Breastfeeding Practice Lab: a New Approach to Telenurse Education

Abstract

Breastfeeding inquiries represent a significant number of calls to HealthLink BC (HLBC). As Telenurses have indicated a great deal of uncertainty and a degree of disparity in practice, findings from previous research revealed a need to expand Telenurse breastfeeding education and a need for a new education delivery approach. This paper will describe the new education approach, an approach that included development of a practice lab framework and development of the first activity based on this framework – The Breastfeeding Practice Labs.

The labs were set-up with six different 30 minute stations designed for independent or group learning, and created to stimulate critical thinking. Each lab was three hours and could also easily accommodate “drop-ins”. The goal of the Breastfeeding Practice Labs was to enhance Telenurse knowledge, skills, and confidence for assessing breastfeeding calls. Post evaluation results of the pilot labs revealed positive shifts in Telenurse confidence for assessing breastfeeding calls.

Introduction

The goals of the Breastfeeding Practice Labs were to enhance Telenurse knowledge, skills and confidence for assessing breastfeeding calls, and in addition, to create opportunities for critical thinking within the lab. This paper will describe the use of the Practice Lab Framework, new to HealthLink BC (HLBC) Nursing Services, and the evaluation results of the initial “Breastfeeding Practice Labs”, developed based on this framework.

Background

HLBC is the gateway for the public to access non-emergency health information and services in BC and Yukon. The services include: Navigation, Nursing, Dietitian, Pharmacist and HealthLink BC Website. Telenursing at HLBC is available 24 hours a day, 7 days a week. There are approximately 145 Telenurses, all Registered Nurses, working at two sites in the lower mainland as well as a few Nurses who work from home.

Telenurse caller support involves providing symptom assessment and making recommendations on seeking health professional care, discussing home treatment options when appropriate, providing health education and information on procedures, and helping callers locate health services and resources in their community. Telenurses reference evidenced-based information available through the Healthwise Connect database, as well as HLBC-approved books and web-based resources. In relation to breastfeeding, some of the evidenced-based resources Telenurses access includes the Healthwise Connect database, La Leche League Breastfeeding Answer Book, Baby’s Best Chance, BC Healthfiles, Health Canada, and Canadian Pediatric Society. Telenurses will also help callers locate breastfeeding resources in their community, such as Public Health breastfeeding clinic locations and hours.

Registered Nurses come to HLBC with a variety of professional nursing experience. Telenurses are considered “generalists”. Education for Telenurses has used a combination of instructor-led workshops and self-directed learning. Because breastfeeding inquiries represent a significant number of calls to HLBC, orientation training includes a small component on breastfeeding education, covering the types of breastfeeding inquiries, required newborn assessment questions, and navigating through our evidenced-based information resources.

Although Telenurses are provided some Breastfeeding education upon arrival, there has still been long-standing disparity and uncertainty in Telenurse practice associated with breastfeeding calls. Findings from previous research revealed a need to expand Telenurse breastfeeding education to include more in-depth knowledge, skills, and practical experience, within the context of Telenursing, and a need to deliver this education through a new and innovative approach. As a result, a Practice Lab Framework was created and the first educational activity based on this framework was the “Breastfeeding Practice Lab”.

Practice Lab Framework Approach

The Practice Lab Framework was developed using the nursing process, general principles of adult education, and insights and information gleaned from a review of critical thinking literature.

The key premise for using a Practice Lab as a delivery mode for education is that the participants already have previous experience and knowledge of the subject. Before calling an educational activity a “Practice Lab”, an assessment of the subject area and of the audience must first be completed to determine if a Practice Lab format is the appropriate delivery method.

A practice lab encompasses a process of “guided discovery” where the participants engage in critical thinking. The lab creates learning experiences that challenge the learner to think. It is important to have the learning activities based on real life experiences, in keeping with a key principle of education for adults. The lab provides opportunities for participants to work together and to share knowledge and experience. The focus is on learning rather than teaching, and the Educator role is to clarify, summarize, highlight, and update.1

As outlined in the Framework, the goals of a practice lab are to provide opportunities:

1. To enhance knowledge, skills and confidence for assessing or managing a call type.

2. For critical thinking, i.e. self-reflection, creativity, flexibility in thinking, contextual perspective, open-mindedness, inquisitiveness, perseverance, intellectual integrity, intuition, and enhancing competence.2

Breastfeeding Practice Lab Content Development

Once the Practice Lab Framework was developed, the next step was to apply it to breastfeeding Telenurse education. Developing the Breastfeeding Practice Lab content was a collaborative process with Nursing Services, encompassing a wide range of print- and web-based breastfeeding literature and subject matter experts. The approach included:

• Small group discussions with 22 Telenurses to find reality-based examples

• 20 retrospective breastfeeding audio call reviews

• Enrollment in Breastfeeding courses

• Feedback from the Telenurses on the draft education activities

• Literature review

• Research and review of videos and textbooks to enhance our current information resources

• Searching for reliable web-based breastfeeding information for further Telenurse professional development

• Cross-checking all information to be incorporated into the lab with our current approved resources

• Looking for visual materials, a component generally lacking in Telenurse information resources

Breastfeeding Practice Lab Delivery

The three hour lab was designed with six different 30 minute stations, presented with independent or group learning activities. Each station and activity had specific learning objectives and was created to stimulate critical thinking. Participants rotated through the stations and Educator support was available throughout. The stations included:

1. Overview video on breastfeeding with questions and answers3

2. Case scenarios to build on breastfeeding assessment skills4, 5, 6

3. Series of video clips on latch and hand expression with questions and answers7

4. Audio of telehealth breastfeeding calls, followed by questions for reflection6, 8

5. Interactive visual displays with questions and answers 5, 6, 9,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26,

6. Selected articles and web links for further professional development and exploration

The workstations were designed for participants to work in groups of two or three, but easily accommodated those who learn best by working independently. The practice labs were held away from the call center floor however, future intent is for Telenurses to also have access to the lab electronically 24/7 from all workstations.

