed, and 5 indicated that a breastfeeding support pack is distributed. One participant indicated that their facility recently stopped distributing them. Rooming-in and visiting hours were investigated. The majority of nurses (80.8%; n = 214) indicated that 24 hour/day rooming-in is encouraged and another 14% (n = 37) indicated that rooming-in is encouraged for 12-23 hours/day. Very few (1.9%; n = 5) indicated that rooming-in is encouraged for less than 12 hours/day or not at all (2.3%; n = 6). Visiting hours were listed as unrestricted for immediate family by 90.2% of nurses (n = 239), relatives (58.9%; n = 155), and friends (54.4%; n = 143). Education & Support. Nurses were asked whether mothers are taught the techniques of breastfeeding; 97.8% (n = 262) indicated that mothers are. Over 2/3 indicated that teaching is done starting with the first feed (69.2%; n = 182); 15.6% (n = 41) indicated that teaching is initiated within 12 hours of birth, 7.2% (n = 19) indicated that teaching is done on an as-needed basis; the remainder indicated that teaching occurs later or at other times. Of those nurses who indicated that teaching is

41 initiated with the first feed, 80 specified that other teaching episodes are provided. There were also 7 nurses that indicated mothers start learning breastfeeding skills in prenatal classes. The majority of nurses indicated that printed materials are distributed to breastfeeding mothers (94.7%; n = 252). Staff nurses were asked who is responsible for providing teaching to breastfeeding mothers. Multiple answers were possible. The delivery room nurse was listed as responsible by 80.6% of participants (n = 216); the postpartum nurse was listed as responsible by 88.8% (n = 238); 75.7% indicated that the nursery nurse was responsible (n = 203); 63.1% of nurses indicated that the lactation consultant was responsible for teaching (n = 169); and 32.1% (n = 85) indicated that the breastfeeding counselor is responsible for teaching. Of the 266 nurses who responded to the question of whether one-on-one teaching is provided, 98.5% (n = 262) indicated that it is; 1.5% (n = 4) indicated that one-on-one teaching is not provided. Of the 262 who indicated that one-on-one teaching is done, 49.2% (n = 129) indicated that there is a protocol for teaching, 45.4% indicated that there is not a protocol for teaching, and 5.3% (n = 14) did not know whether or not a teaching protocol existed. Nurses were asked whether there was a staff member who was responsible for helping mothers who were having difficulty with breastfeeding; 75.1% (n = 199) stated that there was someone available; 24.9% stated that there was not someone designated to assist mothers. More than one answer was possible; a lactation consultant was listed as the responsible person by 65.3% of participants (n = 175), a staff nurse was listed as the responsible person by 16% of participants (n = 43), and a breastfeeding counselor was listed as responsible by 13.8% (n = 37). Nurses were also asked whether they had referred mothers to support services within the past six months. Lactation consultants were the most frequent referral made (73.9%; n = 198) followed by La Leche League (25.7%; n = 269), nursing mother support groups (19.8%; n = 53), the public health department (13.4%; n = 36), physician’s office (11.2%; n = 30), and nurse practitioner/midwife (6.7%; n = 18). Other resources to

42 whom mothers are referred included the WIC breastfeeding coordinator (n = 6), breastfeeding counselors (n = 5), Healthy Start (n = 2), and hospital staff (n = 2). Compliance of Policies with Research Research Question 3a asked, “To what extent are current hospital policies consistent with those identified in the research as supportive of breastfeeding?” The term “compliance” was defined as following research-based recommendations. A compliance score was assigned to each facility based on responses to the 10 questions examining breastfeeding practices. Each response reflecting an appropriate practice was assigned a score of 1; responses reflecting practices that were not research-based received a score of zero. The results were added together to create a sum compliance score. Analysis of Covariance (ANCOVA) was the most appropriate analytical tool for examining the effect of the independent variable (IV) “Perinatal unit level” on the dependent variable (DV) “compliance” while removing the effect of the “number of deliveries” (covariate) based on 3 assumptions: a) both the IV and covariate would correlate with the DV, b) if the covariate was correlated with the DV, the effect would be apparent across the three perinatal unit levels, and c) that if a differential effect was present, conclusions related to the effect of perinatal unit level on compliance would be confounded by the covariate. ANCOVA is a statistical procedure that allows the researcher to negate the effect of a confounding variable and, for the present inquiry, adjusted the mean compliance score for the three perinatal unit classifications based upon their differences in number of deliveries per year. The descriptive statistics and a summary of the Between-Subjects effects for this analysis are provided in Tables 4 and 5. There is insufficient evidence to conclude that Perinatal Unit Level has an effect on compliance once the number of deliveries has been controlled for; this is shown in Table 5. Eta2 in the table is a post-hoc measure of the effect for the variable of interest. R-squared is the proportion of shared variance that a variable provides toward perfectly predicting another. The number of deliveries and unit level together contribute only about 2.5% of what would be needed to perfectly predict compliance. The number of

43 TABLE 4 Descriptive Statistics for Analysis of Covariance: Policy Compliance with Level of Perinatal Unit and Deliveries (Covariate) Level of Perinatal Unit Adj Mean Std Dev n Primary 8.95 1.10 37 Secondary 9.24 .7 21 Tertiary 9.00 .82 13 Total 9.04 .95 71 Dependent Variable: Policy Compliance

TABLE 5 Tests of Between Subjects Effects 2 Source Sum of Squares df Mean Square Fc p Eta Model 1.216 3 .405 .440 .725 .019 Deliveries .04427 1 .04427 .048 .827 .001 Unit Level .954 2 .477 .519 .598 .015 Error 61.657 67 .920 Total 62.873 70 R-squared = .025 Dependent Variable: Policy Compliance

deliveries only contributes about 0.1% and unit level only contributes approximately 1.5% of the information that would be necessary to perfectly predict compliance. What this suggests is that other variables than those selected for the present investigation are influencing compliance with research-based breastfeeding practices in Florida. Compliance of Practices with Policy and Research Research Question 3b asked, “To what extent are current practices consistent with those identified in the literature as supportive of breastfeeding?” Because the degree of compliance of policy to research-based recommendations was previously made, this question was addressed by determining the degree to which practices comply with corresponding policies listed by the UM as standard for the facility. Corresponding UM

44 data were available for 235 nurses from 72 facilities. Descriptive comparisons of policy with practice both for individual staff nurses and for the percentage of facilities with nurses in full agreement with the UM response will be addressed first and will be followed by statistical comparisons. Data is presented in Table 6.

TABLE 6 Agreement Between Staff Nurse (SN) Data and Unit Manager (UM) Data % SN responses ALL SN responses within FACILITY Practice matched UM Matched UM Did Not Match UM Feeding frequency 78.7% (n = 185) 55.6% (n = 40) 5.6% (n = 4) Suckling time 78.1% (n = 182) 54.9% (n = 39) 2.8% (n = 2) Supplementation 24.3% (n = 57) 4.2% (n = 3) 50.0% (n = 36) Complementation 37.4% (n = 85) 15.7% (n = 11) 38.6% (n = 27) Discharge packs 52.8% (n = 124) 25.0% (n = 18) 26.5% (n = 19)

Rooming-In 79.7% (n = 185) 70.8% (n = 51) 11.8% (n = 8) Visiting Hours Immediate Family 82.0% (n = 191) 65.3% (n = 47) 9.7% (n = 7) Relatives 62.7% (n = 143) 36.6% (n = 26) 12.7% (n = 9) Friends 65.8% (n = 150) 38.8% (n = 27) 15.5% (n = 11)

Teaching done by Delivery room nurse 80.4% (n = 189) 55.6% (n = 40) 2.8% (n = 2) Postpartum nurse 89.8% (n = 211) 76.4% (n = 55) 1.4% (n = 1) Nursery nurse 75.9% (n = 178) 47.2% (n = 34) 6.9% (n = 5) Breastfeeding counselor 69.6% (n = 163) 43.1% (n = 31) 8.3% (n = 6) Lactation consultant 87.0% (n = 201) 71.8% (n = 5) 5.6% (n = 4) One-on-one teaching done 98.7% (n = 228) 94.4% (n = 68) 1.4% (n = 1) Teaching protocol in place 52.7% (n = 124) 20.3% (n = 13) 14.1% (n = 9)

Assistance available 88.8% (n = 206) 81.7% (n = 58) 4.2% (n = 3) Breastfeeding counselor 78.3% (n = 184) 62.5% (n = 45) 6.9% (n = 5) Lactation consultant 89.4% (n = 210) 83.3% (n = 60) 4.17% (n = 3) Designated staff nurse 71.1% (n = 167) 50.0% (n = 36) 13.9% (n = 10)

(Values reported indicate ONLY that SN response matched UM response)

45 Frequency of feeding was the first area in which policies were compared with practices. Almost 4 of 5 nurses reported a feeding frequency that matched the UM response for their facility (e.g. both reported demand feeding or both reported scheduled feeding); One-fifth reported feeding frequency that did not match the UM response for their facility. Compliance within facilities was examined in addition to individual nurse compliance. All responding nurses gave a response that matched the UM response in slightly over half of facilities. Suckling time at the breast was the second area in which policies were compared with practices. Nearly 4/5 of individual staff nurses gave responses that matched the UM response for their facility. Restricted suckling time was recommended by 17.6% of nurses (n = 41) when the UM indicated that restricted suckling time was uncommon and 4.3% (n = 10) reported recommending unrestricted suckling time despite the UM reporting that restricted suckling time was the standard for the unit. At just over half of facilities, all responding nurses gave an answer that matched the UM response. Supplement and complement feedings were the third area in which policies were compared with practices; a disparity in policy and practice was found in the area of supplement and complement feedings. The actual amount of disagreement was difficult to quantify due to different phrasing of the UM question and the corresponding staff nurse question. Unit managers were instructed to answer yes or no to the statement “Breastfed babies are normally given supplements between breastfeeding”; staff nurses were asked “Are breastfed babies normally given any supplements between feedings?” and were requested to answer “always,” “occasionally,” or “never” with the qualification that answers were to be based on normal healthy breastfeeding infants. The question regarding complement feeds was identical except for the substitution of the word “complement” for “supplement.” For the staff nurses, “compliant” was defined as having answered “never” to the questions regarding supplement and complement use because the question was directed toward healthy babies. Fewer than 1/4 of the nurses reported practices in full agreement with the UM regarding use of supplement feeds and just over 1/3 of the nurses reported practices in full agreement with the UM regarding use of

46 complement feeds. The amount of agreement dropped substantially when looking at compliance from a facility perspective. In regard to supplement use, there were very few facilities in which all nurses gave a response which fully matched the UM response. Not a single nurse gave a response which fully matched the UM response at half of facilities. The numbers for complement use were better but were still low. Distribution of formula-containing discharge packs was the fourth area in which policies were compared with practices; a substantial disparity was also detected in this area. Slightly over half of individual staff nurses gave responses that corresponded with the response from the UM at their facility; 32.3% (n = 76) reported distributing discharge packs when the UM stated the practice was not common while 14.9% (n = 35) did not distribute them despite the UM indicating that the practice was common. All nurses gave a response which matched the UM response regarding distribution of formula-containing discharge kits at 1/4 of facilities; no nurse gave a response which matched the UM response at just over 25%. There was 79.7% agreement (n = 185) between individual staff nurses and the UM regarding the amount of time rooming-in was encouraged. Nurses at just over 2/3 of facilities were in 100% agreement with the UM regarding the amount of time rooming in was encouraged. None of the nurses gave responses which matched that of the UM at just over 10% of facilities. There was over 80% agreement between UM and staff nurses regarding visiting hours for immediate family. There was nearly 2/3 agreement between UM and staff nurse regarding visiting hours for friends. Finally, over 3/5 of staff nurses were in agreement with the UM regarding visiting hours for relatives. Across the board, nurses were more likely to report visiting hours as more lenient than the UM had indicated. Nurses were more likely to be in complete agreement with the UM regarding visiting hours for immediate family than for friends and relatives. Most staff nurses gave responses that matched the UM response regarding which of the following staff members were responsible for breastfeeding-related teaching: delivery room nurse, postpartum nurse, nursery nurse, breastfeeding counselor, and

