“Motivate to Lactate”: Utilizing Motivational Interviewing to Improve Breastfeeding Rates

Abstract

Promotion of exclusive breastfeeding is a nationwide initiative that has been incorporated into health-care facilities. Staff educators for women's and children's services should consider using motivational interviewing techniques to engage patients in a conversation about breastfeeding. Motivational interviewing has been linked with many positive outcomes in patient-centered care. This research article reveals the staffs' positive perception of adopting these techniques into daily practice and their thoughts on the potential patient outcomes.

INTRODUCTION

With exclusive breastfeeding being one of the top sources for infant nutrition, its promotion has become a nationwide initiative. In 2011, the U.S. Surgeon General implemented a plan to ensure the promotion of breastfeeding education and support throughout health-care facilities and communities (Centers for Disease Control and Prevention [CDC], 2013). According to the World Health Organization (WHO), breastfeeding should be initiated within the first hour of life (WHO, n.d.). The American Academy of Pediatrics (AAP, 2012) recommends that infants are exclusively breastfed from birth to at least 6 months of life. There is a positive relationship between exclusively breastfed infants and a decreased risk for infection of the ears, respiratory tract, and gastrointestinal tract (CDC, 2013). Infants are also at less risk for developing obesity, diabetes, and sudden infant death syndrome (CDC, 2013). Exclusive breastfeeding has also been linked with positive neurodevelopmental outcomes as measured by higher intelligence scores in infants who were breastfed versus infants who were fed with an artificial nutrition supplement (AAP, 2012).

PROBLEM STATEMENT

At a small, fewer than 400 bed hospital in the southeast region of the United States, the obstetrical and newborn services units implemented an initiative in January of 2016 to include a greater than or equal to 50% exclusive breastfeeding rate of infants born at term gestation. At that time, the exclusive breastfeeding rates at discharge had been as low as 22%. Previous initiatives that have been made to promote exclusive breastfeeding include the implementation of a full time lactation consultant (LC), didactic and clinical education for current and onboarding staff, offering expectant mothers a breastfeeding course, and promotion of rooming in with infant during hospital stay. While there has been a significant improvement in exclusive breastfeeding rates, reaching as high as 42%, there remains room for improvement in order to reach a goal of greater than or equal to 50%.

Mothers who are unsure about breastfeeding are usually successful in exclusively breastfeeding when they receive adequate education and support from staff (The American Academy of Pediatrics & The American College of Obstetricians and Gynecologists [AAP & ACOG], 2012). Current practice during admission is to determine if the patient is going to breastfeed, formula feed, or undecided. While the “nurse to patient ratio” in labor and birth is 1:1, it is not current practice for the nurses and staff to routinely engage the patient in a discussion to determine the patient's perception of breastfeeding. Instead, the patient's response is documented, and staff continues with additional admission questions. In an effort to further engage the patients, there is a significant need to utilize motivational interview techniques to encourage this discussion between staff members and the patients. This will allow the patient to express feelings toward breastfeeding and allow the nurse to educate them on the benefits that breastfeeding may offer.

PURPOSE

The purpose of this pilot project is to evaluate the effectiveness of a video learning module demonstrating how to use motivational interview techniques to engage mothers in a conversation about exclusive breastfeeding. This study is aimed at gathering data that shows the positive outcomes of utilizing these techniques and to present the evidence in such a way that health-care facilities will adopt this practice to enhance the communication effectiveness between staff and patients.

LITERATURE REVIEW

Breastfeeding is associated with a multitude of maternal and neonatal health benefits (DiFrisco et al., 2011). In an effort to promote wellness in newborns and postpartum mothers, the CDC (2011) made breastfeeding a national goal. It is estimated that the United States will lose 13 billion dollars per year when breastfeeding goals are not met (DiFrisco et al., 2011). There is a dire need for nursing support and lactation education for perinatal women to ensure these goals are accomplished (Tedder, 2015). With appropriate education, nurses and health care providers can play an important role in the success of breastfeeding mothers (Spatz, 2010).

While there is a plethora of literature regarding breastfeeding support, an analysis of current literature revealed there is little research related to utilizing motivational interview techniques to engage patients in a conversation about breastfeeding. The literature review information was obtained through the use of Medline (EBSCO), JSTOR, and Wiley Online Library databases. Reputable sources, current dates with published years ranging from 2008 to 2015, language, peer reviews, and keywords, such as breastfeeding, motivation, nurses, and support, were applied in the search.

