An Exploratory Study of the Associations Between the Hospital Work Environment and Implementation of Baby-Friendly Hospital Policy

Abstract

A descriptive, cross-sectional study design was used to explore the relationships between the hospital work environment and implementation of the Baby-Friendly USA Ten Steps Policy in an urban hospital. Nurses reported the degree to which the Ten Steps policy was implemented, perceptions of the unit work environment using the Practice Environment Scale of the Nursing Work Index (PES-NWI), and self-efficacy related to the implementation of the policy. Results suggest that the work environment and the implementation of breastfeeding policy have separate and independent effects on nurse self-efficacy. Robust nursing leadership focused on education and skill development for clinicians, and focused on post-hospital care for patients and families are important contributory factors to successful breastfeeding policy implementation.

INTRODUCTION

Rapid adoption of hospital-wide breastfeeding policy has been a strategy to improve breastfeeding outcomes across the United States for over two decades. Originating from the World Health Organization (WHO) Ten Steps Baby-Friendly Hospital Initiative, the Baby-Friendly USA Ten Steps (Baby-Friendly) policy has been the gold standard for this shift in hospital-based breastfeeding care (WHO, 1989; Baby-Friendly USA, 2021). Since 1996, when the first hospital in the United States was designated Baby-Friendly, more than 6.5 million babies have been born in more than 600 Baby-Friendly designated birth facilities (e.g., hospitals and birth centers) (Baby-Friendly USA, 2021). Positive breastfeeding outcomes have been associated with this policy including increased national breastfeeding initiation, exclusivity, and duration rates (Baby-Friendly USA, 2021; Centers for Disease Control and Prevention [CDC], 2019). Although national breastfeeding initiation rates are the highest ever recorded (83.2%), breastfeeding swiftly wanes at 3 months postpartum dropping to 46.9%, and exclusive breastfeeding diminishes to only 24.9% at 6 months after hospital discharge (CDC, 2019). Few quantitative studies have described the link between the work environment and implementation of breastfeeding policy.

BACKGROUND

Hospital leaders recognize that significant organizational investment is required to successfully restructure clinical processes, invoke culture change, and provide adequate education to clinicians and staff in order to implement breastfeeding policy to increase duration rates of breastfeeding (Cassar et al., 2020; Wouk et al., 2017; Yang et al., 2018). The potential transformational institutional change resulting from implementation of health policy relies on the participation and leadership from self-empowered and self-efficacious nursing staff which flourishes within better hospital work environments and is associated with improved quality of care and patient outcomes (Melchionda et al., 2019; Melendez et al., 2019; Wallenborn et al., 2018). These changes are influenced by deep cultural, economic, and social determinants that are distinct to the communities where the birth facility is located (Segura-Pérez et al., 2021).

This paper continues a line inquiry initiated two decades ago with a study by co-investigator Dr. Crivelli-Kovach who developed the Delaware Valley Breastfeeding Questionnaire (Crivelli-Kovach & Chung, 2011; Kovach, 1996). These studies identified the link between hospitals and implementation of breastfeeding policy in hospitals located in Philadelphia and in the surrounding counties. The study methodology contributed to the early development of the national Centers for Disease Control institutional measure of Maternity Practices in Infant Nutrition and Care (mPINC) score (Centers for Disease Control and Prevention [CDC], n.d.). This early work identified improved breastfeeding education of health care professionals and post-hospital discharge support as areas that required improvement in order to successfully implement breastfeeding policy. The purpose of this exploratory study was to revisit these findings and explore the perceptions of nurses related to their own self-efficacy, perceptions of the work environment, and the degree of implementation of the Ten Steps breastfeeding policy to provide an updated snapshot of practices in an urban hospital in Philadelphia.

METHODS

Design

A descriptive, cross-sectional study design was used in this exploratory study at a single urban hospital during Spring 2017 to explore the relationships between the work environment in the Women and Children’s Health Services department related to implementation of breastfeeding policy.

