Abstract
Purpose:
To examine the effect of nurse staffing in varying work environments on missed breastfeeding teaching and support in inpatient maternity units in the United States.
Background:
Breastmilk is the optimal food for newborns. Teaching and supporting women in breastfeeding is a primarily a nurse’s responsibility. Better maternity nurse staffing (fewer patients per nurse) is associated with less missed breastfeeding teaching and support and increased rates of breastfeeding. We examined the extent to which the nursing work environment, staffing, and nurse education were associated with missed breastfeeding care and how work environment and staffing interacted to impact missed breastfeeding care.
Methods:
In this cross-sectional study using the 2015 National Database of Nursing Quality Indicator survey, maternity nurses in hospitals in 48 states and the District of Columbia responded about their workplace and breastfeeding care. Clustered logistic regression models with interactions were used to estimate the effects of the nursing work environment and staffing on missed breastfeeding care.
Results:
There were 19,486 registered nurses in 444 hospitals. Nearly three in 10 nurses (28.2%) reported missing breastfeeding care. In adjusted models, an additional patient per nurse was associated with a 39% increased odds of missed breastfeeding care. Further, a standard deviation decrease in the work environment was associated with a 65% increased odds of missed breastfeeding care. In an interaction model, staffing only had a significant impact on missed breastfeeding care in poor work environments.
Conclusions:
We found that the work environment is more fundamental than staffing for ensuring that breastfeeding care is not missed, but also that breastfeeding care is sensitive to nurse staffing. Improvements to the work environment support the provision of breastfeeding care.
Implications for research and practice:
Nurse staffing and the work environment are both important to improve breastfeeding rates, but the work environment is foundational.
Keywords: Breastfeeding, Maternity Nursing, Missed Nursing Care, Staffing, Work Environment
Precis
Improved staffing and work environments are both associated with less missed breastfeeding teaching and support, but the work environment is foundational.
Background
Breastfeeding is the optimal source of nourishment for most infants.1 The United States’ (US) breastfeeding rates fall far short of national goals and are marked by pervasive disparities for racial minority mothers.2 Accordingly, it is a national priority to increase breastfeeding rates. This is evidenced by a required Joint Commission breastfeeding hospital quality metric.3 In addition, breastfeeding has been promoted through several initiatives, such as the Baby Friendly Hospital Initiative4 and the establishment of the Maternity Practices in Infant Nutrition and Care5 survey by the Centers for Disease Control and Prevention. Despite these focused programs, there is still significant room for improvement in US breastfeeding rates suggesting that there are other avenues to consider.
Nurses provide most direct labor and postpartum care in US hospitals, including most or all breastfeeding care. Breastfeeding care encompasses supporting and advocating for uninterrupted skin-to-skin after birth, providing continuous monitoring of the newborn for the first two hours of life, encouraging rooming-in and safety therein, and providing breastfeeding teaching and support (e.g., recognizing feeding cues and obtaining a good latch). These care items are typically nursing responsibilities.6–9 Both the Ten Steps for Successful Breastfeeding and the Maternity Practices in Infant Nutrition and Care score are comprised of these items that are almost entirely in nursing’s domain .9,10 Lactation consultants, midwives, and physicians may occasionally provide additional support, but registered nurses are the frontline for helping women and newborns establish breastfeeding.1 Therefore, breastfeeding has been suggested as a nurse-sensitive quality indicator, a suggestion of how good the nursing care is in a hospital.11 Unfortunately, nurses may miss providing breastfeeding care due to organizational constraints, which require them to ration care and attend to other clinical care tasks deemed a higher priority.12 Missed nursing care, when nurses do not perform necessary care tasks, has been identified as a reflection of care quality.13
Nurses’ capacity to provide care is impacted by modifiable organizational factors, including staffing and the work environment.7,11,14–16 Staffing is defined as the number of patients assigned per nurse. Inadequate staffing, not having enough nurses to care for the patients on the unit, is associated with poor breastfeeding support and outcomes.7,11 The work environment supports professional nursing practice through collaborative relationships with the healthcare team, supportive nurse managers, nurse participation in policy development, and the ability to practice according to a nursing model of care.17 Importantly, the work environment can be changed to be more supportive of nurses, empowering them to provide better care to the fullness of their scope of practice and thereby improving patient outcomes.
