Know Your Audience: One Hospital's Approach to Quality Improvement Initiatives

Changing health behavior has been widely studied, but no consensus on optimal methods has been reached. One issue is that measurement of behavior and behavioral change is often fraught with obstacles. The carrot and stick philosophy works for some: “Your baby will be healthier if you breastfeed,” or “Your chances of having type 2 diabetes increase if you do not lose weight.” However, patients are also often influenced by their peers, healthcare providers, and societal norms. Reaching out to the decision-makers, grandmothers to governors, is another tactic used to influence behavior, leading to laws such as “all women have a right to breastfeed in public wherever they may lawfully be.”

Public health experts, trying different approaches, have initiated ad campaigns that have stirred controversy when certain examples are used (think of the young woman rolling logs as an analogy to dangers of not choosing to breastfeed). Educating primary care providers to teach families traditionally has worked better, albeit slowly, to effect change, such as yes on seat belts and no on cigarettes. However, these also can send negative messages.

To effect change in the cultural community of a city hospital is an example of where several tactics are needed to convince healthcare providers that “new” is superior to “the status quo.” ¹ The rapidly changing state of evidence-based medicine has left many confused and others unable to catch up with current scientific thinking without great effort. Therefore, our group sought to answer the following question: “What are the current beliefs of our colleagues regarding exclusive breastfeeding in the hospital environment?”

Although having a written policy on infant feeding may be agreed to in print, how well it will be accepted and implemented is another matter. One of the strengths of a large city hospital is staff members who have diverse training experiences and beliefs. For the educator, first knowing those beliefs is a starting point for conversation and educational priorities.

As part of the Best Fed Beginnings (BFB) 2-year quality improvement project, awarded from a National Institute for Child Health Quality grant, our Saint Thomas Midtown Hospital (Nashville, TN) developed skills fairs for nurses to improve their confidence in assisting mothers to breastfeed. During the in-service, nurses were given a brief eight-statement survey and asked to rank the World Health Organization's Ten Steps in their order of priority. Using a Likert scale, we were able to score responses and compared them with those of controls of attending physicians and BFB team leaders. The survey used eight themes based on the following domains: education of the mother–baby dyad, implementation of new policies, health benefits of formula versus breastmilk, time constraints, separation of mother–baby pairs, and economic implications of participating in quality improvement.

Survey questions included positive and negative statements; two items were reverse-scored to blind the responder. The example statements (three of 11) shown below were especially helpful in ascertaining beliefs and nursing staff roles in the hospital setting:

• “Providing breastfeeding education is an essential part of perinatal nursing.”

• “In terms of illness and disease, breastfed babies are the same as formula fed.…”

• “Bringing babies to the nursery for MD exams is the most efficient way.…”

Our survey, administered anonymously to 34 participants, revealed that over half of the nurses were engaged in the quality improvement project and affirmed goals of the BFB initiative. Many agreed that “having time to teach breastfeeding was difficult”; some concurred that “it was the lactation specialists' job (not mine) to assist with teaching feeding cues and latch.”

Since Saint Thomas Midtown Hospital had banned the bags and eliminated routine pacifier use in 2012, nine of the World Health Organization's Ten Steps remained to be ranked. The participants verified these top three remaining priorities as “Informing all mothers about the needs and management of breastfeeding,” “Train all healthcare staff in skills necessary to implement the policy,” and “Show mothers how to maintain lactation even if they are separated from their infants.” The leadership survey given to doctors and team members shared very similar goals. Using accepted methods for anonymous inquiry, the survey was completed in less than 5 minutes, and there was no resistance to the process.^2,3

These results, shared with physician leadership and nurse educators, gave an indication of areas of agreement and priorities in implementing desired changes. After the survey, paid time was allocated for nursing staff to shadow lactation consultants on teaching rounds for 3 hours per individual, fulfilling both the stated intervention priorities and the educational gap among providers. Using a simple survey tool may help other similar hospitals in reaching the ultimate goal of improved exclusive breastfeeding rates and uniformity in staff education and awareness.

Disclosure Statement

No competing financial interests exist.