Data Collection

A purposive sampling approach was used. The sample (n = 55) was recruited from the registered nurse staff (N = 108) employed in the Women and Children’s Services division, comprised of four units Labor and Delivery (LD), Newborn Nursery (NN), Postpartum (PP), or the Neonatal Intensive Care Unit (NICU) within a 548-bed tertiary-care teaching hospital in Philadelphia. At the time of this study, the hospital was actively pursuing both Magnet and Baby-Friendly USA designations.

Institutional Review Board approval was obtained from both the hospital and the author’s university. A 31-question modified form of the Delaware Valley Hospital Breastfeeding Survey was used to measure the extent to which the institution implemented the Baby-Friendly recommendations. The work environment was measured using the Practice Environment Scale of the Nursing Work Index (PES). The PES has been successfully used to measure both nurse outcomes related to perinatal and postpartum hospital care (Hallowell et al., 2016). Finally, the ability of nurses to implement breastfeeding policy through measurement of nurses’ self-efficacy was explored (Melchionda et al., 2019; Melendez et al., 2019).

Instruments

Delaware Valley Hospital Breastfeeding Questionnaire (Ten Steps)

The Delaware Valley Hospital Breastfeeding Questionnaire was last deployed in 2009 to measure the degree to which the maternity services identified in twenty-five hospitals in metropolitan Philadelphia (e.g. Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) had implemented the Ten Steps (Crivelli-Kovach & Chung, 2011). Co-investigator, Dr. Crivelli-Kovach guided the use of the instrument she developed. The original studies measured an aggregate score for each hospital wherein interdisciplinary group interviews were conducted and are published elsewhere (Crivelli-Kovach & Chung, 2011; Kovach, 1996, 2002). The current study occurs 8-years since the questionnaire was last deployed in its original form in 2009. The current iteration explored the use of the questionnaire at the nurse level and focused on the responses of nurses as key implementers of breastfeeding policy. Wording of questions was adapted to collect individual nurse responses which were obtained through an online portal. Several adaptations were made to update the wording of the questions to reflect current clinical practices. For example, a change had to be made regarding whether nurses were able to access the institution’s paper policy. Many facilities including the one studied had long digitized their policy manuals, making these available only online through the hospital-intranet portal.

The current study measured individual nurse perceptions regarding implementation of the Ten Steps. Respondents to the questionnaire indicated whether each of the Ten Steps was implemented within their clinical practice. Items were summed and averaged to create a single score for each step. Four-point Likert items categorized as “All/Most of the time, Often, Sometimes, Rarely/If ever” were transformed to a 3-point scale where the positive responses “All/Most of the time and “Often” were placed in a single category. Hence, each score for each of the Ten Steps was recorded as “Yes, Sometimes, No”. The total Ten Steps score was calculated from the sum of the mean scores to create a score out of ten. This is the first use of the tool at the nurse level, and the sample was small. The Chronbach’s Alpha was 0.62 which cannot be compared to prior iterations of the questionnaire as none were calculated in the original study due to the small number of hospital participants (Kovach, 1996).

Practice Environment Scale of the Nurse Work Index (PES)

The PES is a publicly available measure with a predictive and discriminant validity and has been utilized to describe phenomenon in a number of specific practice environments including the neonatal intensive care unit and labor and delivery (Hallowell et al., 2016). The PES is a 31-item, 4-point Likert–type instrument intended to measure the degree to which certain aspects of a professional work environment are present in a nurse’s workplace (Lake et al., 2010). The PES is categorized into five (subscales) work environment domains with a total of 31 items: Nurse Participation in hospital affairs (9 items), nursing foundations for quality care (10 items), Nurse Manager Ability, leadership and support of nurses (5 items), Staffing and Resource Adequacy (4 items), and Collegial Nurse-Physician Relations (3 items). The internal consistency of the subscales has been reported to range from 0.71 to 0.84 (Lake et al., 2010). The PES was used to measure whether aspects of the perinatal professional work environment were present in the nurse’s current job (Lake et al., 2010). The responses are listed as strongly disagree, disagree, agree and strongly agree. A score of 2.5 is the midpoint between agree and disagree, and a score of 3 or greater indicates agreement that the element is present in the job (Lake et al., 2010). We determined comparable internal consistency of the scale using Crohnbach’s alpha for each of the five subscales (0.74–0.84) and for the composite of the full PES score (0.93). The mean score for each of the subscale measures and the mean value of the five subscale scores was calculated to determine the overall PES composite score.