Poor staffing (more patients per nurse) is associated with increased missed breastfeeding care by nurses7,18 and decreased rates of breastfeeding.11,12,19 Greater adherence to the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) nurse staffing guidelines was associated with increased hospital-level breastfeeding rates.11 In neonatal intensive care units (NICUs), work environments that were more supportive of nursing professional practice were significantly associated with more infants being discharged on breast milk (i.e., infants go home eating breastmilk, whether pumped or from the breast, rather than formula).20 Other research in an adult surgical population suggests that the work environment is more fundamental to patient outcomes than nurse staffing.21 It is not clear how the work environment is associated with missed breastfeeding care in general maternity units. If the work environment is also fundamental to the provision of breastfeeding care, it identifies an actionable target to achieve optimal infant feeding outcomes and suggests the value of investing in nursing organizational capacity. Consequently, the purpose of this research is to examine the effect of nurse staffing in varying work environments (i.e., unit conditions that are more or less supportive of nursing professional practice) on missed breastfeeding care.
Methods
Study Design and Sample
We used a cross-sectional correlational design to examine the effect of nurse staffing in varying work environments on missed breastfeeding care in the 2015 National Database of Nursing Quality Indicator (NDNQI) survey via a secondary analysis. The NDNQI was initiated by the American Nurses Association in 1994 as an approach to measuring quality in hospital nursing in a standardized fashion, including how the nurse-rated quality of care varies across units/hospitals and how it is associated with patient outcomes .22,23 The NDNQI dataset is unique as the only national nursing database with quarterly and annual data on nursing structure, process, and outcomes measures, enabling evaluation at the unit and hospital level.22 When hospitals choose to participate in the NDNQI, the survey is sent out to nurses by unit. The survey is anonymous and voluntary. Currently, about 10% of hospitals in every state in the US choose to participate in this survey, resulting in broad representation of nursing across the country. In the 2015 data set, hospitals participated in all states except Utah and Hawaii. Due to hospital administrative support for survey participation, the typical response rate is around 70%.24 The average response rate at the nursing-unit level for this sample was 73.9%.
The survey questions include measures of the work environment, staffing, and nurse education. Nurse respondents must have worked on their unit for at least three months and spend at least 50% of their time in direct patient care, to participate in the survey. For this study, survey respondents were included in the sample if they were a 1) currently employed 2) registered nurse in a 3) maternity unit - Labor/Deliver/Recovery/Postpartum (LDRP), Labor & Delivery (L & D), or Postpartum (PP). The three units were mutually exclusive (i.e., nurses reported on their primary assignment and did not select both L & D and PP). For stable aggregate measures, we excluded the units with fewer than 5 nurse respondents, resulting in the exclusion of 34 units (16 hospitals). The NDNQI provided hospital characteristics from their records.
Measures
Nurses reported on necessary care that they had missed on their last shift. Specifically, missed care was measured by the question “Which of the following activities were necessary but left undone because of time constraints?” Respondents were given a list of activities and asked to check all that apply. Missed breastfeeding care was captured by the following activity item under the missed care question: help or counsel breastfeeding mothers / support or promote breastfeeding. The item was coded as “1” if the nurse reported missing breastfeeding care and “0” if they did not.
Nurses also answered questions about the quality of their work environment. The NDNQI includes two measures of the work environment: the National Quality Forum-endorsed Practice Environment Scale of the Nursing Work Index (PES-NWI) and the Job Satisfaction Scale (JSS). Prior research confirmed that both instruments have sufficient analogous content to compute a PES-NWI facsimile from JSS items.24 As per that earlier research, we used a composite score to translate JSS scores into PES-NWI composite scores, allowing units to be included no matter which instrument was used to assess the work environment.24 The PES-NWI includes five subscales associated with professional nursing practice: 1) Nurse Participation in Hospital Affairs; 2) Nursing Foundations for Quality of Care; 3) Nurse Manager Leadership, Ability and Support of Nurses; 4) Staffing and Resource Adequacy, and; 5) Collegial Nurse-Physician Relations.17 Nurses respond whether the trait is present at their primary job via a four-point Likert scale ranging from 1 (Strongly Agree) to 4 (Strongly Disagree).17 The composite PES-NWI score was kept as a continuous variable and standardized to ease interpretation. We reverse-coded it so the higher the value, the worse the environment. For purposes of interpretation, particularly with regards to interactions, we then defined “good” as one standard deviation above the mean, mean, and then “poor” as one standard deviation below the mean.