Adoption of National Recommendations

The WHO and United Nations Children's Fund (UNICEF) teamed up to create 10 steps that would ensure successful breastfeeding. Among these 10 steps, several refer to teaching the patient about the benefits and techniques of breastfeeding and the staff's competency in breastfeeding knowledge (CDC, 2011). A study conducted by the CDC (2011), revealed that a little over 89% of facilities educated women on breastfeeding, yet fewer than 27% supported the mother during breastfeeding. This study concluded that the majority of hospital facilities that provide maternal services do not adhere to the national recommendations (CDC, 2011). It is important to establish maternal breastfeeding support into standard practice (CDC, 2008). Utilizing these educational practices for support can ultimately improve overall health for the mother and infant (CDC, 2011).

Staff Education and Perception of Breastfeeding

Staff knowledge about breastfeeding is essential in promoting exclusive breastfeeding rates. Lack of staff education or misguided information can result in negative breastfeeding outcomes (Bernaix, Beaman, Schmidt, Harris, & Miller, 2010). Bernaix et al. (2010) conducted a research study to review the effects of educational programs meant to improve the staff's attitudes, knowledge, and supportive intentions toward breastfeeding. After completion of an informational breastfeeding self-study module, a convenience sample, comprised of 240 registered nurses, reported that when given adequate education, the staff felt more knowledgeable about breastfeeding, their attitudes about breastfeeding improved, and there was an increase in intent to encourage mothers (Bernaix et al., 2010).

Mother's Choice

The health-care provider's role is to support the mother's decision in regard to breastfeeding (Waggoner, 2011, p. 158). It is important to remember that despite national guidelines, mothers have a choice in their feeding preference. According to Waggoner (2011), health-care providers can inadvertently cause anxiety for the patient when reviewing their feeding preferences, but with the implementation of LCs and educated nursing staff, this anxiety is reduced (Waggoner, 2011, p. 156). Health-care providers can significantly influence confidence during breastfeeding with support and education (Hinic, 2016). Breastfeeding support should be tailored to the specific patient setting. Anticipated maternal complications should be reviewed, and mothers should be given an opportunity to ask questions and engage in a discussion about breastfeeding to promote maternal confidence and breastfeeding exclusivity (Renfrew, McCormick, Wade, Quinn, & Dowswell, 2012).

Motivational Nursing Support

Staff education and adoption of national practices to improve breastfeeding rates are crucial to the mother's success rate of breastfeeding. Elliott-Rudder, Pilotto, McIntyre, and Ramanathan (2013) conducted a randomized controlled trial research study to review the correlation of utilizing motivational interviewing with successful breastfeeding. The use of these motivational interview techniques increased exclusive breastfeeding rates for up to 4 months after birth. Elliott-Rudder et al. (2013) demonstrated that these empathetic person-centered techniques allowed the health-care providers to further inquire about the mother's feelings toward breastfeeding, perceived barriers, knowledge of breastfeeding benefits, and anticipated breastfeeding support. At a return rate of 34%, mailed surveys proved to be a study limitation as it is speculated that many rural women may not have responded (Elliott-Rudder et al., 2013). Motivational interviewing can be used as a person/patient-centered supportive approach to communicate with mothers about exclusive breastfeeding and increase the probability of sustaining breastfeeding throughout early stages of infancy (Elliott-Rudder et al., 2013). The use of open-ended questions, statements of affirmation about the mother's choice to breastfeed, and active listening are key elements of motivational interviewing.

Motivational interviewing during patient interaction has been proven beneficial throughout other studies related to health-care issues. Song, Xu, and Sun (2014) concluded that motivationally interviewed patients were better at managing their diabetes over the control group. Educating nurses about using motivational interview techniques during patient interaction may invoke a positive influence on exclusive breastfeeding rates (Bernaix et al., 2010). While there is limited information on educating nurses about using motivational interviewing with perinatal patients, the current studies reveal positive outcomes with exclusive breastfeeding (Elliott-Rudder et al., 2013).