Breastfeeding Support Self-Efficacy Scale (SE)

This is the first known use of a modified self-efficacy scale to assess health care provider confidence in clinical application and knowledge of breastfeeding policy and skill. Breastfeeding is an evidence-based intervention and implementation of breastfeeding policy requires the necessary skills for successful implementation. This study explores the concept of self-efficacy as a measure of education and clinical skills related to the support of breastfeeding. The Generalized Self Efficacy (GSE) scale, a publicly available tool, was adapted to measure the domain specific delivery of clinical breastfeeding support provided by nurses. A scale measuring self-efficacy among midwifery students administering breastfeeding support has been developed, however, strong cultural influences on tool development prevented generalizability and use among nurses and health systems in the U.S. (Melchionda et al., 2019). Therefore, self-efficacy was explored as a concept to assess clinical confidence related to implementation of breastfeeding policy using an adapted form of the GSE. The ten items in this scale have a reported internal reliability using Cronbach’s alphas between 0.76 and 0.90. Alpha testing using the modified items had a Crohnbach’s alpha of 0.82.

Participants were asked to indicate if the statement “I feel confident in my abilities to” was indicative of particular clinical behaviors related to supporting a breastfeeding patient. Respondents rated each of the 10 items from 1–4 to indicate if their ability to support a breastfeeding patient was “not true at all, hardly true, somewhat true, or extremely true.” The SE score consisted of ten items and the total score ranged from 10 and 40, with a higher score indicating greater individual self-efficacy.

Individual nurse participation was voluntary. Consent for participation was obtained through completion of a secure, anonymous, confidential, web-based survey. Inclusion criteria comprised of: Full-time employment in one of the four Women’s and Children’s Services Division units; a completed work shift in the previous 3 months; ability to read and communicate in English; and the ability to follow directions using a computer and the internet. Respondents were de-identified through the use of a unit level password distributed by the nurse manager in order to ensure confidentiality and restrict access to the survey. Respondents were encouraged to complete the survey in one 15–20-minute sitting. Participants were given the opportunity to enter a raffle drawing for a 2017 Apple iPad Air as incentive for participation.

Data Analysis

Descriptive statistics were used to identify percentages, means, and standard deviations to describe the nurse sample, implementation of the Ten Steps, the PES scores, and the SE scores. Cases with missing data were omitted and remaining data were analyzed. In addition to nurse level analysis, unit level SE scores were determined for each of the four practice settings in the Women and Children’s Division. Bivariate correlations were then used to examine the independent variables related to nurses’ characteristics (education level, years of experience, and work setting), the PES subscales and composite score, the Ten Steps, and the dependent variable the nurses total SE score. Ordinary least squares (OLS) regression was used to explore associations between SE and the independent variables. Continuous variables were standardized for ease of interpretation. The statistical significance level was p < .05 for a 2-tailed test. Adjusted R-squared values were used to describe the variability explained by each model. Analysis was conducted using STATA (StataCorp., 2019).

RESULTS

Sample Characteristics

The unit staff consisted of 108 nurses, 65 nurses enrolled in the study, and a total sample of 55 completed the survey (85%) (Table 1). The majority of respondents were registered nurses (91%) and nurse managers (7%). Two-thirds of the sample possessed a BSN degree (62%) and one in five participants had a master’s degree or higher (22%). More than half the sample (60%) had five or more years of nursing experience. Registered Nurses reported a variety of professional certifications in obstetrics and gynecology, maternity-newborn care, neonatal intensive care, Certified Childbirth Educator, and Pediatrics. A third of nurses (34%) possessed lactation specific certification such as International Board-Certified Lactation Consultant (IBCLC), Certified Lactation Consultant (CLC) or Certified Breastfeeding Consultant (CBC).

TABLE 1. Sample Characteristics (N = 55).