Maternity nurse staffing was based on a question regarding the maximum number of patients (not dyads) assigned to the respondent at any one time. The stem of this question was “Think about the last shift you worked.” The response options ranged from “shared one patient with another nurse”, to a number from one to 24, or greater than or equal to 24. The staffing variable was originally calculated as the mean number of patients per nurse. For purposes of interpretation, particularly with regards to interactions, we then defined “good” as one standard deviation below the mean, mean, and then “poor” as one standard deviation above the mean.
Nurse education was determined via the question “What is your highest level of nursing education?” Response options included: diploma, associate degree, baccalaureate degree, master’s degree, or doctorate degree. The nurse education variable represented the percent of maternity nurses who reported having a bachelor’s degree in the hospital.
Hospital characteristics were variables available in the data set. Bed size was a categorical variable with hospitals having 0 – 199, 200 – 399, or ≥ 400 beds. Teaching status was defined as being an academic medical institution, teaching, or non-teaching hospital. Hospital Magnet® status, ownership (e.g., non-profit or for-profit), rurality, and type (e.g., general or critical access) were also available in the NDNQI data set. Regions were based on the American College of Obstetricians and Gynecologists’ five regions but only included states in the US and the District of Columbia (see Table 1).25
Table 1:
Regions
| Region | States |
|---|---|
| 1 (Northeast) | Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, and Vermont |
| 2 (Mid-Atlantic/West) | Delaware, Indiana, Kentucky, Michigan, New Jersey, Ohio, and Pennsylvania |
| 3 (Southeast) | Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, and West Virginia |
| 4 (Plains/South) | Alabama, Arkansas, Illinois, Iowa, Kansas, Louisiana, Minnesota, Mississippi, Missouri, Nebraska, Oklahoma, Tennessee, Texas, and Wisconsin |
| 5 (West) | Arizona, California, Colorado, Nevada, New Mexico, Oregon, and Washington |
Note: Utah and Hawaii would have been part of Region 5 but were not included in the 2015 National Database of Nursing Quality Indicator data. Alaska is not listed in any of the regions.
Analytic Procedure
We used descriptive statistics to describe the hospital sample and distribution of the key variables across hospitals. We used logistic regression models to estimate the effects of the nursing work environment, nurse staffing, and nurse education on missed breastfeeding care. Analyses were conducted at the nurse-level with nurses being clustered (or aggregated) at the unit-level to account for non-independence of nurses within hospitals. We ran models that were unadjusted, adjusted with hospital characteristics, including the type of unit, and adjusted with an interaction between staffing and the work environment. To better understand the continuous-by-continuous interaction we divided staffing and work environment into categorical variables as described above. Model estimates were computed using Huber-White (robust) procedures to adjust for the clustering of the standard errors at the hospital-level. STATA version 17 MP (STATA Corp, College Station, TX) was used for all calculations.26 This study used de-identified data and does not meet the criteria for human subjects research. This was confirmed by the Institutional Review Board.
Results
The study sample included 19,486 registered nurses in 444 hospitals spread across 48 states and the District of Columbia. Most of the hospitals in the sample were non-profit (87.8%), general (98.4%), non-teaching hospitals (55.6%). Hospitals with fewer than 200 beds comprised 48% of the sample. Most of the hospitals in the sample were in the Mid-Atlantic/Midwest and Plains/South regions. Nurse respondents worked primarily in L & D (42%) units, followed by PP units (37.8%). About one in five (19.8%) respondents reported working in an LDRP. These units were more likely to be found in rural hospitals (19.5%) with fewer than 200 beds (74.4%). The critical access hospitals only had LDRP units. LDRPs were more likely to be in hospitals that were not Magnet® (62.2% vs 47.1% overall) and were located in the Northeast or Mid-Atlantic/Midwest regions. Further details are reported in Table 1.