METHODOLOGY

This pilot study utilized a non-experimental descriptive methodology to analyze data. The women's and children's staff at a community hospital in the southeastern portion of the United States were given access to a video learning module that discussed the incorporation of motivational interviewing into clinical practice. Access to this video for future reference was made available via disc and through a link on the facility's homepage. This video utilized roleplaying to define how motivational interviewing techniques such as asking permission, open-ended questioning, reflective listening, normalizing, and feedback could help engage patients in a conversation about breastfeeding, thus allowing the patients to make a true informed decision about their feeding preference (Sobell & Sobell, 2008). These techniques became conversation tools that guided the nurse in effective communication with the patient. Initially, the video described how to utilize open-ended questioning such as, “What are your thoughts on breastfeeding versus bottle feeding?” Next, the nurse asked permission to discuss breastfeeding by asking, “Do you mind if we talk about breastfeeding?” Reflective listening was demonstrated in the video by statements such as, “It sounds like you know someone who has breastfed, what are your thoughts on breastfeeding? Tell me more about what you know in regards to breastfeeding.” Utilizing this tool affirmed the technique of active listening during the conversation. Lastly, feedback was elicited by using statements such as, “Since you are interested in learning more about breastfeeding, I will schedule a time for the Lactation Consultant to meet with you.” Breaking through the communication barrier with these motivational techniques offers segue into competent person-centered care.

A Qualtrics survey questionnaire, containing open-ended and multiple-choice questions, was then given to the women's and children's nursing staff. The questions were developed to gain an understanding of the staffs' perspective of the effectiveness of the video and how applying these motivational interview techniques in a clinical setting would benefit the patient. Perceived time constraints at the bedside, the staffs' attitude toward breastfeeding versus bottle feeding, and their ideas on what can be done differently to improve breastfeeding rates were also evaluated. An electronic survey was used for quick access for the staff, ease of typing answers to open-ended questions as opposed to handwriting them, and to improve response times and rates (Kwak & Radler, 2002).

Participant Recruitment

Participants were recruited via an Institutional Review Board (IRB) approved e-mail that outlined the pilot study. This e-mail contained both a QR code and link to the survey. The survey was opened for 2 weeks and participation reminder e-mails were sent biweekly.

Considerations

Participant involvement in the study was voluntary and an option to withdraw participation without consequence was given. Their employment status at the study location was not in any way affected by the participation or lack thereof during this study. Answers to survey questions were utilized for the study only and had no merit toward current employment status. Data was only accessible per the principle investigator and the professor.

THEORETICAL FRAMEWORK

Peplau's Interpersonal Theory of Nursing Practice, developed in 1952, was the theoretical framework applied to this pilot study. Peplau's four stages—orientation, identification, exploitation, and resolution—were utilized to develop each stage of the study.

During the orientation phase of the study, a learning video module was created that addressed the identified patient need, which was how to initiate a conversation about preferred feeding preferences (Ramesh, 2013). Throughout the video module, the identification phase revealed how the patient and nurse developed goals related to the need. The patients will rely on expert opinions and support during the exploitation phase (Ramesh, 2013). This study will suggest that staff knowledge and support from the LC can improve exclusive breastfeeding rates. The exploitation phase was utilized in the video to show how educated staff can directly affect the breastfeeding rates. During the resolution phase of the video, the nurse and patient finalize and accomplish the goals set forth. The nurse can assume many roles throughout these phases such as the counselor, leader, resource person, and educator (Ramesh, 2013).

LEGAL/ETHICAL CONSIDERATIONS

IRB approval was obtained from the university and from the facility in which the pilot study was conducted. A participation e-mail was sent to potential subjects asking them to participate in the study. Due to the author's position in leadership, every effort was made to ensure that the participants understood that their participation, or lack thereof, would not affect their status as an employee. Any personal responses that could be linked to the identity of the participant were maintained as confidential and only available to the research team (Fouka & Mantzorou, 2011). Participants' age verification was obtained in the informed consent.

RESULTS

Participant Characteristics

With a maximum sample size of 76 potential participants from the staff of the women's and children's services, the minimum ideal sample size was 64; however, a total of only 56 participants accepted and completed the survey with two additional participants who initiated but did not complete the survey. The sample had a diverse level of experience with subjects having less than 1 year of experience to more than 16 years of experience. Of the three departments—labor and birth, nursery, and postpartum—labor and birth was most represented in the study. It is assumed that there was more representation from labor and birth because there was a higher number of employees in that specific area rather than nursery and postpartum. Seventy-four percent of participants had completed at least a 4-year degree or higher.

Analysis

The staff of the women's and children's services viewed an educational role-playing video that discussed the use of motivational interview techniques to guide staff on how to engage patients in a conversation about exclusive breastfeeding. Ninety-five percent of the participants stated that, after watching the video, they felt they were either very or extremely knowledgeable about how to implement those techniques into daily practice. The majority of participants had confidence that the techniques would be effective in continuing to promote exclusive breastfeeding. Over 56% felt that, after using motivational interview techniques, patients would be more responsive to breastfeeding.