47 lactation consultant. There were some cases that even though the UM indicated the following staff members were responsible for teaching, staff nurses did not indicate that they were: delivery room nurse (14.9%; n = 35), postpartum nurse (8.5%; n = 20), nursery nurse (17.9% n = 42), breastfeeding counselor (20.1%; n = 47), and lactation consultant (11.7%; n = 27). The percentage of facilities with complete agreement between all staff nurses and the UM in reference to whether or not the following were responsible was highest for the postpartum nurse followed by the lactation consultant, delivery room nurse, and the nursery nurse with the fewest for the breastfeeding counselor. There were only 8 facilities from which all nurses gave responses which matched the UM’s response for all five roles. Virtually all nurses agreed with the UM from their facility that one-on-one teaching is done; however, there was substantial disagreement between UM and staff nurse as to the existence of teaching protocols. Just over half of nurses gave responses that matched the UM response for their facility as to whether or not a teaching protocol existed. A large portion of staff nurses gave a response that did not match the UM response regarding whether a teaching protocol was in place. Nearly a quarter of staff nurses indicated a protocol did not exist when the UM at their facility indicated that one did (21.3%; n = 50) and 13.2% (n = 31) stated one existed when the manager reported that there was no protocol. For the few facilities in which the manager did not know whether a protocol existed, 3.8% of nurses (n = 9) stated one did and 3.0% of nurses (n = 7) stated that one did not. The remaining 6% of nurses (n = 14) did not know whether or not a protocol existed. Nurses at the majority of facilities were in complete agreement with the UM regarding one-on-one teaching being done; however, nurses were in complete agreement with the UM regarding whether or not a teaching protocol existed at just over 1/5 of facilities. There was 88.8% agreement between the staff nurse report and the UM report regarding whether there was a staff member available to assist mothers who were having difficulty initiating breastfeeding. Only 1.7% of nurses (n = 4) reported there was a responsible person when the manager indicated there was not and fewer than 10% of

48 nurses reported that there was no responsible person at facilities where the UM indicated that there was. Nurses from over 4 in 5 facilities were in complete agreement with the UM that there was a staff member available to assist mothers with problems. In reference to the availability of specific personnel, 16 (6.8%) did not indicate that a lactation consultant was available when the UM responded that one was, 32 (13.6%) did list a breastfeeding counselor as available, and 34 (14.5%) did not indicate that a designated staff nurse was responsible. Statistical Comparisons In order to compare practice compliance with policy compliance, a Paired- Samples t-test was utilized. The practice compliance score for each individual facility was paired with the corresponding policy compliance score for facilities (n = 72) that had policy data as well. The mean policy compliance score was 9.029 compared with the mean practice compliance score of 6.785. The mean difference between scores was 2.244 with a standard deviation of 1.283. This difference was statistically significant (p < .001). The majority of facilities had lower staff nurse compliance scores than UM compliance scores (negative rank) (n = 65) and 1 facility had higher staff nurse compliance than UM compliance; two facilities had matching compliance scores. The Wilcoxon Signed Ranks Test, which is a nonparametric analogue to the related samples t-test was used as confirmation of the degree to which the data provided evidence of conformity with the assumptions required for it, yielded a Z score of -7.017 based on positive ranks; this was statistically significant with a value of p < .001. Due to the findings from the Paired-Sample t-Test, another ANCOVA was run comparing practice compliance (DV) with perinatal unit level (IV) using deliveries per year as the covariate. Results are shown in Tables 7 and 8. There was insufficient evidence to conclude that perinatal unit level has an effect on practice compliance once deliveries per year has been controlled for. In the table, Eta2 is a post-hoc measure of the effect of the variable of interest; R squared is the proportion of shared variance that a variable provides toward perfectly predicting another. In this case, only about 1.2% of the information required for predicting practice compliance is provided by knowing

49 TABLE 7 Descriptive Statistics for Analysis of Covariance: Practice Compliance with Level of Perinatal Unit and Deliveries (Covariate) Level of Perinatal Unit Adj Mean Std Dev n Primary 6.82 1.41 129 Secondary 6.86 1.67 66 Tertiary 6.93 1.56 40 Total 6.85 1.50 235 Dependent Variable: Practice Compliance

TABLE 8 Tests of Between Subjects Effects 2 Source Sum of Squares df Mean Square Fc p Eta Model .354 3 .118 .052 .985 .001 Deliveries .0141 1 .0141 .006 .938 .000 Unit Level .215 2 .108 .047 .954 .000 Error 529.433 231 2.292 Total 529.787 234 R-squared = .012 Dependent Variable: Practice Compliance

perinatal unit level and deliveries per year. Perinatal unit alone and number of deliveries alone contribute less than 0.1% of the information required for predicting practice compliance. Again, this suggests that something else is contributing to compliance. Staff nurse demographic data was compared with compliance scores in an attempt to generate an explanation for differences in compliance scores. Age, educational preparation, and personal breastfeeding experience showed no correlation with practice compliance scores. Table 9 contains correlation coefficients for practice compliance and select demographic variables. Experience in nursing and in obstetric/neonatal nursing both showed a positive correlation with practice compliance. Nurses who had attended breastfeeding-related inservices more recently had higher compliance scores than nurses who had not. Nurses who perceived they had enough time to help mothers had higher

50 TABLE 9 Correlation of Practice Compliance with Selected Demographic Characteristics Characteristic Correlation p Perception of adequate time to help .196 .001* Increased nursing experience .163 .008* Increased obstetric/neonatal experience .150 .014 Attitude score toward breastfeeding higher .137 .025 More recent inservice attendance .132 .031 *= significant to p < .01; all others significant to p < .05

compliance scores than those who did not. When used as a demographic trait, nurse attitude toward breastfeeding had a positive correlation with practice compliance. A regression analysis was conducted using practice compliance as the dependent variable and nursing experience, obstetric/neonatal nursing experience, inservice attendance, perception of adequate time, and attitude toward breastfeeding as independent variables; the five IVs only provided 5.7% of the information required to perfectly predict a nurse’s practice compliance. Once again, this suggests that other factors which were not examined in this investigation are contributing to the disparity in compliance scores. Nurse Attitude Toward Breastfeeding Research Question 4 stated: “What are perinatal nurses’ attitudes toward breastfeeding?” This data was gathered using Cusson’s Attitude toward Breastfeeding survey, which is an 18-question Likert-scale questionnaire in which participants were asked to answer questions with “strongly agree,” “agree,” “neutral,” “disagree,” or “strongly disagree.” Part of the questions were phrased positively and part were phrased negatively. Scores for each question ranged from 1 to 5; the total attitude score was derived by calculating the mean score of the 18 answers. A positive attitude was defined as 3.5 or above; a negative attitude was defined as less than 2.0. Missing answers were

51 handled by calculating the mean score for the questions that were answered and inserting that value into the blank fields; this was the same technique Cusson used. Of the 268 nurses who returned surveys, 267 completed the attitude survey. The majority of nurses (89.5%, n = 239) had a positive attitude score; no nurses had a negative attitude score. Scores ranged from 2.44 to 4.94. The mean attitude score was 4.108 with a standard deviation of .457. The median attitude score was 4.111; skew was -.515. There were several individual questions for which high mean scores approaching “strongly agree” or “strongly disagree” were obtained: 8) Breastfeeding is healthier for the baby; 9) Breastfeeding provides insufficient milk; 10) Breastfeeding may not provide the right kind of milk; and 12) Breastfeeding provides a closer link with the mother. There were two questions for which the mean score approached neutrality: 4) Breastfeeding improves the appearance of the breast and 6) Breastfeeding is more attractive to the husband. Mean scores and standard deviations for these questions are presented in Table 10.

TABLE 10 Attitude Scores for Select Individual Questions Question Mean SD 8) Healthier for baby (pos) 4.831 .448 10) May not provide right kind of milk (neg) 4.718 .603 12) Closer link with mother (pos) 4.667 .703 9) Provides insufficient milk (neg) 4.562 .665 6) More attractive to husband (pos) 3.126 .878 4) Improves appearance of breast (pos) 2.769 1.069 (pos: 5 = Strongly Agree; 3 = Neutral; 1 = Strongly Disagree) (neg: 5 = Strongly Disagree; 3 = Neutral; 1 = Strongly Agree)

52 Relationship of Attitude to Compliance Research Question 5 stated, “What is the relationship between attitudes and compliance as well as other demographic variables?” Nurse attitude toward breastfeeding had a positive correlation with compliance score which did reach statistical significance (r =.137; p = .025). In other words, nurses with a positive attitude toward breastfeeding were more likely to have high compliance scores. Four demographic characteristics had correlations with attitude score; these are included in Table 11. A regression analysis indicated that 18.4% of the information required to perfectly predict a nurse’s attitude is provided by knowledge of a nurse’s level of obstetric experience, perception of having enough time and knowledge to help breastfeeding mothers, and personal breastfeeding experience; something else accounts for the rest.

TABLE 11 Correlation of Attitude Score with Selected Demographic Characteristics Characteristic Corr. p Increased obstetric/neonatal experience .131 .033 Perception of adequate knowledge to help .285 .000* Perception of adequate time to help .268 .000* Breastfed at least one child (n/a excluded) .354 .000* *= significant to p < .001; all others significant to p < .05

Current Results Compared to Churchill’s Results Research Question 6 stated, “To what extent are the results of the present investigation consistent with those reported by Churchill in 1992?” Descriptive comparisons were made between demographic characteristics of participants and of practices and attitudes. To aid in making comparisons, grouped data estimate of mean/median were calculated where possible.

53 Demographics Unit Manager. A total of 57 unit managers (68%) participated in Churchill’s 1992 study compared with 75 managers (63%) in the present investigation. Although the return rate was slightly less, the overall number of surveys returned was greater due to the larger number of available facilities. Data related to changes in facility demographics are reported in Table 12. There were a larger percentage of Level I perinatal units and a smaller percentage of Level II perinatal units; although the mix of facilities changed, the number of each type facility responding increased since 1992. The grouped data estimate of mean was calculated to be ~1647 births per year with a grouped data estimate of median of ~1750 births per year in 1992. By 2002 the grouped data estimate of mean and median had dropped to ~1505 and ~1250 births per year respectively. A larger percentage of hospitals were managing under 1000 births per year and fewer hospitals were managing over 2000 births per year. The breakdown of community size showed tremendous change; percentages are based upon managers who knew their community size. The percentage of managers reporting a community size of fewer than 30,000 decreased in the present investigation; the percentage of managers reporting a community size of greater than 60,000 people increased substantially in the present investigation (Churchill, 1992, p. 31) Staff Nurse. Churchill received a 57.2% response rate (151 of 264) from staff nurses; the present investigator received a 56.5% response rate (269 of 476). Data related to changes in staff nurse demographics are reported in Table 13. There were striking changes in the population between 1992 and 2002. The grouped data estimate of mean for age increased from ~38.12 years in 1992 to ~41.17 in 2002. Similarly, the grouped data estimate of median increased from 38 to 43. When Churchill surveyed the nurses in 1992, the age distribution was mostly even with the exception of the 20-25 year old category. In the present investigation, nearly half of nurses were 46 and older; over 3 in 5 were over 40 years old. Although educational preparation remained very similar, the percentage of nurses with 4-year degrees or higher increased. Nearly half of participants in both investigations had associate degrees. A smaller proportion of nurses were