Across the 444 hospitals, the average nurse staffing (number of patients per nurse) was 5.8 (standard deviation (SD) 3.3). About one-fifth of the hospitals (21.4%) had staffing that was better (1 SD less than the mean) and 23.2% had staffing that was poorer (1 SD greater than the mean). The average hospital-level work environment score was 2.05 (SD 0.44) on a hypothetical scale of 1.00 to 4.00, representing a moderately good work environment. Around one in ten (11%) of hospitals had a better work environment score (1 SD above the mean). The median frequency of nurses with at least a bachelor’s degree across hospitals was 62.3% and ranged from 50% to 72.1%. Further details are reported in Table 2.
Table 2:
Hospital and Nurse Sample Characteristics
| Variable | Hospitals, n (%) | Nurses, n (%) |
|---|---|---|
|
| ||
| Number | 444 | 19,486 |
|
| ||
| Rurality | ||
|
| ||
| Non-metro | 59 (13.3) | 969 (5) |
| Metro | 385 (86.7) | 18,517 (95) |
|
| ||
| Bed Size | ||
|
| ||
| 0–199 | 214 (48.2) | 5,327 (27.3) |
| 200–399 | 152 (34.2) | 7,613 (39.1) |
| ≥ 400 | 78 (17.6) | 6,546 (33.6) |
|
| ||
| Teaching status | ||
|
| ||
| University teaching | 40 (9) | 2,850 (14.6) |
| Teaching | 157 (35.4) | 7,539 (38.7) |
| Non-teaching | 247 (55.6) | 9,097 (46.7) |
|
| ||
| Hospital ownership | ||
|
| ||
| Non-profit | 390 (87.8) | 17,451 (89.6) |
| Government Non-federal | 28 (6.3) | 1,338 (6.87) |
| For-profit | 26 (5.9) | 697 (3.6) |
|
| ||
| Hospital type | ||
|
| ||
| General hospital | 437 (98.4) | 19,414 (99.6) |
| Critical access | 7 (1.6) | 72 (0.4) |
|
| ||
| Magnet® | ||
|
| ||
| No | 289 (65.1) | 10,464 (53.7) |
| Magnet | 155 (34.9) | 9,022 (46.3) |
|
| ||
| Unit Type | ||
|
| ||
| Labor and Delivery | 156 (35.1) | 8,271 (42.5) |
| Labor/Delivery/Recovery/Postpartum | 162 (36.5) | 3,859 (19.8) |
| Postpartum | 126 (28.4) | 7,356 (37.8) |
|
| ||
| Region | ||
|
| ||
| Northeast | 46 (10.4) | 1,690 (8.7) |
| Mid-Atlantic/West | 114 (25.7) | 4,688 (24.1) |
| Southeast | 74 (16.7) | 3,840 (19.7) |
| Plains/South | 147 (33.1) | 6,119 (31.4) |
| West | 63 (14.2) | 3,149 (16.2) |
Note. Magnet recognition is an earned accreditation given for excellence in nursing professional standards. Regions were based on the five regions defined by the American College of Obstetricians and Gynecologists (2021).
On average across hospitals, breastfeeding care was missed on 28.2% (SD 45%) of nurses’ last shifts. The average number of nurses reporting missed breastfeeding care was highest on PP units (33.6%). The frequency of missed breastfeeding care on PP units was significantly higher than that reported by nurses in L & D (21.6%) or LDRP units (28.1%; p < 0.001).