	Value (%)a
Nurse Characteristics, n = 45
Age, mean (SD)	42 (15)
24–34	18 (38)
35–44	6 (8)
45–54	12 (25)
55–64	7 (12)
65+	3 (6)
Gender, n = 45
Female	44 (80)
Male	1 (2)
Race, n = 55
African American	9 (16)
Native American	0
Asian	2 (4)
Hispanic	3 (6)
Mixed Race	1 (2)
Native Hawaiian or Pacific  Islander	1 (2)
White Non-Hispanic	27 (49)
Other	2 (4)
Highest Level of Education, n = 45
< High School	0
High School/GED	0
Some College	3 (7)
2-year AD	4 (9)
4-year BSN	28 (62)
MSN or higher	10 (22)
Clinical Role, n = 55
RN	50 (91)
IBCLC	1 (2)
Nurse Manager	4 (7)
Work Status, n = 54
Full Time	46 (86)
Part Time	5 (9)
Per Diem	3 (6)
Work Setting, n = 53
Postpartum	17 (32)
Newborn Nursery	3 (6)
NICU	18 (34)
Labor and Delivery	15 (28)
Years of Experience, n = 45
<1 year	3 (7)
1–<5 years	12 (20)
5–<10 years	10 (22)
10–<20 years	7 (16)
20 years or more	16 (36)
Professional Certifications, n = 55
None	12 (22)
RNC-OB	7 (13)
RNC-MNN	2 (4)
RNC-NIC	9 (15)
IBCLC	2 (4)
CLC/CBC (9)	17 (29)
Certified Childbirth Educator	1 (1)
Certified Pediatric Nurse	1 (1)

^aValues are number (%) unless otherwise indicated. Percentages may not sum to 100 due to missing values.

Delaware Valley Hospital Breastfeeding Ten Steps Questionnaire Analysis

Nurses in this study reported the degree to which they implemented each of the Ten Steps in their clinical practice (Table 2). Step 4 “Help mothers initiate breastfeeding within one hour of birth” (31%) and Step 10 “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center” (62%) were policy steps nurses implemented the least.

TABLE 2. Nurse Reported Degree of Implementation of the Breastfeeding USA Ten Steps Policy.

	N	Yes	Sometimes	No
Step 1 - Have a written breastfeeding policy that is routinely communicated to all health care staff.	47	25 (53)	14 (30)	8 (17)
Step 2 - Train all health care staff in the skills necessary to implement this policy.	55	38 (69)	17 (31)	0
Step 3 - Inform all pregnant women about the benefits and management of breastfeeding.	49	40 (100)	0	0
Step 4 - Help mothers initiate breastfeeding within one hour of birth.	49	31 (63)	9 (19)	15 (31)
Step 5 - Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.	48	42 (88)	2 (10)	4 (2)
Step 6 - Give infants no food or drink other than breast-milk, unless medically indicated.	47	32 (68)	10 (21)	5 (11)
Step 7 - Practice rooming in – allow mothers and infants to remain together 24 hours a day.	47	37 (79)	1 (2)	9 (19)
Step 8 - Encourage breastfeeding on demand.	47	43 (91)	0	4 (9)
Step 9 - Give no pacifiers or artificial nipples to breastfeeding infants.	47	27 (57)	6 (13)	14 (30)
Step 10 - Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center.	55	18 (33)	3 (5)	34 (62)

Note. The Ten Steps score consisted of more than one item per step: Step 1 (6 items), Step 2 (1 item), Step 3 (1 item), Step 4 (3 items), Step 5 (6 items), Step 6 (1 item), Step 7 (1 item), Step 9 (2 items), and Step 10 (13 items).

Practice Environment Scale of the Nursing Work Index Analysis

Examination of the mean PES scores for each of the five subscales: Nurse Participation in Hospital Affairs, Nursing Foundations for Quality Care, Nurse Manager Ability, Leadership and Support of Nurses, Staffing and Resource Adequacy, and Collegial Nurse-Physician Relations was conducted. The subscale Nurse manager ability, leadership and support was ranked highly (3.36), followed by quality of care rooted in nursing foundations (3.34). The overall mean of PES was highly rated (3.27). Nursing characteristics (e.g., level of education (e.g., AD, BSN, MSN, or higher) and years of experience as a nurse (e.g., less than 5 years, 5 < 20 years, and >20 years) were not significantly associated with SE scores.