Time constraints at the bedside due to other nursing/staff obligations proposed a potential issue with implementing these techniques into practice; however, seventy-three percent of the participants felt that they would have sufficient time for the implementation. More than 50% of participants felt they would continue to incorporate these techniques in practice.

Suggestions for Improvement

The participants were questioned on what could be done differently to promote breastfeeding in addition to implementing motivational interviewing. Their suggestions for improvement included support, increased knowledge, more time at the bedside, and increased exposure. To correlate with the implementation of motivational interviewing, 15 participants suggested improving the availability of the LC, adding more LCs or breastfeeding coaches to the staff, and utilizing the consultant as an admission engagement nurse to integrate the motivational interview techniques during the admission process. Eighteen participants suggested more education for the staff and the patients. Concerns with staff competency seemed to be the trend throughout the obtained data and suggestions were made to include staff educational courses on breastfeeding promotion, practices, techniques, and problem solving. Updated educational materials and postnatal breastfeeding classes were suggested for the patients. While education and lactation support are important, 11 participants concluded that even though nurse to patient ratios were 1:1, more time at the bedside and additional staffing were needed to implement and promote exclusive breastfeeding. Five of the remainder participants suggested increased exposure by implementing breastfeeding education and patient engagement through perinatal obstetrical office visits and educational classes.

DISCUSSION

According to the American Nurses Association (2014), over 46% of registered nurses, in urban areas of the United States, hold at least a 4-year bachelor's degree. In contrast, a significant finding of this study was that approximately 65% of the participants held at least a 4-year degree, which is almost 20% higher than the national average. Thirty-two percent of the participants had over 16 years of nursing experience. This finding could be a result of the lower turnover rates on the maternity and pediatric units as compared to other specialty areas such as the emergency department, behavioral health, and medical/surgical units (NSI Nursing Solutions, 2016). It was anticipated that the results of this study would reveal the staff's willingness to adopt motivational interviewing into practice and to disclose their thoughts on the outcomes of using these techniques. The results of the survey revealed that the staff feel that they can better engage patients in a conversation about breastfeeding when they are properly educated, enough time is allotted at the bedside, support is provided from the LC, and additional information is implemented prior to admission. After watching the video module on using motivational interview techniques, the participants of this study felt that they were more knowledgeable about how to promote breastfeeding and how to provide accurate information so patients can make a true informed decision. Sixty-two percent of staff felt that they would most likely continue to implement these techniques into practice. Utilizing these tools can evoke an affirmative change in patient care and patient behavior (Rollnick, Miller, & Butler, 2008).

Limitations

The sample size was small and limited to only the staff of the women's and children's services. The goal of a sample size of 64 was not reached and staff termination and/or resignation was not anticipated as a limitation. Modality of survey delivery was via e-mail correspondence in which factors such as delivery to the clutter or spam folder was not anticipated. The survey answers were subjective to the sample population's own views and beliefs, thus creating a potential weakness as a result that all beliefs will not necessarily be the same.

Future Implications

Future research should include expansion of motivational interviewing education to the staff in the obstetrician offices, as this will serve to begin patient education from the initial prenatal visit. Furthermore, surveying the patients in the postpartum stage would give an insight to the effectiveness from the patient's perspective. In addition to using motivational interview techniques by the staff, the availability of LCs on both day and night shifts will continue to support mothers on their exclusive breastfeeding journey.

CONCLUSION

The participants were receptive to adopting the new techniques to help promote exclusive breastfeeding and many claimed that they would continue to utilize motivational interview techniques for all future patient interactions. Suggestions were made to implement a breastfeeding admission consultant to utilize motivational interviewing when the patient initially arrives to the labor and birthunit. The staff felt that with more education, support, and the use of motivational interviewing techniques that the patients would most likely initiate and continue exclusive breastfeeding. Exclusive breastfeeding rates increased 7% after just 1 month of utilizing motivational interviewing techniques. These study findings are a key insight to the staff's perspective on applying motivational interviewing to promote exclusive breastfeeding and could positively contribute to the health of the patients and their babies.

Biographies

MELISSA DEFOOR is a lecturer of Nursing at the Anderson College of Nursing and Health Professions at the University of North Alabama. Ms. DeFoor is also an OB Educator, a Certified Labor Doula, and Lamaze Certified Childbirth Educator.

WENDY DARBY is a Professor of Nursing in the Anderson College of Nursing and Health Professions at the University of North Alabama. Dr. Darby is a Certified Nurse Educator and Family Nurse Practitioner.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.