In unadjusted models, staffing, the work environment, and nurse education were all significantly associated with the odds of missed breastfeeding care (see Table 3). In adjusted models, more patients per nurse was associated with a 39% increased odds of missing breastfeeding care (95% CI 1.32–1.47) after adjusting for work environment, nurse education, and hospital characteristics. Worse work environments were associated with a 65% increased odds of missed breastfeeding care (95% CI 1.58–1.74) after adjusting for staffing, nurse education, and hospital characteristics. In the adjusted regression with the interaction of staffing and work environment, good staffing in a poor work environment was associated with a 36% decreased odds in missed breastfeeding care (95% CI 0.47–0.86) compared to mean staffing in a mean environment. None of the other interactions, e.g., good staffing in a good work environment, were statistically significant. Table 3 provides further detail.
Table 3:
Hospital Organizational Features and Missed Breastfeeding Care
| Hospital (n = 444) | |
|---|---|
| Staffing, n (%) | |
| Good | 95 (21.4) |
| Mean | 246 (55.4) |
| Poor | 103 (23.2) |
| Work Environment, n (%) | |
| Good | 49 (11) |
| Mean | 334 (75.2) |
| Poor | 61 (13.7) |
| Education (% BSN), median (IQR*) | 62.3% (50%−72.1%) |
| Missed Breastfeeding Care,† m (SD) ‡ | 24.1% (42.8%) |
IQR = interquartile range;
Percent of nurses reporting that they missed this care item on their last shift;
Standard Deviation
Discussion
Breastfeeding is a critical quality metric in maternity care and one for which nurses are primarily responsible. We were interested in knowing the effect of nurse staffing in varying work environments on missed breastfeeding care in inpatient maternity units. We found that staffing, good or poor, had no effect on missed breastfeeding care in units with good work environments. Only in poor work environments did good staffing significantly decrease missed breastfeeding care. As staffing does not have a significant impact on missed breastfeeding care in units with good work environments, we concluded that the work environment is foundational for ensuring that breastfeeding care is not missed.
Missed nursing care is an independent predictor of exclusive breastfeeding at discharge.19 Simpson et al. looked at the association of missed nursing care and adherence to AWHONN’s staffing guidelines during labor with hospitals’ rates of exclusive breastfeeding.19 They conducted this research in a sample of 512 labor nurses representing 36 hospitals in California, Michigan, and New Jersey. Mean missed breastfeeding within one hour of birth for women who were breastfeeding was 2.33 (SD 0.41), indicating that this was missed at least some of the time, per the authors.19 We found an average of 28.2% (SD 45%) of maternity nurses per hospital reporting missing necessary breastfeeding care. In subsequent work, Simpson et al. reported that two particular aspects of missed nursing care were partial mediators of the relationship between nurse staffing and exclusive breastfeeding at discharge.11 8,12,27 Our findings agree with those of Simpson et al. regarding the prevalence of missed breastfeeding care, and the role of staffing therein, and expand our understanding by including the work environment and postpartum nurses.19
Breastfeeding rates are associated with nurse staffing ratios. Teaching and supporting a mother in breastfeeding is time- and labor-intensive, especially for first-time mothers. Women are frequently surprised by the difficulty and discomfort, compounded by fatigue, associated with the early days of breastfeeding. Good staffing ensures that nurses have the time to dedicate to supporting women in this critical process and quality metric. Our finding that breastfeeding is sensitive to nurse staffing aligns with prior research. In qualitative research, nurses stated that inadequate staffing prevented them from being able to provide all the breastfeeding care that was necessary to ensure successful latching and nursing.8,12,27 Quantitative studies that examined nurse staffing and breastfeeding have used different staffing metrics (acuity-adjusted ratios20 and adherence to guidelines11,19) and outcomes (breastfeeding support,16 discharge on breastmilk,20 hospital exclusive breastfeeding rate11), making comparison difficult. Hallowell et al. conducted two studies related to organizational factors and human milk in the NICU. In the first of these, Hallowell et al.16 found that a 1 SD higher acuity-adjusted staffing ratio was associated with a 2% increase in infants provided breastfeeding care.16 Subsequently, Hallowell et al.20 examined human milk use at discharge from the NICU and did not find a significant association between this outcome and acuity-adjusted staffing ratios. By contrast, we found that, as the number of patients per nurse increased, the odds of missed breastfeeding care increased, too. Similarly, Simpson et al. found an association between adherence to AWHONN staffing guidelines and a hospital’s exclusive breastfeeding rate.11 That the findings of Hallowell et al.’s second study did not find a significant association between staffing and discharge on human milk from the NICU may be due to the different outcome that be more sensitive to length of stay and the course of the infant’s illness. The other three studies, which focused on breastfeeding (as compared to the provision of human milk), did find an association between staffing and the breastfeeding outcome of interest.16,20 We further expanded what is understood by looking at breastfeeding in all maternity unit types and examining the interaction of staffing and the work environment.16
The work environment has many different aspects representing a nurses’ ability to function at the full scope of their professional practice.17 When nurses have the resources, support, and autonomy, to function as the independent health professionals that they are, they are best able to do their work – which includes supporting and teaching breastfeeding – and breastfeeding rates in a hospital flourish as a result. Prior work by Lake et al. reported similar findings to our own, that better maternity unit work environments were associated with less missed nursing care.15 Hallowell et al., using 94 NICUs in the Vermont Oxford Network, found that a 1 SD increase (0.25) in the PES-NWI composite score was associated with a four-percentage point increase in the fraction of infants discharged on human milk (p < 0.05).20 In a similar manner, we also found that the better work environments were associated with less missed breastfeeding care.