Breastfeeding Support Self-Efficacy Score Analysis

Total SE scores were determined for each of the practice settings in the Women and Children’s Division (LD, PP, NICU, and NN). The mean total SE score for the sample was high (M = 35, SD = 3.6). When viewed by setting, respondents in the NN reported the highest total self-efficacy score (M =39, SD = 1.2), followed by the PP unit (M = 36, SD = 3.3), NICU (M = 35.4, SD = 4.4), and LD (M = 34.7, SD = 3.1). Across all settings self-efficacy scores were highest with regard to their ability to “Provide accurate evidenced-based breastfeeding information to families” (M = 3.81, SD = 0.45). Scores reporting the nurse’s ability to “Resolve an unfamiliar breastfeeding issue with a mother and infant” were lower for the total sample (M = 3.17, SD = 0.60), in the NICU, and LD.

The SE score was modestly and significantly correlated with all of the individual subscales of the PES as well as the composite score. Self-efficacy was most highly correlated with the subscale “Nursing Foundations for quality care” (r = 0.51, p = .00) and significantly correlated with reported implementation of several of the Ten Steps items as well as with the overall Ten Steps Score. Notably, Step 5 “Showing mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants” (r = 0.40, p < .01) and Step 10 “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center” (r = 0.32, p < .03) were significantly correlated. The SE correlation with the total Ten Steps score was significant (r = 0.36, p < .01).

The significant relationships between the Ten Steps score and the independent variables SE and the PES were examined using OLS regression models. In bivariate OLS regression analysis, a 1 SD increase in the total PES score (0.4) was associated with a 1.7-point increase in the total SE score (p < .01). The PES subscale “Nursing Foundations for quality care” was examined to explore the strong correlation to self-efficacy. A 1 SD increase in the “Nursing Foundations for quality care” subscale (0.44) was associated with a 4.3 increase in the total SE score (p < .01).

A 1 SD increase of the total Ten Step score (1.4) was associated with a 1.06 increase in the total SE score (p < .05). In a multivariate model where SE was examined with the Ten Steps, the addition of the PES increased the explained variance from 0.06 to 0.26. In this jointly estimated model, the coefficient for Ten Steps was slightly reduced (B = 1.02, p < .05). The PES relationship remained stable with an associated increase of 1.66 on the SE (p < .01). This suggests that: 1) the PES and Ten Steps have separate and independent effects on SE score, and 2) that accounting for PES modestly attenuates the effect of the Ten Steps on SE.

DISCUSSION

Our findings suggest that nurses’ perceptions of self-efficacy related to breastfeeding policy are cultivated in a work environment where a clear philosophy of nursing underlies high-quality, evidence-based, and patient-centered hospital care. Although two thirds (62%) of the nurses in the study sample held a baccalaureate degree or higher, more than 70% of nurses reported a lack of undergraduate didactic and clinical training in human lactation. This finding validates a longstanding gap in undergraduate knowledge across the health professions regarding basic knowledge, assessment, and diagnosis of the human lactating breast and clinical guidance for breastfeeding women (Cassar et al., 2020; Wouk et al., 2017; Yang et al., 2018). Nurse education has been associated with a number of positive patient outcomes including a higher proportion of breastfeeding infants in the NICU (Gomez-Pomar & Blubaugh, 2018).

Our findings suggest many professional nurses receive initial educational and skill-based experiences related to human lactation only once they have entered professional practice. Our data validate findings from other studies that highlight the inadequacy of preparation for health care providers who work with mothers and newborn infants, especially nurses associated to both didactic and clinical experiences related to breastfeeding and lactation (Cassar et al., 2020; Grossniklaus et al., 2017; Yang et al., 2018). Implementation of Ten Steps policy creates an opportunity for a hospital to provide knowledge and skills training nursing staff specific to lactation services. The availability of lactation support is limited, there are 4.57 CLCs and 3.79 IBCLCs per 1,000 live births in the United States, within Pennsylvania the rate is similarly modest wherein only 4.42 CLCs per 1,000 births and 1.05 IBCLCs per 1,000 births serve the entire state (Blair et al., 2020). Investment in nursing knowledge both through implementation of breastfeeding policy and added certification would allow hospitals to augment the services of limited lactation consultant staff.

