Cultural Interpretations of Patients and Employees in an Organization Certified Through the Baby-Friendly Hospital Initiative: A Focused Ethnographic Study

Knowledge is power

Participants described how the variety of resources available to support breastfeeding was integral to an organizational culture of breastfeeding support. Resources for patients ranged from information about “skin to skin” (Patient Participant 104) to how colostrum is like “liquid gold.” (Patient Participant 105). The importance of this information was described as “supporting patient learning and education” (Employee Participant 112) and to inform patients about the benefits of breastfeeding.

We have a little chart where we have all the benefits of breastfeeding. Like everything that’s in the breast milk and then everything that’s in the formula and then you’ll see visually the ingredients in the formula are like here and breastfeeding has a lot more nutrients. So, it helps them (patients) visualize as well and they get more motivated to store their milk for baby. (Employee Participant 113)

The availability of human resources and hands-on support was also described as important by many participants within the organizational culture. This support ranged from a formal “breastfeeding class” (Patient Participants 109, 110) to one-on-one “feedback” (Patient Participant 110) from nurses and Internationally Board-Certified Lactation Consultants (IBCLCs). The comprehensiveness of this education within the NICU was described by Employee Participant 118:

Educating is huge too. These moms have to be there as much as possible, talking to them about the frequency of feeding, the frequency of their pumping, the frequency of how we give oral immune therapy through the colostrum. Educating them on the composition of colostrum, why it’s so good. Foremilk, hindmilk, all of that.

Conversely, participants noted how a lack of human resources can be detrimental to organizational culture, specifically a lack of IBCLCs. The need for “more” lactation support (Patient Participant 103, Employee Participant 115) due to IBCLC’s “support of [breastfeeding] initiatives” (Employee Participant 117) was described by a variety of participants. However, the expertise of other staff members was significant in enhancing the experiences of both patients and employees and could help bridge this gap. From two employee’s perspectives, “watching” (Employee Participant 117) or being “paired up” (Employee Participant 113) with experienced staff members developed their own competence in providing breastfeeding support. Patient Participant 109 described her experience of receiving breastfeeding support from a nurse:

I really appreciated that the nurse, that even though she wasn’t an educator, she was competent enough in breastfeeding. That she was aware that there was a struggle and what would’ve been the best sort of, I don’t know, treatment plan or sort of what would have helped facilitate breastfeeding.

Having adequate preparatory knowledge prior to birth was described by many participants as integral to positive breastfeeding experiences. Patient participants remarked how they did “research” (Patient Participant 106) and sought information through “reading” (Patient Participant 105) and attending “prenatal workshops” (Patient Participant 101). Some of this knowledge was experiential from breastfeeding previous children

They put them on me, and I didn’t really know much with my first. And I was kind of indifferent. I didn’t really know about breastfeeding that much. I was just like, “I’ll try it.” And they taught me a ton. And then with my second, I felt super comfortable, and I knew kind of what to do right away. (Patient Participant 107)

Despite some patient participants having preparatory knowledge, the process of learning was ongoing during the initiation of breastfeeding. One participant noted how she “did not do enough research” (Patient Participant 107). Employees also agreed that some patients are “more educated [in breastfeeding] than others” (Employee Participant 117) and that “a lot of education needs to be done” (Employee Participant 113).

Community of support

Fostering a community of support within a BFHI-certified organization was seen as imperative to positive organizational culture in a variety of ways. The importance of discharge coordination for breastfeeding support was discussed by multiple participants, including information on resources such as La Leche League (Patient Participant 102) and Public Health (Patient Participant 109). Patient Participant 108 described the importance of these resources:

I think there’s so much information out there that it sometimes can be overwhelming, especially when you come home with a newborn that you’re expected to take care of yourself. So, it’s good to just get a handout or something that tells you, this is exactly what you should be following or what you can do if this is what you want, this is your goal.

Including family members and care partners as collaborators was also seen as a cultural norm. Employee Participant 112 remarked how it should be the “standard to include them [family members]” especially when they will be involved in supporting breastfeeding upon discharge: “If their support people are grandparents or sisters or aunts or things like that, making sure they’re involved in that conversation and that education, or discharge teaching, or whatever stage they are there for.”

Within a community of support, participants also emphasized the importance of teamwork and compassionate care. One participant remarked how she felt that care was delivered on a “personal level” (Patient Participant 105), and an employee explained how one can, “feel good when [breastfeeding] works” (Employee Participant 115). Employee Participant 116 explained the process of a team approach to supporting breastfeeding in the NICU:

I noticed in rounds, it’s one of those questions that are brought up as a standard, whether or not the child is going to be breastfed, have we gotten consent for donor milk. It’s become standard work for the interprofessional team. So, it’s affected your nurse practitioners and occupational therapists, and physicians, including RNs, of course.