We did not find an association between the percentage of nurses with a bachelor’s degree and the odds of missed breastfeeding care. In a recent study by Cassar et al., the authors reported that a breastfeeding training course, but not their highest level of education, was significantly associated with support for breastfeeding.28 Hallowell et al. did find that a 1 SD increase (0.15) in the fraction of nurses with a bachelor’s degree in nursing was associated with a three percentage point increase in the fraction infants discharged on human milk (p < 0.05).20 Due to the heterogeneity of the studies, it is difficult to make any further statement about the association of nurse education and breastfeeding.20
Our work builds on that of Aiken et al., who evaluated an interaction between staffing and the work environment as they relate to the odds of failure-to-rescue and mortality for adults hospitalized for common surgery.21 They showed that staffing had an effect in hospitals with good work environments but not in those with poor, suggesting that the work environment was foundational.21 We found that staffing, whether good or poor, had no significant effect on missed breastfeeding care in good work environments. Good staffing was only associated with less missed breastfeeding care in poor work environments. We interpret this to mean that the work environment is foundational because in a unit with a good work environment, staffing does not have a significant impact on missed breastfeeding care. The work environment was also associated with greater variance in missed breastfeeding care than staffing (65% vs. 39%, respectively). Staffing, however, can still make a difference for missed breastfeeding care if the work environment is poor.
Implications
Early breastfeeding initiation is associated with greater exclusive breastfeeding duration and health benefits for neonate and mother.10 Increasing early breastfeeding initiation rates, as well as exclusive breastfeeding duration rates, are national goals. If nurses are, indeed, the part of the maternity workforce with the primary responsibility for providing breastfeeding care (as well as the care that supports breastfeeding, like skin-to-skin and rooming in), then ensuring that they have the organizational resources necessary to support their work is a critical way to support breastfeeding. The Baby-Friendly Hospital Initiative currently recommends numerous evidence-based practices to support breastfeeding initiation and duration, most of which are the professional prerogative of nurses.9 Our work suggests that these guidelines could be expanded to include recommendations for staffing and the work environment to support nurses in providing this care that is critical for population health.
Our findings suggest that focusing on improving the work environment is the fundamental action for improving a unit’s breastfeeding care. If a hospital unit participates in the NDNQI, or surveys the nurses about the work environment, managers could then identify the domains that scored lowest to target improvements. Generally, however, the work environment can be improved by supporting nurses in functioning to the fullest extent of their professional capacity. Specific ways to accomplish that might include increasing opportunities for maternity nurses to participate in developing hospital and unit policies and procedures related to nursing care in general and breastfeeding specifically; asking nurses for feedback, or including them in the process, of purchasing supplies or materials (e.g., investing in a patient education program on breastfeeding); and providing ongoing continuing education for nurses on the importance of breastfeeding and how best to promote and support it. Focusing on the work environment is also important given ongoing concerns about nurse staffing and the likelihood of future catastrophes, whether natural or man-made, impacting health care.