54 TABLE 12 Changes in Hospital Demographics by Unit Manager Report 1992 2002 Deliveries per year Under 1000 33.4% (n = 19) #40.0% (n = 30) 1001-2000 28.0% (n = 16) 30.7% (n = 23) Over 2000 38.6% (n = 22) *29.3% (n = 22) Total: 57 75 Perinatal Unit Level Level I 47.4% (n = 27) #53.3% (n = 40) Level II 35.1% (n = 20) *28.0% (n = 21) Level III 17.5% (n = 10) 18.7% (n = 14) Total: 57 75 Community Size Under 30,000 18.2% (n = 8) *3.3% (n = 2) 30,001 - 60,000 22.8% (n = 10) 21.3% (n = 13) Over 60,000 59.1% (n = 26) #75.4% (n = 46) Total: 44 61 n = number of Unit Mangers reporting % = percent of Unit Managers reporting * >5 percentage point decrease from 1992 to 2002 # >5 percentage point increase from 1992 to 2002 (1992 data: Churchill, 1992, p. 31)

diploma prepared and a larger proportion were bachelors prepared. Although the number of masters prepared nurses remained the same, the percentage decreased from 3.4% to 1.5% (Churchill, 1992, p. 38) The distribution of the level of the amount of experience nurses have changed as well; these data are also contained in Table 13. At the time of Churchill’s investigation, the distribution of nurses between categories for general nursing experience was mostly symmetrical once the 0-1 and 2-5 years experience categories were combined. The grouped data estimate of mean was ~13.10 years of nursing experience in 1992 and the grouped data estimate of median was ~13 years of experience. At the time of the present

55 TABLE 13 Changes in Staff Nurse Demographics by Staff Nurse Report 1992 2002 Age 150 268 20-25 5.6% (n = 2) 5.6% (n = 15) 26-30 15.9% (n = 24) *6.3% (n = 17) 31-35 21.9% (n = 33) *11.6% (n = 31) 36-40 20.5% (n = 31) *13.8% (n = 37) 41-45 19.2% (n = 29) 19.8% (n = 53) 46 and older 20.5% (n = 31) #42.9% (n = 115) Educational Preparation 149 263 LPN 0% (n = 0) 1.5% (n = 4) Diploma 24.8% (n = 37) *19.4% (n = 51) Associate Degree 49.0% (n = 73) 47.9% (n = 126) Bachelors Degree 22.8% (n = 34) #29.7% (n = 78) Masters Degree 3.4% (n = 4) 1.5% (n = 4) Nursing Experience ( in years) 148 267 0 - 1 0.7% (n = 1) 2.6% (n = 7) 2 - 5 16.2% (n = 24) *11.2% (n = 30) 6 - 10 20.9% (n = 31) *11.6% (n = 31) 11 - 15 25.7% (n = 38) 16.9% (n = 45) 16 - 20 17.6% (n = 26) 18.0% (n = 48) Over 20 18.9% (n = 28) #39.7% (n = 106) OB/Neonatal Experience (in years) 150 267 0 - 1 6.0% (n = 9) 4.9% (n = 13) 2 - 5 28.7% (n = 43) *19.9% (n = 53) 6 - 10 22.7% (n = 34) *12.7% (n = 34) 11 - 15 26.7% (n = 40) *20.6% (n = 55) 16 - 20 9.2% (n = 14) #16.9% (n = 45) Over 20 6.7% (n = 10) #25.1% (n = 67) Attended Breastfeeding Inservices 151 268 Within Past Year 55.6% (n = 84) *42.5% (n = 114) 2 - 5 Years Ago 23.2% (n = 35) #37.3% (n = 100) 6 - 10 Years Ago 1.3% (n = 2) #8.2% (n = 22) 11 or More Years Ago 2.0% (n = 3) 3.4% (n = 9) Have Never Attended 17.9% (n = 27) *8.6% (n = 23) n = number of Staff Nurses reporting % = percent of Staff Nurses reporting * >5 percentage point decrease from 1992 to 2002 # >5 percentage point increase from 1992 to 2002 (1992 Data: Churchill, 1992, p. 38)

56 investigation nearly 2 in 5 nurses had over 20 years experience; this was double the percentage reported by Churchill. In 2002, the grouped data estimate of mean and median were ~15.89 and ~18 years of experience respectively. The portrait for obstetric/neonatal nursing experience was quite different as well. In Churchill’s investigation, the distribution was skewed loaded toward fewer years of experience in obstetric/neonatal nursing with a grouped data estimate of mean of ~9.53 years experience and a grouped data estimate of median of ~8 years experience. In the present investigation, the opposite was true; a quarter of nurses had over 20 years of experience in obstetric/neonatal nursing and the grouped data estimate of mean and median were ~13.22 years and ~13 years respectively (Churchill, 1992, p. 38). Attendance at formal breastfeeding-related inservices has changed. Data related to inservice attendance is also contained in Table 13. The only true improvement was that the percentage of nurses who never attended a breastfeeding-related inservice decreased by close to half. The percentage who attended within 5 years remained similar although fewer had attended in the past year and more attended between 2 and 5 years ago in the present investigation. The percentage of nurses for whom it had been over 6 years since their most recent attendance at inservice training increased threefold (Churchill, 1992, p. 38) Policies & Practices Policies. At the time of the present investigation a smaller percentage of facilities reported restricted suckling time, use of supplementary and complementary feeds, and unrestricted distribution of discharge packs as common practices. These data are reported in Table 14 along with whether the practices were regulated or unregulated. At the sole facility where supplementation was common in the present investigation, the practice was regulated by both orders and unit policy. At the facilities where distribution of discharge packs was unrestricted, nearly half of unit managers (48.6%) reported that the practice was unregulated or did not know how or if the practice was regulated. Both of these were an improvement from Churchill’s investigation. There were two practices, however, that were less regulated than in the previous investigation. Restriction of suckling time was

57 TABLE 14 Changes in Unsupportive Unit Policies and regulators Reported Not No Unsupportive Practice (% of total) Regulated Regulated Answer Restricted suckling time 1992 19.0 72.8 13.6 13.6 2002 (n = 4) 5.4 *50.0 25.0 25.0 Supplementation common 1992 10.5 75.0 25.0 0.0 2002 (n = 1) 1.3 #100.0 0.0 0.0 Complementation common 1992 29.8 77.8 11.1 0.0 2002 (n = 9) 12.3 *55.5 33.3 11.1 D/c packs distributed routinely 1992 68.4 34.4 65.6 0.0 2002 (n = 35) 46.7 #51.4 34.3 14.3 Values reported as a percentage of unit managers responding Regulated = Controlled by written policy, MD order, or both # regulated by higher percentage of facilities * regulated by lower percentage of facilities 1992 values available as percentages only (Churchill, 1992, p. 33)

regulated at half of facilities in 2002 compared with nearly three-quarters of facilities in 1992. Use of complementary feeding was regulated at just over half of facilities in 2002 compared with over three-quarters of facilities in 1992 (Churchill, 1992, p. 33). Churchill investigated whether facilities had a staff member available to assist mothers experiencing difficulty with breastfeeding. Fewer than half of facilities reported having a lactation consultant on staff (41.5%), 26.8% had a breastfeeding counselor, and 37.1% reported that a staff nurse filled this role (Churchill, 1992, p. 44). By 2002, 70.7% of facilities (n = 53) reported having a lactation consultant, 20% (n = 15) reported having a breastfeeding counselor, and 14.7% (n = 11) indicated that a staff nurse was responsible. Some facilities had more than one individual responsible; 11 facilities indicated that there was no staff member responsible for assisting mothers who experienced difficulties.

58 Churchill also investigated whether one-on-one teaching was provided to breastfeeding mothers and whether a teaching protocol existed. Nearly all facilities reported doing one-on-one teaching (98.3%) and 70% (n = 42) had a teaching protocol (Churchill, 1992, p. 44). The present investigation revealed that 98.7% of facilities (n = 74) provide one-on-one teaching; however, only 58.1% of facilities (n = 43) reported having a teaching protocol. Although the percentage of facilities indicating that a teaching protocol was in place decreased, the raw number increased. Visiting hours were also investigated. Churchill reported that 13.6% of facilities restricted visiting hours for immediate family, 46.6% restricted visiting hours for relatives, and 55.9% restricted visiting hours for friends (Churchill, 1992, p. 44). The percentage of facilities reporting restricted hours in 2002 was strikingly similar: 13.3% reported restricted visiting hours for immediate family, 44.0% reported restricted visiting hours for relatives, and 54.7% reported restricted visiting hours for friends. Reasons for discontinuing or interrupting breastfeeding were investigated in both 1992 and 2002. The six reasons identified by Churchill in descending order were as follows: maternal or infant fever, 70%; jaundice, 51.7%; hypoglycemia, 25%; other reasons, 11.7%; inadequate weight gain, 10%; and low birth weight, 8.3% (Churchill, 1992, p. 35). While fewer facilities reported interrupting breastfeeding for fever (34.7%) and jaundice (36%), interruption of breastfeeding increased for the following areas: hypoglycemia (52%), inadequate weight gain (25.3%), other reasons (18.7%), and low birth weight (10.7%). In the case of hypoglycemia and inadequate weight gain, the number of facilities reporting at least some interruption doubled. Practices. The following practices were identified in Churchill’s 1992 investigation: unrestricted suckling time, 57%; no distribution of discharge packs, 28.5%; no complement use, 14%; and no supplement use, 10% (Churchill, 1992, p. 39). In the present investigation, 80.1% of staff nurses reported unrestricted suckling time, 32.3% reported restricted distribution of discharge packs, 29.6% reported no routine complement use, and 22.3% reported no routine supplement use. All areas showed

59 improvement from the previous investigation although there was still a disparity between policy and practice. Attitude. In addition to investigating policies and practices, Churchill investigated nurse attitudes toward breastfeeding using Cusson’s Attitude Toward Breastfeeding Scale. In Churchill’s investigation, the mean score was 4.003 with a range of 2.28 to 4.89; just over 5 in 6 (84.4%) of respondents had a positive attitude score and no nurses had a negative attitude score. Statistically significant correlations were found between a positive attitude toward breastfeeding and having breastfed own children, perception of having inadequate knowledge, and with being less likely to use complement feedings. Although no statistically significant correlation was found, higher educational preparation and more years of obstetric experience came close to having an impact on attitude (Churchill, 1992, 42-43). The current investigation yielded results that were very similar. The mean attitude score was 4.108 with a range of 2.44 to 4.94. Of the 267 nurses who responded, 89.5% had a positive attitude score and no nurses had a negative attitude score. The present investigation revealed statistically significant correlations between having breastfed own children, perception of having knowledge to help, perception of having adequate time to help, and increased obstetric experience. Summary Study findings were reported. Surveys were returned by 75 unit managers and 268 staff nurses. Policies and practices on perinatal units of Florida hospitals were discussed. The majority of policies were in compliance with research-based recommendations; there was insufficient evidence to conclude that perinatal unit level or number of deliveries per year influenced policy compliance. Practices were frequently not in compliance with policies; there was insufficient evidence to conclude that hospital or nurse demographics examined within the present investigation influenced practice compliance. Nurse attitude toward breastfeeding was examined; the majority had a positive attitude toward breastfeeding. Nurses with positive attitudes toward breastfeeding were more likely to have high compliance scores. Present findings were compared to Churchill’s findings from 1992. Policies and practices improved between

60 1992 and the present investigation although disparities between policy and practice continue to be problematic.