The Ten Steps

The Delaware Valley Hospital Breastfeeding Questionnaire was first deployed in 1994. Since that time, fourteen of nineteen hospital obstetric units have closed in Philadelphia County (Lorch et al., 2013). The resulting 50% reduction in maternity services has been re-distributed among five remaining maternity hospitals which accommodate the more than 20,000 annual births in the city (Lorch et al., 2013). Despite these changes, hospital implementation of breastfeeding policy has steadily improved. Our study highlights the continued progress among the remaining five hospitals where at the time of the writing of this article, all have achieved Baby Friendly USA designation.

Our results reveal that despite constant improvement reported as 83% agreement in Crivelli’s 2009 survey, successful implementation of “Step 10: Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center” remains elusive. It is clear that improvement in patient care that bridges patients’ needs as they transition from the hospital to their homes is one of the most difficult steps to implement across the country (Munn et al., 2016). Despite a robust initiation rate (88%) nurses reported that only one third of women in our sample were referred to a breastfeeding support group after discharge. The successful implementation of this critical step may be indicative of the quality of clinical care provided at a hospital during the postpartum period. The challenge for nurses is to achieve two important goals during the hospital newborn experience—first, achieve breastfeeding initiation success during the brief 24–72 hospital admission period, and second, establish links to available resources in the community to improve exclusive breastfeeding rates necessary to maximize the infant’s benefit from breast milk during the first year of life (CDC, n.d.).

The Nurse Work Environment

Establishment of hospital breastfeeding policies and practices creates an atmosphere that both protects and supports the mother–infant dyad. The modest, yet significant relationship between the nurse’s total self-efficacy score and the PES suggests that the work environment contributes to nurses’ perceived self-efficacy when implementing breastfeeding policy. The results reveal the significant correlation between the work environment score for strong foundations in nursing leadership, and high-quality nursing care with implementation of breastfeeding policy in practice. Similar impact of nursing leadership on nurse and patient outcomes is supported in the literature (Hallowell et al., 2016). Nursing leaders, especially perinatal educators, are integral to fostering work environments that support the ability of nurses to create a clinical climate to promote breastfeeding through implementation of breastfeeding policy. Investing in strategies to promote a sound work environment simultaneously improve implementation of Baby-Friendly USA Ten Steps policy and nursing self-efficacy. Leaders may consider investments in education beyond the 20-hour minimum required for implementation of the policy to allow nurses to attain additional certification CLCs or IBCLCs, in addition to investing in full-time employment of lactation support professionals that possess these certifications. In this way, hospitals may customize and translate breastfeeding policy into clinical care that is comprehensive and individually tailored to the needs of every family within the specific communities they serve. Educational programs at both the undergraduate level and within healthcare organizations may be developed to create more robust clinical preparation for nurses that specifically address development of the skills necessary to support women to effectively breastfeed (Prokop et al., 2021).

Nurse’s Self Efficacy

The results suggest that strategies to improve nurses’ self-efficacy should address the specific needs expressed by particular units. It was expected that nurses in the NN and PP units would have the highest self-efficacy scores as their work to achieve successful breastfeeding initiation is acutely related to the brief hospital stay of patients. Findings from our study suggest that improvements could be made in intensive care settings (NICU) where the process of breastfeeding requires the use of a breast pump or hand expression to initiate and sustain a supply of human milk. Improved self-efficacy suggests that nurses should be equally facile at educating families who are unable or chose not to breastfeed, and to teach them to safely prepare formula for newborns who must establish clinical stability within a Baby Friendly environment. This is especially true for infants born in underserved settings where the needs of families disproportionately unable to access adequate lactation support and resources for their newborns should be addressed. Fostering self-efficacy among nurses cultivates a person-centered patient culture, within the context of lactation policy this focus may help alleviate barriers to lactation support in order to promote health equity for families within the communities served (National Academies of Sciences, Engineering, and Medicine, 2021).