Eight pilot labs on four days were hosted by the Educators in July 2011, and a total of 32 Telenurses attended the 3-hour sessions. An additional 21 staff from various departments dropped in for an overview of the lab and/or to participate in an individual workstation activity.

For the pilot labs, each participant completed a short pre- and post-evaluation questionnaire, rating confidence in assessing breastfeeding calls. At the finish of the lab, each participant completed an informal evaluation questionnaire which included questions on knowledge, skill, confidence and participants’ appraisal of the effectiveness of each workstation activity.

Key Lessons

Findings from the Breastfeeding Practice Lab pilot evaluations included:

• 76% of Telenurses had previous breastfeeding experience either through the hospital, as a Public Health Nurse, through a breastfeeding course, and/or having breastfed their own children.

• 24% of Telenurses had no previous breastfeeding experience (other than general nursing training program)

• Positive shifts in Telenurse confidence to assess a breastfeeding call after attending the Breastfeeding Practice Lab,

• Workstation activities within the lab were an effective way to learn, and

• Participants commented how the assessment skills seen, heard and discussed in the lab will positively impact the management of their breastfeeding calls.

The following figures are the results from the Breastfeeding Practice Lab evaluations:

Figure 1.

Previous Breastfeeding Experience.

Figure 2.

Confidence to assess breastfeeding calls.

Figure 3.

Confidence to assess for a correct latch during a call.

Figure 4.

Effectiveness of interactive display items

Figure 5.

Effectiveness of the case studies.

Figure 6.

Effectiveness of learning how to recognize a correct sucking/swallowing pattern during breastfeeding.

Figure 7.

Effectiveness of learning when to compress the breast during breastfeeding.

Figure 8.

Effectiveness of listening to an audio call to learn more about breastfeeding assessment.

Figure 9.

Effectiveness of the Question and Answer format to learn about latch, suckling and positioning.

Figure 10.

Participant’s comments on the impact on the management of breastfeeding calls post-lab

Discussion

In the past at HLBC, education activities used instructor-led workshops or individual activities (videos, documents) and some mixed models to introduce new information. Practice Labs are a new methodology for Nursing Services education. The premise of this lab model is that participants are given the opportunity for hands-on practice to build on previous skills, knowledge and experience. By encouraging participants to work together, the practice lab fosters cooperative learning. Guiding principles of critical thinking, principles of adult education, and the nursing process were threaded throughout the Practice Lab Framework and Breastfeeding Practice Lab.

The framework and the breastfeeding lab were developed over a period of three months requiring significant educator resource hours. This included customizing best practice of breastfeeding knowledge to Telenurse practice. Key to the success of the practice lab was speaking with the Telenurses who assisted in contributing to the development of the activities. The activities were based on real experiences, and therefore were meaningful and more engaging. The evaluation results and comments clearly indicate a positive shift in Telenurse confidence for assessing and managing breastfeeding calls. The pilot lab participants provided resounding approval for the various lab activities. The positive results validate the resource hours needed for the lab development.

Positive shifts in confidence provided in this lab is likely related to the content, activities, and time allotted for interaction between participants, and future focus will concentrate on facilitating current breastfeeding practice labs to the rest of the Telenurses, development of a new breastfeeding lab with new content and activities, and providing an electronic-breastfeeding lab for Nurses who may have difficulty attending a lab outside of their work environment/schedule i.e. those who work from home and/or work nightshifts. Future development will include the list of breastfeeding topics Telenurses indicated on the post evaluation that they desire more knowledge and practice to further improve their confidence.

Keeping work station activities short and varied kept engagement high. In addition, it allowed participants the option to attend a 3- hour block or to “drop-in” for a shorter duration. The “drop-in” option, although discussed and planned collaboratively, did not “catch-on” as envisioned. This may have been due to a variety of factors, possibly that this was a new approach, the labs at one site were located on a different floor from the Telenurses, or perhaps further explanation about a “drop-in” approach was needed. Quite possibly the “drop-in” approach is a quantum change versus a minor change to the current model of scheduling participants who work in a 24/7 operation.

Conclusion

Findings from previous research revealed a need to expand Telenurse breastfeeding education and a need for a new education delivery approach. This paper described the new education approach, an approach that included development of a practice lab framework and development of the first activity based on this framework – The Breastfeeding Practice Labs. Evaluations indicated a positive shift in Telenurse confidence to assess breastfeeding calls, and responses were positive for this new concept and method of learning in a 24/7 call centre environment.