61 CHAPTER FIVE DISCUSSION This chapter contains a discussion of the implications of the findings laid out in Chapter Four. Facility and nurse demographics will be discussed. Findings related to policies and practices will be explained. An evaluation of nurse attitudes toward breastfeeding will occur. Assumptions and limitations will be re-evaluated in light of study findings. Recommendations for multiple levels of nursing practice will be made. Participant Demographics Return Rate The return rate for unit managers was 63% and the return rate for staff nurses was 56.5%. This exceeded the return rate that was hoped for and by far exceeded the 20% return rate identified as typical for postal survey research by Bourque & Fielder (as cited in Norton, 2000). King, Pealer, & Bernard (2001) conducted a meta-analysis of studies that examined factors influencing return rates. Five areas were identified as having a positive influence on response rates. First, a personalized envelope to the addressee and return postage had an influence; in the present investigation, return postage was included for all surveys and the packets were addressed to the Director of Nursing by name. Second, a cover letter that includes university sponsorship, an appeal for response, personalization, and assurances that responses will be anonymous and confidential were influential; in the present investigation, the cover letters indicated the affiliation of the researcher, explained the significance of the research, and assured both anonymity and confidentiality to respondents. The letter addressing the Director of Nursing was personalized but due to anonymity of respondents, addressing them personally was impossible. Third, financial incentives were identified as a factor influencing response rate; the present investigator did not include incentives for participation. Fourth, characteristics of the questionnaire including paper color other than white, a topic that is

62 important and pertinent, a user-friendly design, and a length of four pages or less; the present investigation met the criteria of significance and user-friendliness but was on white paper with a length of four pages for the unit managers and six pages for the staff nurses. Finally, participant contact including follow-up and repeat mailings was mentioned; the present investigator placed follow-up calls to facilities from whom no response was received at the four-week post-mailing mark and mailed duplicate packets to facilities who indicated the initial packet was not received and were interested in participating. There were eight facilities which fell into that category; responses were received from 100% of those facilities including 7 of 8 unit managers (87.5%) and 22 of 32 staff nurses (68.75%). These return rates by far exceeded those obtained for the surveys at large. Facility Demographics The number of facilities in Florida that provide obstetric services was higher at the time of this investigation than when Churchill completed the 1992 investigation. The increased number of facilities increases the options that women who are giving birth have to choose from and increases competition between hospitals that provide services within a given region. Hospitals that are not providing care that is in line with research-based recommendations are at risk for losing customers who are concerned about getting breastfeeding off to a good start to hospitals that are providing research-based care. The mix of hospitals for both perinatal unit level and for deliveries per year were mostly similar to the breakdown in those categories documented in the Agency for Health Care Administration (AHCA)2000-2001 Cesarean Section Report with a few exceptions. The percentage of facilities identifying themselves as Level 1 was a little lower than the actual percentage whereas the percentage of facilities identifying themselves as Level 2 and Level 3 was slightly higher than the actual percentage. The significance of this finding is that the non-response bias in Level 1 facilities could be higher than for the Level 2 and Level 3 facilities. There were far fewer facilities in the present investigation reporting <250 births per year than were listed as having <250 births per year; the same

63 was true for the 2100-2500 births per year category. Again, this increases the amount of non-response bias that could potentially be present for those categories (AHCA, 2001). One change in hospital demographics that is potentially alarming is a possible decrease in the number of facilities located in small communities. Churchill received responses from 18 facilities located in cities with populations of 60,000 or less; the present investigation identified only 15 such facilities. When examining cities with populations of 30,000 or less, Churchill reported that there were 8 facilities whereas the present investigation revealed 2 facilities. If this truly represents the trend in hospital location and not merely sampling error, then women located in small communities are having to travel to larger cities to obtain obstetric services. The implication of this reaches beyond child-birth and could extend to ease of receiving prenatal care. Staff Nurse Demographics There were multiple findings related to staff nurse demographics which have implications that stretch far beyond the scope of this investigation. While Churchill’s 1992 investigation revealed a mostly even distribution of staff nurses between the age groups examined, the present investigation revealed that nearly half of nurses were 46 and older; and nearly 2/3 of the sample were 41 and older. The 20-30 age group accounted for just over 10% of the respondents and the 31-40 age group only accounted for a quarter of nurses. The second finding was related to experience. Churchill’s investigation revealed an even spread between experience brackets once the 0-1 and 2-5 year increments were combined; the present investigation revealed nearly 40% of nurses with greater than 20 years of experience. The implication is that over the next decade as the older and more experienced nurses retire there may not be an adequate number of younger incoming nurses to replace them. The percentage of nurses who breastfed of the 227 nurses who had given birth to children (86.8%) was higher than anticipated and was higher than the 70.5% initiation rate cited the Florida Pregnancy Risk Assessment Monitoring System (PRAMS) report and the 81.1% rate cited for individuals with 16 or more years of education (Miller, 2001). While the high percentage of mothers having breastfed at least one child is

64 encouraging, the level of success experienced by the nurses was not evaluated nor was the level of satisfaction with the experience. Although the mean attitude score for nurses who breastfed was 4.185 compared to 3.7001 for nurses who did not breastfeed and 4.027 for nurses who did not have children, there were 6% of nurses who breastfed that had a neutral attitude toward breastfeeding. This would imply that their experience with breastfeeding was less than satisfactory and, therefore, their willingness to support breastfeeding mothers could be negatively influenced. Policies & Practices Unit Manager Results Practices. It was encouraging to see that the majority of facilities support unrestricted suckling time, demand feeding, and limited use of supplement and complement feeds. The high percentage of facilities that do not restrict distribution of discharge packs was not as encouraging. It was disturbing to see that there was not always a clear means of communicating with the nursing staff how a given practice was to be managed. Both unrestricted distribution of discharge packs and use of complement feeds had no clear regulator in nearly half of facilities. The implication of this is that staff nurses are left up to their own devices for determining how the practice is handled, which contravenes the World Health Organization’s recommendation that all hospitals have a policy for breastfeeding that is communicated to all staff. (World Health Organization, 1991). It was also noted that some unit managers may have been unfamiliar with the term “complement” which actually can be interpreted two different ways: “new foods added to the growing breastfed infant’s diets to meet the energy and nutrient needs that are not met by human milk alone” or “‘topping off’ the breastfed infant with liquids other than human milk... [usually with] water or ” (Lauwers & Shinskie, 2000, p. 509). The definition for “supplement” is a little clearer but reads “foods other than human milk fed to the infant in place of or following a breastfeed. Some refer to this as ‘topping off’ the breastfed infant with liquids other than human milk” (Lauwers & Shinskie, 2000, p. 517.) Shrago (1987) defined supplementary feedings as being provided as a replacement for breastfeeding and complementary feedings as being given to “top off” breastfeeding (As

65 cited in Henrikson, 1990). It should be noted that the unit managers were not alone in misunderstanding the terms and that the same confusion was seemingly present among many of the staff nurses responding. Teaching & Support. Another finding that was particularly disturbing was that nearly half of managers reported that no teaching protocol existed or did not know whether one existed. While it is crucial to tailor teaching about breastfeeding and other content to the individual needs of the mother, there are areas that need to be addressed. Biancuzzo (1999) identifies the following teaching priorities for the immediate postpartum period: proper positioning and ; listening for swallowing; avoiding supplements, scheduled feeds, restricted suckling time and pacifiers; infant cues for readiness to feed; professional and peer support resources; and danger signs that breastfeeding may not be going well. All areas except for danger signs are subject to individual bias and without defined guidelines, nurses are left to their own knowledge and to their own opinions when determining what to teach. In addition, because more than one person is generally involved in the teaching process, some areas could be covered more than once and other areas completely omitted. Furthermore, the potential for conflicting advice increases substantially. It was encouraging to see that a large percentage of facilities have a staff member available to assist mothers who are having difficulty initiating breastfeeding. Over 75% of facilities have a designated staff member designated to assist mothers who are having problems. Over 2/3 of responding facilities have a lactation consultant on staff. It is worth noting, however, that hospitals performing fewer than 500 deliveries per year and designated Level 1 perinatal were less likely to have a support person on staff. The same was true for lactation consultants: hospitals with fewer than 500 deliveries, Level 1 designation, and community size smaller than 45,000 people were all less likely to have a lactation consultant on staff. The significance is that mothers giving birth in these facilities may not have access to the staff with the most training to assist them should they encounter difficulty.

66 Although a large portion of facilities offer assistance to mothers have difficulty with breastfeeding while in the hospital, far fewer– in fact, not even half of– managers indicated that there was a policy for referring mothers to support services upon discharge if they were still having difficulty. Just over half of managers report that referrals are actually made. Facilities with higher numbers of births per year were more likely to make referrals; facilities in communities with fewer than 30,000 people were less likely to make referrals. While the large percentage of referrals to lactation consultants among facilities that do make referrals was not surprising, the low percentage referring mothers to La Leche League, who has been a major source of support for breastfeeding mothers, was surprising. Hospitals in communities with populations of fewer than 30,000 people were the least likely to make referrals to La Leche League. Considering that La Leche League has groups in at least 20 cities throughout the state including Pensacola, Tallahassee, Jacksonville, Gainesville, Tampa, Orlando, and Miami, which all have more than one hospital serving the area (http://www.lalecheleague.org/Web/Florida.html), it is expected that there would have been a larger number of referrals made. While one of the unit managers indicated that referrals were not made because there were no community agencies or support personnel to refer to, the remainder did not give a reason for the lack of referrals. The outside support from both a social standpoint and from a problem management standpoint can make a difference as to whether a mother is ultimately successful with breastfeeding. Breastfeeding Interruption. The high number of facilities reporting disruption of breastfeeding for various problems was quite disturbing. Hypoglycemia was identified as a reason for disrupting breastfeeding at over half of facilities. Haninger & Farley discuss hypoglycemia in breastfeeding neonates and indicate that routine screening of all newborns yields high numbers of false positives and that glucose screening should be reserved for at-risk infants or for babies that are symptomatic. Risk factors for hypoglycemia in the newborn include being born to a diabetic mother, a mother who received large quantities of intravenous dextrose solution during labor, being small for (SGA), having intrauterine growth restriction (IUGR), prematurity, low

67 birth weight, or an infection; large for gestational age (LGA) infants are only at risk when the mother was known to be diabetic. Furthermore, recurrent hypoglycemia indicates a metabolic or endocrine disorder (Haninger & Farley, 2001). The Academy of Breastfeeding Medicine (ABM) has developed a clinical protocol for hypoglycemia. The ABM indicates that symptomatic hypoglycemia in a term infant is not a result of underfeeding and that an underlying illness must be ruled out. Management in an asymptomatic infant with hypoglycemia includes continuing breastfeeding with continued monitoring of blood glucose levels prior to subsequent feeds until values stabilize. If the newborn is unable to suckle or tolerate oral feeds, intravenous therapy with glucose solution is indicated along with evaluation for an underlying cause; breastfeeding should continue once glucose levels are stabilized into normal range and the infant should be weaned from the intravenous glucose. In symptomatic infants, intravenous glucose solution is to be initiated but breastfeeding is to continue once symptoms are relieved; intravenous fluids are gradually weaned. In both cases where intravenous glucose is provided, monitoring of blood glucose levels continues until stable without the IV solution. It is also stated that oral or tube feeds are not adequate for relieving symptomatic hypoglycemia (ABM, 1999.) Jaundice was identified as the second most common reason identified for disrupting breastfeeding. Elevation of unconjugated bilirubin may result from one of two causes in breastfed infants. In infants with no other pathologic cause, early onset of jaundice is usually a result of inadequate feeding and has even been called “lack of breastfeeding” jaundice. This type of jaundice can be reduced by early frequent breastfeeding paired with monitoring. In cases where serum bilirubin levels exceed 20 mg/dL, phototherapy and supplementation is appropriate. Late-onset jaundice, which is defined as starting after the 5th day of life, results from ingestion of breastmilk. The infant is otherwise healthy and active and gains weight adequately but has elevated serum bilirubin levels. Continued breastfeeding with monitoring is appropriate provided bilirubin levels remain under 20 mg/dL. In cases where bilirubin levels exceed 20 mg/dL and levels have been increasing steadily, it may be appropriate to discontinue