Participants also commented on how the BFHI must be promoted to uphold organizational championship and a supportive breastfeeding culture. Employee Participant 115 remarked, “It’s all over the hospital. Big giant posters. We’re breastfeeding, we’re Baby-Friendly. You can breastfeed anytime, anywhere.” Informing patients of how the organization promotes this initiative was viewed as important by Employee Participant 118:

It’s supporting patients, and the development of children, of babies, properly. As we know, the health benefits of that. And so, it allows the organization to say they’re supportive of something that has been well researched as being the best for newborns, and having that kind of gold standard, and that you really care.

Contextual considerations

Understanding the context of specific situations was described by participants as integral to organizational culture. From an employee perspective, workload must be considered as a critical barrier to upholding BFHI-specific policies. As Employee Participant 114 stated, “I feel like it added to our workload, so sometimes it’s hard to do the Baby-Friendly Initiative, and sometimes that takes a backseat.” Implementing BFHI policies was also described as sometimes “arduous” (Employee Participant 116) and can be time-consuming. Employee Participant 118 explained,

If I have three babies and all three of them are term, and they all have latching difficulties, it’s very hard for me to divide myself and give my full BFI attention to each individual one, every 3 hours. That’s my biggest challenge.

As this study was conducted directly following the COVID-19 pandemic, context was provided by multiple participants on how it affected their breastfeeding experiences or ability to provide care within an organizational culture that typically promotes breastfeeding. Employee Participant 111 described how some supportive practices were “backburned.” Care coordination was also affected, as explained by Employee Participant 112:

You had to put all your PPE on and go in rooms, so you kind of tried to bundle your care. And that meant that there wasn’t as much spontaneous attendance in rooms because it took you so long to get in and out of each room. You had to be a bit more thoughtful about planning and spending your time.

Health implications were also discussed specific to patients and their infants and how this must be considered within the organizational culture. Some notable infant conditions included weight loss (Patient Participants 106, 108), hypoglycemia, prematurity, and other factors causing separation. Employee Participant 113 described difficulties in upholding hypoglycemia protocols within the organization:

I think it can be challenging sometimes, especially with the other protocols. For example, the hypoglycaemia protocol, a lot of the times, even if the sugar is borderline or below 2.5, we have to encourage the formula as per the protocol. And a lot of times the mothers don’t want to, they want to stick to breastfeeding. But at that time, it can be challenging because it’s more important to make sure the baby’s sugars are stable.

Maternal health implications that can interfere with breastfeeding ranged from mild to severe circumstances. For example, Patient Participant 109 explained, “I have an inverted nipple, even the nurse sort of noticed that but she was sort of still trying to support me.” However, Employee Participant 115 described severe cases in which implementing some BFHI principles may not be possible,

And there are some extreme cases that moms end up in ICU straight from delivery, and that baby gets bottle fed with the formula, because that mom is fighting for her life. And we have to remember about those moms, too. (Participant 115)

Participants recognized the importance of considering these health implications within an organizational culture that supports and promotes exclusive breastfeeding.

Environment for breastfeeding

An environment that is favorable to breastfeeding was viewed as an important cultural consideration for most of the participants. For example, the normalization of breastfeeding practices emerged as a cultural consideration, which participants described as “second nature” (Employee Participant 111) and “automatic” (Employee Participant 115). Physical environments for promoting breastfeeding were also described as beneficial, for example, through “rooming in” (Patient Participant 105) which is a clinical component of the BFHI. Coordination between units was also described through a process of “transitional care” (Employee Participant 115). Employee Participant 112 thoroughly described this process:

Right from the beginning of when they get admitted we talk about their feeding choices so that we can provide any discussion or information or have that conversation right from when they come. So then when they deliver, we’re promoting and supporting their feeding options then too, right? And then continuing that postpartum where they’re going to get a lot more, because baby’s here now, and then that ongoing education postpartum.

Patient Participant 103 described in more detail how coordination occurs between the postpartum unit and NICU: “They mostly showed me how to express my milk, like, my colostrum. And then, it was in the NICU that I kind of had, you know, people showing me how to feed the baby.” This care coordination was deemed imperative across the organization to promote optimal breastfeeding support.

Patient factors

Emotional responses to breastfeeding were described by participants as inherent to their cultural experiences. Two participants stated how breastfeeding processes can make individuals feel “overwhelmed” (Patient Participant 103, Employee Participant 113) despite being within a BFHI-certified organization. Patient Participant 104 described this phenomenon from an internal perspective, “It’s like your own hormonal, it’s your societal expectations, it’s your hormones. It’s what you’ve dreamt of or imagined your entire life going completely wrong, and not following through in any type of way that you anticipated.”

However, determination to breastfeed was an internal factor described by multiple participants. Patient Participant 101 remarked, “This was my second child, and my first breastfeeding journey was not successful. I was determined to breastfeed this baby.” Patient Participant 106 described a similar sentiment:

I delivered twins. So, I did a lot of research on breastfeeding before going into it because I had a lot of people around me telling me that it was pretty unlikely that I’d be able to breastfeed them, and I was fairly determined to be able to do it.

Most employees also described that despite the organizational culture of breastfeeding support, patient choice still had to be respected. As described by Employee Participant 113, “It is the patient – parent’s decision. If they have decided [to use formula] even if it’s not medically indicated.”