LIMITATIONS

This study is limited since it provides a single snapshot in time of the work environment of a single urban hospital and relied upon nurses’ self-reports of following the Ten Steps and providing breastfeeding support to new mothers and infants. Self-reporting may be an accurate representation of support, but there may also be an under-reporting or even exaggeration of actual behavior(s) or care delivered. Three NN nurses comprised the sample of nurses in the NN, hence, these results are not generalizable. Additionally, due to shifts in evidence-based recommendations in perinatal care, many hospitals have forgone the use of NN in order to support maternal-infant non-separation practices. A significant revision of the WHO Baby Friendly Ten Steps was published in 2018. These changes were not reflected in the tool used in this study as it was conducted in 2017 (WHO, 2018). The sample was highly educated with more than half of the nurses with a baccalaureate degree or higher and also highly experienced with greater than five or more years of practice. The majority of survey respondents were Caucasian and may not adequately reflect the experiences of the diverse population the hospital serves. As a descriptive study with several notable limitations, the findings are not very generalizable. A larger multi-center trial that concurrently examines the impact of hospital breastfeeding policy among infants who are unable or families who chose not to breastfeed would be of interest in order to provide a more nuanced exploration of the relationship between the work environment and implementation of breastfeeding policy. Finally, a multi-site, longitudinal study design that links contributions of both maternal and infant variables to outcomes from nurse interventions that examines the impact of hospital care from pregnancy through the postnatal period would further inform our knowledge of these relationships.

CONCLUSIONS

Hospital care at birth may leave a lasting impression of the health system on families. Vital teaching and care that new parents are taught has the potential to influence parent behaviors far beyond the newborn period. Nurse leaders who are able to cultivate a work environment that enhances self-efficacy among nurses, recognize that improved clinical practice behaviors related to breastfeeding may result from implementation of breastfeeding policy. The PES is a promising tool for evaluating the associations between the work environment and implementation of evidence-based breastfeeding policy.

Our finding that Step 10 “Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birth center” is a call to action to create bridges of care between the hospital and the surrounding communities where families live. Nurses are important advocates who may live in these communities and can lead efforts to recruit and develop appropriate strategies to address the cultural needs unique to each community in order to establish breastfeeding supportive communities. This idea is supported by findings which suggest that Baby Friendly policy may need to shift out of the hospital and into the community to establish sustained breastfeeding impacts as infants grow (Munn et al., 2016; Gomez-Pomar & Blubaugh, 2018; Segura-Pérez et al., 2021). Hospital-based breastfeeding experiences have the potential to impact and sustain exclusive breastfeeding practices, in the surrounding community well beyond the first six months of life.

Implications for Practice

Robust education and skill development among nursing staff may balance the attenuating effect of the work environment when implementing breastfeeding policy.

Our findings suggest that nurses’ perceptions of self-efficacy related to breastfeeding policy are cultivated in a work environment where a clear philosophy of nursing underlies high-quality, evidence-based, and patient-centered hospital care.

Nursing leaders, especially perinatal educators, are integral to fostering work environments that support the ability of nurses to create a clinical climate to promote breastfeeding through implementation of breastfeeding policy.

Biography

SUNNY G. HALLOWELL is an Assistant Professor and Pediatric Nurse Practitioner at the M. Louise Fitzpatrick College of Nursing, Villanova University and a Senior Fellow at the Center For Health Outcomes and Policy Research, University of Pennsylvania. She is an expert in the nurse work environment, staffing, Pediatric, and Neonatal outcomes. At the time of this study Dr. Hallowell was an International Board Certified Lactation Consultant (IBCLC).

DISCLOSURE

At the time of this study the author was an International Board Certified Lactation Consultant (IBCLC).

FUNDING

This work was supported by the M. Louise Fitzpatrick College of Nursing, Villanova University Research Development Grant 2017-2018.