68 breastfeeding for 24-48 hours while having the mother continue to express milk and then to resume breastfeeding coupled with regular monitoring (Smith & Tully, 2001). Medications incompatible with breastfeeding was a reason given by several facilities. Few medications are true contraindications to breastfeeding. The American Academy of Pediatrics Committee on Drugs (2001) released a revised statement on medications and human milk. The following general recommendations were made: a) avoidance of unnecessary drug therapy and having the mother’s physician consult with the baby’s pediatrician to determine the safest choice, b) choosing the safest drug that will manage the problem, c) Considering measurement of blood concentration of the drug in the baby if there is concern about affect on the infant, and d) minimizing drug exposure by timing medication administration to avoid breastfeeding during the drug’s peak. Drugs listed as true contraindications for breastfeeding include cytotoxic drugs and drugs of abuse; some radioactive compounds used for diagnostic testing or treatment require temporary cessation of breastfeeding. Drugs that are known to have significant side effects on nursing infants and should be used with caution include acebutolol, atenolol, aspirin, clemastine, ergotamine, lithium, phenindione, phenobarbital, primidone, and sulfasalazine. Drugs that are listed as having an unknown effect but that may be of concern include anti-anxiety drugs, antidepressants, and anti-psychotic medications. The remainder of drugs are considered compatible with breastfeeding in most circumstances (AAP, 2001). Inadequate weight gain was identified as a cause of breastfeeding interruption by several facilities. Newborns do not generally gain weight during the first week of life and, in fact, a weight loss of 5 to 10 percent of birth weight during the first few days is expected. Newborns should have regained their birth weigh within 2 weeks of birth (Biancuzzo, 1999). Several facilities also identified low birth weight as a cause for interrupting breastfeeding. The American Academy of Pediatrics states, “Human milk is the preferred feeding for all infants, including premature and sick newborns, with rare exceptions .... When direct breastfeeding is not possible, expressed human milk, fortified when necessary for the premature infant, should be provided” (AAP, 1997). Although

69 very few facilities indicated that support and education were provided in order to assist mothers who need to pump breastmilk, in all fairness it must be stated that unit managers were not specifically asked whether pumping-related teaching and assistance were provided; hence, it is both hoped and anticipated that more facilities actually do so. In cases where mothers and babies must be separated due to illness, mothers need to be taught how to initiate pumping in order to establish and maintain their milk supply (World Health Organization, 1991.) Staff Nurse Results Practices. While it was good to see that the majority of nurses indicated that breastfed babies are fed on demand, it was difficult to explain why nearly 1 in 5 nurses continue to recommend that mothers breastfeed on a fixed schedule. The recommendation is that infants should be breastfed whenever they show signs of hunger and that “crying is a late indicator of hunger” (AAP, 1997). Early signs of hunger include arm/leg movement, hand-to-mouth movement, rooting, toungeing, lip-smacking, and early sounds of rousing (Auerbach, 2000). Furthermore, it was not encouraging to see that close to 1 in 6 nurses recommended scheduled feeds even when the UM stated that demand feeds were the norm. Almost 1 in 5 nurses recommend restricted suckling time. What was truly disturbing about this finding was that the advice given by the nurses that recommend restricted suckling time was wildly disparate. Nurses who indicated that they recommend restricted suckling time were asked to describe the advice they give. Not only did advice vary from nurse to nurse, there were even differences within facilities as to what was recommended. The advice ranged from starting with 5 minutes per side and increase gradually to 10-15 minutes per side to 30 minutes per side even up to an hour or more per side; there were multiple other recommendations between those. The potential for confusion among mothers who are learning to breastfeed is high. Biancuzzo (1999) indicates that limited suckling time does not prevent or minimize sore nipples but that sore nipples are usually the result of poor latch on. What is most disturbing is that of the

70 nurses recommending restricted suckling time, virtually all were working in facilities where unrestricted suckling time was considered the norm by the UM. The questions regarding supplement and complement use seem to have generated substantial confusion among the staff nurses. Again, the term “complement” was unfamiliar to many. In addition, it is unclear whether the nurses truly understood that both questions were in reference to normal, healthy breastfed infants even though this was stated in the instructions for the section. The Academy of Breastfeeding Medicine (ABM) indicates that small colostrum feedings are physiologically appropriate due to the newborn’s small stomach and that the majority of babies do not need to be supplemented. They further state that supplementation has a strong potential to disrupt establishment of a maternal milk supply and that supplementation should not be initiated until after an evaluation of the mother/baby dyad including assessing the actual breastfeeding process. For the following situations, breastfeeding management should be used in preference to supplementation: sleepy infant with <8-12 feedings in the first 1-2 days with less than 7% weight loss; bilirubin level <20 mg/dL after 3 days of age in a baby who is feeding well, stooling, and has not lost more than 7%; babies who are fussy at night; and sleeping mothers (ABM, n.d.). No clear indications were found for complement feeds. Formula followed by glucose water and sterile water were the most common substances used by nurses for supplement and complement feedings; bottles by far were the most common means of supplementing used. It is recommended by the ABM that expressed human milk is the optimal choice for supplemental feeding and that donor milk is preferable to commercial formula. It is also recommended that the following means are preferred: supplemental nursing device at the breast, cup, spoon, dropper, or finger-feeder, and that bottle-feeding should be the last choice (ABM, n.d.). In comparing the staff nurse responses with the UM responses, it became apparent that the unit standard may not have been clearly communicated with all staff nurses. It is possible that all supplementary and complementary feeding was being done appropriately, but it is also possible that in many cases, that standard of care was not being followed. It is also worth noting that the most common reason for supplement and complement feeds given by staff nurses was maternal

71 request. This is an indicator that there may be a knowledge deficit among the mothers as to normal physiology of breastfeeding and of normal behavior of breastfed infants. Over 2/3 of nurses reported routine distribution of discharge packs. Some indicated that the formula was removed. In addition, some nurses who stated that discharge packs are not routinely distributed stated that packs with the formula removed were given out. Hence, it was clear that the nurses had different ideas as to what constituted distribution of discharge kits. There were also multiple respondents that indicated that “breastfeeding support kits” were given out although many indicated that these were provided by formula companies. It is probable that many of the nurses have never looked inside the kits to see what the contents include. What was truly disturbing is that only half of the nurses were distributing or restricting distribution in compliance with the unit standard. Of the remaining half, most were giving them out even though the manager indicated the practice was uncommon and the remainder were not distributing them despite the manager indicating that they are distributed; in either case, the expected standard was not being followed. Teaching & Support. It was great to see that nearly all nurses reported that mothers are taught breastfeeding techniques at their facility, but one must wonder why mothers are not taught breastfeeding techniques at the remainder. There was, however, some confusion as to who was responsible for providing the teaching. In cases that a nurse thinks it is her responsibility but it truly is not, there is not really a problem provided appropriate content is taught; it is a problem, however, if nurses from one area are not teaching and passing it off to other areas when their own is actually responsible. This “passing the buck” can result in omission of appropriate and necessary teaching. Another serious problem was that only half of the nurses were correct in their answer regarding whether or not a teaching protocol existed at their facility. Nearly 1 in 5 nurses did not know a protocol existed and almost 1 in 7 thought a protocol existed when the manager stated that one did not. The level of agreement between individual staff nurses and the unit manager for their facility was a little over 1 in 2 but when the level of agreement between nurses within a facility was examined, it was found that all

72 responding nurses gave a response matching that of the unit manager in barely 1 of 5 facilities. It is difficult to decide what was more disturbing: nurses not knowing a protocol existed or nurses thinking a protocol was in place when one was not. In any case, it is evident that information regarding existence of a teaching protocol had not been clearly communicated with the staff. Three quarters of nurses identified an individual at their facility who is responsible for providing assistance to mothers who were having difficulty. A large portion had also made referrals to support services upon discharge within the 6 months preceding completion of the surveys. Lactation consultant referrals were the most common; although La Leche League was the second most common referral, only a quarter of nurses had made a referral to La Leche League. As with the unit managers, based on the high number of hospitals in areas where La Leche League has chapters, it is expected that more referrals would have been made. Policy & Practice Compliance with Research Level of perinatal unit and number of deliveries per year had only a minimal influence on compliance at both the policy and the practice level. It was difficult to draw any association between community size and compliance because nearly 20% of managers did not know the size of their community. In addition, it was not possible to compare the impact of any of the three hospital demographics with compliance scores for the 35 staff nurses for whom no corresponding UM data was available because hospital demographics were not collected from staff nurses. It was disturbing to see a statistically significant difference between policy and practice. The level of agreement between individual staff nurses and the unit manager for their facility was relatively high for feeding frequency and for suckling time but was substantially lower for discharge pack distribution and for supplement and complement use. In examining the number of facilities in which all responding nurses gave a response which matched that of the unit manager for their facility, the percentages were much lower for all five areas. The discrepancies lend further credence to the notion that expectations may not have been clearly communicated to nursing staff by the unit

73 manager. Most of the discrepancy resulted from complement and supplement use which had the lowest levels of agreement. Both supplement and complement use have the potential to undermine breastfeeding although in slightly different ways. Supplement feeds replace breastfeeding and deprive the mother of the stimulation of her breasts that help bring her milk in. Complement feeds result in infants spacing out feeds further with the same result. In addition, mothers who already may be lacking confidence in their ability to breastfeed can have their confidence further shaken by seeing their baby seemingly gulp down a bottle happily. Attitude Toward Breastfeeding The large portion of nurses with positive attitudes toward breastfeeding was a very positive although expected finding. Nurses who do not have positive attitudes toward breastfeeding most likely move into other areas of nursing where it is not encountered on a daily basis. Nurses who have a positive attitude toward breastfeeding are also more likely to be willing to spend time working with breastfeeding mothers to help them get off to a good start. While knowing whether or not a nurse breastfed her children alone did little to predict a nurse’s attitude toward breastfeeding, having knowledge of the nature of her experiences might have allowed a more accurate prediction. One of the individual questions regarding attitude toward breastfeeding yielded a score that approached neutrality was “Breastfeeding is more attractive to the husband.” While the mean perception was not negative, it was not positive either. In other words, the nurse perception of husband’s reaction to breastfeeding is that although it is not unattractive, that it is not attractive either. are influential in whether or not breastfeeding is successful, and fathers may discourage breastfeeding if they have negative perceptions of breastfeeding including considering it unattractive, believing that it negatively impacts the appearance of the breast, negatively influences -baby relationships, gets in the way of sexual activity, and being more difficult than bottle- feeding (Pavill, 2002). Sometimes even fathers who initially have positive attitudes toward breastfeeding prior to the birth have difficulty adjusting after the birth; the negative feelings are often hidden, which contributes to further isolation. It is important

74 to consider that helping fathers find ways that they can bond with the baby without undermining breastfeeding in the early days is crucial. Evaluating the father’s perceptions of breastfeeding prior to the birth and in the early postpartum phase is important so that misconceptions can be addressed. Support for fathers of breastfed babies is crucial for promoting success among mothers. Current Findings vs. Churchill’s Findings The changes in the hospital and participant demographics between Churchill’s investigation and the present investigation, as indicated previously, could have an impact on obstetric care in Florida. Women have a larger number of facilities to choose from when deciding where to obtain childbirth-related services; however, women in smaller communities may have to travel further to obtain care especially if they require specialty care. The aging of the nursing population, which is well documented in the literature, has the potential to further contribute to an already growing nursing shortage. While the larger percentage of experienced nurses both in nursing as a whole and in the field of obstetric/neonatal nursing affords women the opportunity to receive care from experienced nurses, the lack of new nurses coming in has the implications of lack of replacement nurses coming as well as a lack of influx of new knowledge and ideas. The percentage of unit managers reporting supportive policies and practices increased between Churchill’s investigation and the presentation; however, some practices actually became less regulated rather than more regulated. The availability of support personnel for mothers experiencing difficulty increased as well. This gives more mothers who are struggling the opportunity to obtain appropriate professional assistance. A major change that is potentially disturbing is related to teaching and teaching protocols. The percentage of facilities indicating that a teaching protocol existed decreased between investigations; the number, however, increased by one. It is unknown whether this is a result of sampling error, a result of facilities that started providing obstetric services failing to draft a teaching protocol, or some other reason. In any case, the lack of clear guidelines is concerning especially in light of the litigious attitude present in today’s society. It is not inconceivable that a mother who was ultimately