Limitations
We used the average number of patients per nurse. Using the average does not reflect the range in staffing but provides a point from which to understand how more or fewer patients per nurse were associated with missed breastfeeding care. Future work could disaggregate the L & D and PP units (instead of controlling for unit type and clustering by unit) to allow for comparison of nurse staffing in this sample with AWHONN’s staffing guidelines18 and state staffing mandates,29 both of which use the metric of patients per nurse.
While there is broad representation of hospitals in the NDNQI, the sample is skewed towards hospitals that hold Magnet® designations, representing a certain amount of sampling bias. Hospitals in the NDNQI are disproportionately Magnet® because accreditation requires participation in a benchmarking database. Currently, one in three hospitals in the US participates in the NDNQI.30,31 While only about 8.6% of US hospitals have obtained Magnet® status, however, these hospitals represent about 25% of the hospitals in the NDNQI.30–32 As a result, the NDNQI is a rich source of data with broad geographic coverage but heavy with hospitals acknowledged for having excellent nursing resources. Our findings, therefore, may represent a conservative estimate of the actual interplay of work environment and staffing on breastfeeding teaching and support. Finally, the data were collected in 2015. While this data is now almost a decade old, this work adds to the current evidence by allowing us to examine the relationship between staffing and the work environment for missed breastfeeding care across a broad sample of units in the US.
Conclusions
We found that the work environment superseded staffing and nurse education in its impact on missed breastfeeding care. Hospital managers looking to improve breastfeeding outcomes need to understand the relationship between staffing and the work environment if they want to improve their institution’s perinatal quality measures. In the context of nursing workforce shortages that limit the ability to increase staffing, managers can work on improving breastfeeding care (and nurse retention)33,34 by focusing on improving the work environment of the unit. Examples of this might include providing continuing education on breastfeeding support for nurses, having nurses engaged in policy creation and decision making impacting clinical care around breastfeeding, management empowering nurses to practice to the fullness of their scope with regards to breastfeeding, and providing nurses with adequate support resources (e.g., a lactation consultant) for challenging cases. The “golden hour” for establishing successful breastfeeding initiation occurs in the hospital, and the hospital stay itself is a short, critical window in which nursing care leads to the discharge of successfully breastfeeding dyads, resulting in improved health outcomes for mother and infant. This is made possible by providing nurses with the organizational support they need, especially a good work environment, to function at the peak of their professional practice.
Table 4:
Effects of Nurse Staffing and the Work Environment on Missed Breastfeeding Care
| Odds Ratios from Models for Missed Breastfeeding Care | ||||||||
|---|---|---|---|---|---|---|---|---|
| Staffing | Work Environment | Education | Staffing x Work Environment | |||||
| Model | OR* | 95% CI† | OR | 95% CI | OR | 95% CI | OR | 95% CI |
| Breastfeeding | ||||||||
| Unadjusted | 1.64 | 1.56 – 1.73 | 1.69 | 1.61–1.77 | 1.54 | 1.03–2.3 | ||
| Adjusted | 1.39 | 1.32–1.47 | 1.65 | 1.58 – 1.74 | 1.17 | 0.83 – 1.65 | ||
| Adjusted with categorical interaction (staffing x work environment) | 1.2 | 0.85 – 1.69 | ||||||
| Good x good | 1.11 | 0.78–1.54 | ||||||
| Good x bad | 0.64 | 0.47–0.86 | ||||||
| Bad x good | 0.79 | 0.61–1.02 | ||||||
| Bad x bad | 1.12 | 0.9–1.4 | ||||||
Unadjusted models are bivariate models which estimate the effect of each nursing characteristic on missed care separately. Adjusted models estimate all three nursing characteristics simultaneously while controlling for hospital characteristics.
OR, odds ratio;
CI stands for confidence interval.
Conflicts of Interest and Source of Funding:
This work was supported by T32NR007104 (Dr. Clark during her postdoctoral fellowship, when this work was begun, and Ms. Mason, currently) and ANCC’s Margretta Madden Styles Credentialing Research Grant.
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