75 unsuccessful breastfeeding due to poor information and/or management of breastfeeding could file suit against the hospital and/or the nursing staff. Even if the case never made it to court, a substantial amount of time, resources, and energy would be expended. In regard to practices, all areas showed improvement between investigations. It was good to see that more nurses are following up-to-date practices although the high percentage of nurses that continue to provide supplement and complement feedings was disconcerting especially since the indications most nurses used for providing supplements was not clear. Conceptual Framework The findings related well in many ways with the conceptual framework. Imogene King’s Dynamic Interacting Systems was utilized. The personal system consisted of the mother/baby dyad, the interpersonal system contained the staff nurses and practices, and the social system contained the facility and policies. It was clear that even though that policies are to influence practice that this is not always true; if it were, then there would have been a perfect correlation between policy and practice. In fact, there were areas where the match between policy and practices was quite poor. The converse is that in facilities where the policies were not compliant with research-based practices, some nurses were using research-based practices in violation of the standards set for the unit; the most appropriate course would have been for the nurses to work toward changing policies to reflect present recommendations instead of going out on their own. Acting in violation of set policies, regardless of the correctness of the practice, leaves the individual nurse out on a limb especially if an adverse outcome occurs. The biggest piece missing was the impact of the policies and practices on the mother/baby dyad. There were no correlations between practices or demographics and breastfeeding outcomes; therefore, it is difficult to see how that piece tied in. Limitations A significant limitation of this study was that the sample was, for all practical purposes, a convenience sample. All hospitals in Florida known to provide perinatal services were included in the survey; however, it is probable that a few may have been

76 missed. Although nearly 3/4 of facilities surveyed responded, non-response bias certainly could cloud the picture of what policies and practices truly are in the state, especially in categories where fewer facilities responded than expected. A limitation in regards to staff nurse participation is that the nurses were selected by the UM. Managers were asked to select nurses randomly based on the flip of a coin. While this procedure was simple enough that following it would not be an undue burden, it is impossible to guarantee that this actually occurred. It is worth noting that there is little reason to believe that the manager hand-picked nurses who were deemed likely to provide the “right answers.” Had this been the case, it is expected that the degree of agreement between policy and practice would have been substantially higher. There were some areas within the data collection phase that could have influenced results. In the UM survey, the range used for collecting data regarding breastfeeding rates was wide enough that it was difficult to identify whether there were substantial changes from initiation to discharge breastfeeding rates. The term “complement” was misunderstood by at least a few nurses despite having clarified the term on the surveys. The item regarding reasons for disrupting breastfeeding may not have been clear as to exactly what information was being sought. Clarifying the question and adding specific responses for how the various conditions are managed might have yielded more accurate results. There were also difficulties with several areas on the staff nurse survey. First, although the 5-year windows for age worked well, the final window was for age 46 and older. Considering the aging of the nursing population, having additional information about nurses within the 46-50 and 51-55 windows and possibly even the 56-60 and 61-65 windows could have added depth to the picture and to correlations. The question regarding breastfeeding experience only yielded a yes, no, or not applicable for answers. No data was collected regarding the nature of the breastfeeding experience; this information could have had an impact on attitude and/or compliance. There were limitations with the questions on supplement & complement use. In addition to being unclear on the definition of the two terms, respondents did not seem to

77 have remembered that the question was directed toward normal healthy full-term newborns and yielded a large number of nurses indicating that supplements and/or complements are used at least on occasion. It is difficult to determine based on their responses whether the supplementation was medically appropriate and whether it was being done in compliance with the standards of their units. Assumptions Both assumptions held true. There is little reason to believe that the responses received do not reflect policies and practices in place at the responding facilities. Both nurses and mangers seemed to have responded honestly even when the picture painted was not pretty. There is also little reason to believe that nurse respondents were hand- selected by the managers even if they did not completely follow the requested procedure for randomization. Implications for Practice Nursing Practice The study findings have implications for nursing practice. Although both policies and practices have improved since 1992, many facilities still have practices that are not in compliance with research-based recommendations. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), one of the professional organizations for nursing professionals within the health care field, has published standards of professional performance for nurses. These standards include the following: 1. Systematic evaluation of the quality of care provided including using the results to change practice and, when appropriate, the system. 2. Evaluation of own nursing practice in relation to professional practice standards as well as legal regulations. 3. Acquisition and maintenance of current knowledge including participation in educational activities. 4. Contribution to professional development of others including sharing knowledge and skills.

78 5. Ethical decision-making and behavior including advocacy for the patient and delivery of nonjudgmental and nondiscriminatory care. 6. Collaboration with the patient and partner as well as other health care providers working with the patient. 7. Utilization of research findings in practice including utilization of interventions supported by research. 8. Appropriate utilization of resources in provision of patient care. 9. Promotion of safe and effective care delivery including assuring that evidence-based practices and organizational policies and procedures are followed. 10. Accountability including staying up to date with changing practices and maintaining current education. (AWHONN, 1998). The American Nurses Association also has eight standards of clinical practice: “quality of care, performance appraisal, education, collegiality, ethics, collaboration, research, and resource utilization” (ANA, 1998, p. 3); several of these are especially pertinent. Quality of care activities include evaluating how effective current practices are and working toward change in the health care system when practices are ineffective. Education includes maintenance of skills through continuing education. Ethics includes advocating for patients which in this context includes working toward evidence-based practice through appropriate channels. Collaboration includes working with other health care professionals when appropriate, including making referrals. Research includes staying current with developments in their field and providing evidence-based care; this also includes communicating findings with others and using the findings to develop appropriate guidelines for patient care. (ANA, 1998). While provision of care that is out of date is not in keeping with either set of standards, providing care that is up to date even though hospital policy indicates otherwise is equally unacceptable. Nurses that find themselves in a situation where they know that the set policies are out of date must work through the appropriate channels to have the policies updated.

79 Advanced Nursing Practice Advanced practice nurses, including clinical nurse specialists, nurse anesthetists, nurse-midwives, and nurse practitioners may have responsibility for providing care to mothers and newborns; the clinical nurse specialists and nurse practitioners are the most likely to have a direct influence on the care provided to newborns. The nurse practitioner may be responsible for performing the initial newborn assessment and writing orders for the newborn’s care; therefore, the nurse practitioner needs to be up to date on current breastfeeding-related recommendations in order to write orders that will facilitate getting breastfeeding off to a good start. Clinical nurse specialists (CNS) working on perinatal units are in a unique position to function as change agents by utilizing the researcher role; in fact, the American Nurses Association’s (ANA) standards for advanced practice registered nurses indicate that advanced practice nurses have a responsibility to critically evaluate practices based on current research recommendations and to share that information with colleagues in the roles of educator, care provider, or consultant. (ANA, 1996, p. 20). The CNS could help draft policies that are up to date and work with other departments within the hospital and with ancillary care providers to bring their practices up to date when necessary. Administration It was apparent within several areas of the investigation that staff nurses were not aware of the expectations for practice on their unit; somewhere along the way, there was a breach in communication. In some cases, the correct policies were in place but staff nurses were not following them; in other cases, out of date policies were in place and nurses who were up to date on the recommendations were following their own knowledge base instead of the policy for their unit. It is crucial that expectations are clearly communicated. One means by which this can be done is unit policies & procedures. If none are currently in place, new ones would be drafted following the hospital’s usual protocol. If policies are in place, they must be evaluated for currency and, if necessary, updated. It is also crucial for unit managers to see to it that the policies are

80 communicated to all nurses on the unit and to newly hired nurses regardless of whether hired from another department or from outside the hospital. The American Nurses Association (1995) has a document discussing standards for nurse administrators. The nurse manager is identified as responsible to the nurse executive and is responsible for one or more areas of an organization. Nurse managers are also responsible for implementing the “vision, mission, plans, and standards of the organization and nursing services within their defined area of responsibility” (ANA, 1995, p. 8). Tasks subsumed within these responsibilities include creation of policies, evaluation of quality of care, acceptance of accountability for care provided, provision of supervision for personnel, provision of continuing education, participation in performance evaluation of personnel, and participation in evaluative research. In other words, the nurse manager is responsible for assuring that care is provided in accordance with the policies set by the facility and that these policies are communicated. (ANA, 1995). Education Continuing Education. It was noticed that although most nurses had recently attended continuing education courses, there were still a substantial number who had no recent continuing education. As previously mentioned, it is a nursing standard that nurses maintain their current education. Provision of breastfeeding-related continuing education must be as much of a priority as continuing education related to other areas within the field of obstetric and neonatal nursing. Many hospitals already provide continuing education courses in other areas; therefore, it would not be an undue burden for those facilities to add breastfeeding-related courses. In addition, nurses are required to meet continuing education requirement for licensure and attendance of breastfeeding-related courses would meet a portion of that requirement. Nursing Schools. It is crucial for student nurses to learn correct and up to date information regarding breastfeeding during the course of nursing education and to realize that breastfeeding is the biological norm for human babies. This is especially important as many college students may have never been around breastfed babies and, therefore,

81 have little practical experience. A hands-on component for breastfeeding care would be helpful in order to give students at least a brief introduction to breastfeeding techniques and to the role of lactation consultants. Health Care One change that would greatly assist efforts to improve breastfeeding rates is to change an attitude that was clearly present in the vast majority of literature reviewed. Breastfed babies were treated as the experimental group and formula-fed babies were treated as the control group, which is in opposition to the normal standard of using the biologic norm as the control group and the modification as the experimental group. Because breastfeeding is the biologic norm for the human species, the breastfed babies should be the control group and the formula fed babies the experimental group which would result in a shift within the language from breastfeeding having advantages to lack of breastfeeding having disadvantages. Wiessinger (1996) discussed the issue of the language used to educate people about breastfeeding. Utilization of terminology such as “breastfeeding has advantages,” “breastfeeding is best,” or that breastfeeding is “special” gives the implication that it is something that is not really that important but is an extra bonus. Changing the mind set to reflect that breastfeeding is the biologic norm and, therefore that lack of breastfeeding has risks and disadvantages is critical. Recommendations for Future Research An area of future research would include an investigation of demographic characteristics that influence nurse attitude toward breastfeeding. Cusson’s Attitude Toward Breastfeeding scale, which has been utilized among nursing staff in previous investigations, could be utilized to collect attitudinal data. Basic demographic data should include the following: age, gender, nursing experience, neonatal/obstetric nursing experience, and number of children. To obtain information about the breastfeeding experience, data should be collected for each child by birth order regarding whether the child was breastfed, duration of breastfeeding, whether breastfeeding was successful, and whether the experience was perceived as positive or negative. It might be necessary to

82 develop a tool for investigating the nature of the breastfeeding experience. The study would very likely be a mix of qualitative and quantitative methodologies. Another study related to attitude that could be done in conjunction with the examination of characteristics influencing attitude is an investigation regarding the factors influenced nurses’ decision to breastfeed or not. The results could be especially interesting for the older nurses who gave birth during a time period that breastfeeding was not well supported. Data could be collected on whether or not the nurse has family members and/or friends who breastfed, whether they perceived their partner as supportive of breastfeeding, the nature of advice they received from health care providers, and whether they received support in the work place for continued breastfeeding. It would probably be necessary to develop a tool for collecting data. The study would likely be a mixture of quantitative and qualitative methodologies. A third area for future investigation relates to referral of mothers who are having breastfeeding difficulty to support services upon discharge. It was found in the present investigation that few nurses and facilities were referring mothers to La Leche League even among the nurses and managers from hospitals in cities where local chapters are in existence. It is possible that there are misconceptions or mistaken perceptions regarding La Leche League that make nurses hesitant to refer to them; it is also possible that the nurses do not know about chapters in their area. In any case, an investigation into reasons nurses do or do not refer mothers to La Leche League would be worth while especially in light of research which has shown outside support increases duration of breastfeeding. This could be expanded to include the other referral options and to investigate why nurses do or do not make referrals. A fourth area for future study would be an examination of factors that influence initiation and duration of breastfeeding among Hispanic mothers. Several staff nurses indicated that Hispanic mothers at their facility use a combination of breastfeeding and bottle-feeding from birth. While research indicates that supplementation and especially early supplementation are detrimental on the initiation and duration of successful breastfeeding, the successful initiation rate among Hispanic mothers exceeds the state-

83 wide rate (76.7% vs. 70.5%) and the three-month rate nearly matches the state-wide rate (24.2% vs. 26.5%; Miller, 2001). An evaluation of the factors that influence their success despite practices that by all counts should undermine breastfeeding could yield a wealth of information that, perhaps, could be used to promote success among all mothers. A qualitative design would most likely be appropriate for this investigation. Summary Breastfeeding is a health promotion behavior that requires both support and education. Although policies and practices throughout the state have improved over the past decade, there is still substantial room for improvement, especially regarding communication of breastfeeding-related policies to staff nurses. Nurses can provide optimal support by learning what current research-based recommendations are and by working through appropriate channels to change policies when they are out of date. Nurse managers can facilitate breastfeeding by making sure that policies are up to date and that these policies are enforced. Hospital administration can provide support by providing inservice education on research-based practices. These changes can make the hospital environment more conducive to success for mothers who are breastfeeding.

84 APPENDIX A PERMISSION TO UTILIZE HOUSTON & FIELD TOOL

85 86 87 APPENDIX B PERMISSION TO USE CHURCHILL MODIFICATIONS

88 89 APPENDIX C PERMISSION TO USE ATTITUDE TOWARD BREASTFEEDING SCALE

90 91 APPENDIX D FLORIDA STATE UNIVERSITY IRB APPROVAL LETTER

92 93 APPENDIX E DIRECTOR OF NURSING COVER LETTER

94 Florida State University School of Nursing, Graduate Program Mail Code: 4310 Tallahassee, FL 32306-4310

January 15, 2002

Joe Blow, RN, MBA Director of Nursing Aanywhere Medical Center 12345 Boulevard Road Aanycity, ST 99999-9999

Dear Mr. Blow:

Over the past several years many new benefits of breastfeeding have been identified. Increasing numbers of women are choosing to breastfeed their babies. Despite this, the number of women who initiated breastfeeding fell short of the Surgeon General's goal of 75%. Research has shown that breastfeeding-related policies and practices impact the successful initiation of lactation. Women are the primary decision makers regarding health care facility use in many families and their choice of facilities is influenced by the care they receive in the perinatal period. Hence, the policies and practices of the perinatal unit have a direct effect on the use of other hospital services.

As part of degree requirements at Florida State University, I am conducting a study, entitled "Breastfeeding Support on Perinatal Units in Florida Hospitals," under the direction of Deborah Frank, ARNP, PhD. which will examine breastfeeding-related hospital policies and practices as well as nurse attitudes toward breastfeeding. I would be grateful if you would assist me as the Director of Nursing by forwarding the enclosed surveys to the nurse manager of your perinatal unit.

Enclosed you will find a survey for the unit manager and surveys for 4 staff registered nurses. The unit manager should randomly select 4 nurses from the staff roster of the perinatal unit earliest convenience. The unit manager survey will address breastfeeding-related hospital policies. The staff nurse surveys will address unit practices as well as nurse attitudes toward breastfeeding. The surveys should not take more than a few minutes of your staff members' time; however, their responses are crucial for completion of my study.

The study will identify strengths and weaknesses of breastfeeding-related care in Florida. This will result in a long-term benefit of enabling Florida hospitals to better meet the needs of their obstetric patients. The process of filling out the survey could also have the benefit of encouraging both unit directors and staff nurses to evaluate the current policies and practices.

95 The study should not pose any risk to participants, although it is possible that a participant may experience emotional discomfort or distress if they realize that policies or practices are not up to date.

Your consent will be implied by forwarding the surveys to your unit director. Participant consent will be implied by completing and mailing the survey. No one should be required to participate in this survey. Participants who begin the survey are not required to complete it, although once it has been mailed there is no means of withdrawal.

All responses will be mailed directly to me in a stamped window envelope. The surveys will bear a numeric code to allow me to group data; however, no individual nurses, unit directors, or facilities will be identified in the study. Responses will be kept confidential to the extent allowed by law. The surveys will be retained by the researcher in a secure location.

Results of this study will be available upon request. You can get a copy of the abstract by contacting me at the above address. If you have concerns or questions, you may reach me at the above address, by e-mail ([email protected]). I greatly appreciate your help and the contribution you are making to this nursing research.

Sincerely,

Elisa H. Casey, R.N., B.S.N.; M.S.N. Candidate Florida State University School of Nursing

Enclosures

96 APPENDIX F UNIT MANAGER COVER LETTER

97 Dear Unit Manager:

Over the past several years many new benefits of breastfeeding have been identified. Increasing numbers of women are choosing to breastfeed their babies. Despite this, the number of women who initiated breastfeeding fell short of the Surgeon General's goal of 75%. Research has shown that breastfeeding-related policies and practices impact the successful initiation of lactation.

As part of degree requirements at Florida State University, I am conducting a study, entitled "Breastfeeding Support on Perinatal Units of Florida Hospitals," under the direction of Deborah Frank, ARNP, PhD. The study will examine breastfeeding-related hospital policies and practices as well as nurse attitudes toward breastfeeding. I would be grateful if you would assist me as the unit manager by completing the unit manager survey and by selecting 4 registered nurses from your unit to participate in the staff nurse surveys. The unit manager survey addresses actual unit policies. The staff nurse surveys address unit practices as well as nurse attitudes toward breastfeeding. The surveys should not take more than a few minutes of your staff members' time; however, their responses are crucial for completion of the study.

I prefer that you randomly select 4 nurses from your staff roster. To do so, please do the following: 1) Flip a coin. 2) If the coin shows heads, then start with the first nurse on your roster and pick every other nurse after that until you have 4 nurses. 3) If the coin shows tails, pick the second nurse on your roster and pick every other nurse after that until you have 4 nurses.

Responding to the survey is completely voluntary and consent to participate in the study is implied by completing and mailing your survey and by selecting registered nurses to participate. The study will identify strengths and weaknesses of breastfeeding-related care in Florida. This will result in a long-term benefit of enabling Florida hospitals to better meet the needs of their obstetric patients. The process of filling out the survey could also have the benefit of encouraging both you and staff nurses to evaluate the current policies and practices on your unit. The study should not pose any risk to participants, although it is possible that you or your staff members could experience emotional discomfort or distress if they realize that policies or practices are not up to date.

All responses will be mailed directly to me in the stamped window envelopes which accompany the surveys. The surveys will bear a number to assist me in grouping the data, but no individual nurses, unit managers, or facilities will be identified in the study. The results will be kept confidential to the extent allowed by law. The surveys will be retained by the researcher in a secure location.

98 Results of this study will be available to you upon request by contacting me at the Florida State University School of Nursing or by e-mail ([email protected]). You can also reach me at either address if you have questions or concerns. I greatly appreciate your help and the contribution you are making to this nursing research.

Sincerely,

Elisa H. Casey, RN, BSN; MSN Candidate Florida State University School of Nursing Mail Code: 4310 Tallahassee, FL 32306-4310

99 APPENDIX G UNIT MANAGER QUESTIONNAIRE

100 UNIT MANAGER QUESTIONNAIRE

Instructions: Please check or circle the most appropriate answer for each question. Mark only one answer for each question unless otherwise instructed for a question. There are questions on the front and back of each page. When you have completed the survey please fold so that the address shows through the window of the stamped envelope that has been included with your survey. Drop the sealed envelope in any mailbox. Please return by April 15, 2002.

Elisa H. Casey, RN, BSN; MSN Candidate 3962 Calle de Santos Tallahassee, FL 32311-3403.

======fold here ======

Part 1: This section will provide a little information about your facility.

1. How many deliveries did you have last year? Under 250 _____ 251 - 500 _____ 501 - 1000 _____ 1001 - 1500 _____ 1501 - 2000 _____ 2001 - 2500 _____ Over 2500 _____

2. The hospital is based in a community with a population of: Under 15,000 people _____ 15,001 - 30,000 people _____ 30,001 - 45,000 people _____ 45,001 - 60,000 people _____ 60,000 - 90,000 people _____ 90,000 - 150,000 people _____ More than 150,000 people _____

3. Is the perinatal unit (OB and Nursery) classified as Primary (Level 1) _____ Secondary (Level 2) _____ Tertiary (Level 3) _____

4. Approximately what percentage of mothers choose to start breastfeeding in your hospital? (Please estimate to the best of your knowledge.) Under 10% _____ 11 - 25% _____ 26 - 50%_____ 51 - 75% _____ 76 - 100% _____

5. Approximately what percentage of mothers are discharged from your hospital breastfeeding? Under 10% _____ 11 - 25% _____ 26 - 50% _____ 51 - 75% _____ 76 - 100% _____

101 Part 2: For the following questions, please indicate: 1) Whether an activity is a common practice in your facility, and 2) how decisions for these care practices are made: UP = Unit Policy; MD = Physician Orders; Both = ; or Neither.

Common Decision Made By Unit MD Yes No Policy Order Both Neither 1. Well infants are allowed to breast Yes No UP MD Both Neither feed within the first hour after birth. 2. Breastfed infants are given fluids Yes No UP MD Both Neither other than breast milk for a first feeding. 3. Mothers are given the opportunity to Yes No UP MD Both Neither have skin contact with their babies in the delivery room. 4. Breastfed infants are normally fed on Yes No UP MD Both Neither a fixed schedule. 5. Sucking time at the breast is restricted Yes No UP MD Both Neither for breast fed babies 6. Breast fed babies are normally given Yes No UP MD Both Neither supplements BETWEEN breast feeding. 7. Breast fed babies are normally given Yes No UP MD Both Neither complements WITH breast feeding. 8. Breast fed babies are routinely test Yes No UP MD Both Neither weighed before and after feedings. 9. Babies are routinely kept with the Yes No UP MD Both Neither mothers after birth. 10. Breast feeding mothers are given Yes No UP MD Both Neither formula discharge packs.

102 Part 3: Please mark the answer that applies to your facility.

11. a. Is rooming in encouraged at your hospital? Yes, 24 hrs/day _____ Yes, 12 - 23 hrs/day _____ Yes, less than 12 hrs/day _____ No _____

b. Is a physician order required to allow rooming in? Yes _____ No _____

12. Who is responsible for teaching the mother the techniques of breastfeeding (i.e. latching?) (Check all that apply) Delivery room nurse _____ Postpartum nurse _____ Nursery nurse _____ Breastfeeding counselor _____ Lactation consultant _____

13. a. Do you have a person primarily responsible for breastfeeding problems in your hospital? Yes_____ No _____

b. If yes, is this person Lactation Consultant _____ Breastfeeding Counselor _____ Staff Nurse _____

14. Is printed information distributed to mothers on breastfeeding? Yes _____ No _____

15. a. Are mothers given one-to-one teaching about breastfeeding? Yes _____ No _____

b. If yes, do you have a teaching protocol for this? Yes _____ No _____

16. Are your visiting hours for the following people Unrestricted Restricted (If restricted, list hours) Immediate Family ______Relatives ______Friends ______

17. Are sleeping pills used to secure a good nights sleep for breastfeeding mothers? Yes _____ No _____ On request only _____

103 18. a. Does your unit have a written policy for discharge referral to support services if mothers are having difficulty with breastfeeding? Yes _____ No _____

b. Who does the policy state that mothers are to be referred to? (List all that are included) Lactation consultant _____ La Leche League _____ Nursing mothers support group _____ Physician’s office _____ Public health department _____ Nurse practitioner/nurse midwife _____ Other (describe) _____

19. Infants are occasionally removed from the breast for medical reasons. Which of the following are the most common reasons in your facility? Check any that apply. Jaundice _____ Inadequate weight gain_____ Low birth weight _____ Fever (mother or baby)_____ Low blood sugar _____ Other (please elaborate)

104 APPENDIX H STAFF NURSE COVER LETTER

105 Dear Staff Nurse:

Over the past several years many new benefits of breastfeeding have been identified. Increasing numbers of women are choosing to breastfeed their babies. Despite this, the number of women who initiated breastfeeding fell short of the Surgeon General's goal of 75%. Research has shown that breastfeeding-related policies and practices impact the successful initiation of lactation.

As part of degree requirements at Florida State University, I am conducting a study under the direction of Deborah Frank, ARNP, PhD. entitled "Breastfeeding support on Perinatal Units of Florida Hospitals" It will examine breastfeeding-related hospital policies and practices as well as nurse attitudes toward breastfeeding. I would be grateful if you would assist me by completing the attached survey. The survey should not take more than a few minutes of your time; however, your response is crucial for completion of the study.

Responding to the survey is completely voluntary and consent to participate is implied by completing and mailing the survey. The study will identify strengths and weaknesses of breastfeeding-related care in Florida. This will result in a long-term benefit of enabling Florida hospitals to better meet the needs of their obstetric patients. The process of filling out the survey could also have the benefit of encouraging you to evaluate the current policies and practices on your unit. The study should not pose any risk to you, although it is possible that you could experience emotional discomfort or distress if you realize that policies or practices are not up to date.

Your response will be mailed directly to me in the stamped window envelope which accompanies the survey. The survey will bear a numeric code to assist me in grouping the data, but no individual nurses, unit managers, or facilities will be identified in the study. All responses will be confidential to the extent allowed by law. The surveys will be retained by the researcher in a secure location.

Results of this study will be available to you upon request by contacting me via e-mail ([email protected]) or at the School of Nursing. You can also reach me at either address if you have questions or concerns. I greatly appreciate your help and the contribution you are making to this nursing research.

Sincerely,

Elisa H. Casey, RN, BSN; MSN Candidate Florida State University School of Nursing Mail Code: 4310 Tallahassee, FL 32306-4310

106 APPENDIX I STAFF NURSE QUESTIONNAIRE

107 STAFF NURSE QUESTIONNAIRE

Instructions: Please check or circle the most appropriate answer for each question. Give only one answer for each question unless otherwise instructed for a question. There are questions on the front and back of each page. When you have completed the survey please fold so that the address shows through the window of the stamped envelope that has been included with your survey. Drop the sealed envelope in any mailbox. Please return by April 15, 2002.

Elisa H. Casey, RN, BSN; MSN Candidate 3962 Calle de Santos Tallahassee, FL 32311-3403.

======fold here======

Part 1: This section will tell a little about you.

1. My age is: 20 - 25 26 - 30 31 - 35 36 - 40 41 - 45 46+

2. Highest educational preparation in nursing: Diploma A.D.N. B.S.N. M.S.N.

3. Years of experience in nursing: 0 - 1 2 - 5 6 - 10 11 - 15 16 - 20 Over 21

4. Years of experience in Obstetrics or Neonatal nursing: 0 - 1 2 - 5 6 - 10 11 - 15 16 - 20 Over 21

5. I have attended inservices or formal training in breastfeeding: Never In the last year 2 - 5 years 6 - 10 years 11 or more years ago

6. I feel that I know enough to really help breastfeeding moms. Always Usually Rarely Never

7. I feel that on a typical shift, I have enough time to help breastfeeding mothers that are having problems. Always Usually Rarely Never

8. I chose to breastfeed at least one of my children. Yes No Not Applicable

108 Part 2: This section asks questions about practices on your units and deals with normal, healthy breastfeeding infants.

1. How soon after birth is a well baby normally put to breast for the first time? In the delivery room immediately after birth _____ In the delivery room within one hour of birth _____ Within two hours of birth _____ 2 - 4 hours after birth _____ From 4 - 8 hours after birth _____ Varies (explain) ______

2. What are breast-fed babies given as a first feeding? (Check all that apply) Breast milk _____ Formula _____ Glucose _____ Water _____ Other: _____

3. a. Is the opportunity provided for mothers to have skin contact with babies in the delivery room? All mothers _____ Some mothers _____ Never encouraged _____ Don’t know _____

b. If mothers do have skin contact with their baby in the delivery room, how long does this contact normally last? Under 10 minutes _____ 10 - 20 minutes _____ 21 - 30 minutes _____ Over 30 minutes _____

4. a. Are breast-fed babies in the hospital fed: According to a fixed schedule _____ When they cry or appear hungry _____

b. Can a mother or father who wishes feed outside the schedule? Yes _____ No _____ Depends _____

c. Does the breastfeeding mother usually feed the baby herself at night? Yes _____ No _____

5. Do you normally advise restricting sucking time for breast fed babies? (If yes, please describe) Yes _____ No _____

109 6. a. Are breast-fed babies normally given any supplements BETWEEN breast feedings? Always _____ Occasionally _____ Never _____

b. If YES, what is used? (Indicate all possibilities) Water _____ Glucose _____ Formula _____ Other (explain) _____

c. Is supplemental feeding done by (Indicate all possibilities) Spoon _____ Bottle _____ NG/OG _____ Other (explain) _____

7. a. Are breast fed babies normally given complements WITH breastfeeding? Always _____ Occasionally _____ Never _____

b. If YES, what is used? (Indicate all possibilities) Water _____ Glucose _____ Formula _____ Other (explain) _____

8. a. Do you routinely test weigh babies before and after feedings? Yes _____ No _____

b. If yes, Are mothers normally told the results of test weighing? Yes _____ No _____

9. a. In the 12 hours after birth, is the baby: Routinely kept with the mother _____ Separated from the mother and kept in _____ the nursery except for feeds Other (describe) ______

b. How long is the baby’s initial stay in the nursery? Under 2 hours _____ 2 - 4 hours _____ 4 - 5 hours _____ 6 - 8 hours _____ Over 8 hours _____

c. What criteria are used to decide baby no longer needs constant observation? (Check as many as apply) Hospital policy states time _____ Temperature stable _____ Color and respiration stable _____ No mucus _____ Has taken first feed _____ Other (explain) _____

110 10. a. Do you think rooming in is encouraged in your hospital? Yes , 24 hrs/day _____ Yes, 12-23 hrs/day _____ Yes, less than 12 hrs/day _____ No _____

b. Approximately how much time do mother and baby spend together each day while in hospital? Less than 6 hours _____ 6 - 8 hours _____ 9 - 12 hours _____ 13-16 hours _____ 17-20 hours _____ 21-24 hours _____

11. a. Are mothers routinely taught the techniques of breastfeeding (e.g. latching, holding the baby?) Yes _____ No _____

b. If yes, when does this breastfeeding teaching normally happen? With the first feed _____ In the first 12 hours _____ In the first 12 - 24 hours _____ In the first 24 - 72 hours _____ On as-needed basis _____ Other (describe) _____

12. Who is responsible for teaching the mother the techniques of breastfeeding (e.g. latching)? (Check all that are appropriate) Delivery room nurse _____ Postpartum nurse _____ Nursery nurse _____ Breastfeeding counselor _____ Lactation consultant _____

13. a. Do you have a person primarily responsible for breastfeeding problems in your hospital? Yes _____ No _____

b. If yes, is this person Lactation consultant _____ Breastfeeding counselor _____ Staff nurse _____

14. Do you distribute printed information for mothers on breastfeeding? Yes _____ No _____

111 15. Do you have formal postpartum classes for mothers while in hospital that include breastfeeding teaching? Yes _____ No _____

16. a. Are mothers given any one-to-one breastfeeding teaching? Yes _____ No _____

b. If yes, do you have a teaching protocol for this? Yes _____ No _____

17. Are your visiting hours for the following people: Restricted Unrestricted Immediate Family ______Relatives ______Friends ______

18. Are sleeping pills used to secure a good nights rest for the breastfeeding mother? Yes _____ No _____ On request only _____

19. Within the last 6 months, have you made a referral to one of the following for mothers with breastfeeding problems? (Check those to whom you have made a referral.) Lactation Consultant _____ La Leche League _____ Nursing mothers support group _____ Physician’s office _____ Public health department _____ Nurse practitioner/nurse midwife _____ Other (describe) ______

20. Are formula discharge packs routinely distributed in your hospital to breastfeeding mothers? Yes _____ No _____

112 Part 3: This section asks about your view on breastfeeding.

There are 5 possible responses to each of the items below. SA - Strongly Agree; A - Agree; N - Neutral; D - Disagree; SD - Strongly Disagree. Please circle the response which best represents your attitude.

1. Breast feeding ties you down. SA AND SD

2. Breast feeding is more convenient. SA AND SD

3. Breast feeding provides more freedom. SA AND SD

4. Breast feeding improves the appearance of the breast. SA AND SD

5. Breast feeding makes the breast less attractive. SA AND SD

6. Breast feeding is more attractive to the husband. SA AND SD

7. The baby enjoys the breast more than the bottle. SA AND SD

8. Breast feeding is healthier for the baby. SA A N D SD

9. Breast feeding provides insufficient milk. SA AND SD

10. Breast feeding may not provide the right kind of milk. SA AND SD

11. Bottle feeding is more sanitary. SA A N D SD

12. Breast feeding provides a closer link with the mother. SA AND SD

13. There is less chance of an infection in the baby with SA AND SD breast feeding.

14. Breast feeding provides the amount of milk the baby SA AND SD needs.

15. Breast feeding requires special skills. SA AND SD

16. Breast feeding is better for recovering the figure. SA AND SD

17. Breast feeding is embarrassing. SA AND SD

18. All things considered, breast feeding and bottle SA AND SD feeding are about equal.

113 APPENDIX J FACILITY APPROVAL FROM BAPTIST HOSPITAL MIAMI

114 115 116 117 118 119 REFERENCES

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Academy of Breastfeeding Medicine (n.d.) Clinical Protocol Number 3– Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate. Retrieved November 2, 2002 from the World Wide Web. http://www.bfmed.org/proto3.html

Agency for Health Care Administration (2001). Hospital outcome series: Cesarean deliveries in Florida hospitals: 2000-2001 report Retrieved June 28, 2001 from the World Wide Web. http://www.floridahealthstat.com/rptsalphalist.shtml

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American Nurses Association (1998). Standards of clinical nursing practice, 2nd ed. Washington, DC: American Nurses Publishing.

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Committees on Health Care for Underserved Women and Obstetric Practice of the American College of Obstetrics and Gynecology. (2000). ACOG educational bulletin. Breastfeeding: Maternal and infant aspects. Number 258, July 2000. Obstetrics and Gynecology, 96

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Ertem, I. O., Votto, N., & Leventhal, J. M. (2001). The timing and predictors of early termination of breastfeeding. Pediatrics, 2001, 543-548.

121 Florida Hospital Association (2001). Directory of Hospitals. Orlando, FL: Florida Hospital Association.

Haninger, N. C. & Farley, C. L. (2001). Screening for hypoglycemia in healthy term neonates: Effects on breastfeeding. Journal of Midwifery & Women’s Health, 46, 292-301.

Henrikson, M. (1990). A policy for supplementary/complementary feedings for breastfed newborn infants. Journal of Human Lactation, 6,11-14.

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124 BIOGRAPHICAL SKETCH Elisa H. Casey, RN, BSN, was born May 25, 1970 in Norfolk, VA. She grew up in Jacksonville, Florida. She received her Bachelor of Science in Nursing from Florida State University School of Nursing on May 1, 1993. She has worked for 10 years as a registered nurse in adult medical/surgical nursing and has served as a teaching assistant for two years. She is presently pursuing her Masters of Science in Nursing in the Family Nurse Practitioner track and is interested in focusing on Women’s Health and has interest in working with breastfeeding mothers. She is also working toward completing the Post- Masters Educator Certificate. She is married and has a daughter.

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