- Email: [email protected]
Beyond the latch: A new approach to breastfeeding
Accepted Manuscript Beyond the latch: A new approach to breastfeeding Betty Ann Robinson, Gweneth Hartrick Doane PII:
S1471-5953(17)30048-3
DOI:
10.1016/j.nepr.2017.07.011
Reference:
YNEPR 2251
To appear in:
Nurse Education in Practice
Received Date: 20 January 2017 Revised Date:
27 July 2017
Accepted Date: 31 July 2017
Please cite this article as: Robinson, B.A., Hartrick Doane, G., Beyond the latch: A new approach to breastfeeding, Nurse Education in Practice (2017), doi: 10.1016/j.nepr.2017.07.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
BEYOND THE LATCH: A NEW APPROACH TO BREASTFEEDING Authors & Affiliations: Betty Ann Robinson
RI PT
University of Victoria
Gweneth Hartrick Doane
SC
School of Nursing
PO Box 1700 STN CSC Victoria BC V8W 2Y2 Canada
TE D
Corresponding Author: Betty Ann Robinson
[email protected]
EP
1.902.470.7820 (B) 1.902.220.5090 (C)
AC C
55 Summit Crescent
Upper Tantallon NS B3Z 1P9 Canada
M AN U
University of Victoria
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding ABSTRACT Health professionals supporting breastfeeding play an important role in women successfully achieving their breastfeeding goals. Instrumental knowledge has dominated health
RI PT
professionals’ breastfeeding education and practice. Because breastfeeding is a contextual and embodied experience, a relational orientation is required to identify effective strategies to
support women. A relational inquiry approach to breastfeeding practice offers a practical way to
SC
support women to better achieve their breastfeeding goals within the complexities of their own lives. Incorporating a relational inquiry approach to breastfeeding practice may assist health
M AN U
professionals to more effectively respond and engage with women in practice so that women’s breastfeeding goals are protected; women’s capacity and self-efficacy are promoted; and women feel and experience the support from health professionals that they require to be successful with breastfeeding.
TE D
HIGHLIGHTS
Current breastfeeding approaches limit health professionals’ capacity to support women
•
A relational approach provides more opportunities and strategies to provide support
•
Relational inquiry is a breastfeeding practice and education framework
•
Relational inquiry develops practical and responsive practice
AC C
EP
•
KEY WORDS
Breastfeeding; relational practice; relational inquiry
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
1
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding INTRODUCTION When supporting breastfeeding women and babies there are times when all goes well. However, there are also times when challenges are encountered. Stop for a moment and think
RI PT
about how you respond when working with a mother to initiate breastfeeding and things are not going smoothly. Most often positioning and latch are checked. Nipples and breasts are
inspected. Milk transfer is assessed. Sometimes, babies are also checked for tongue ties.
SC
Everything looks good and you cannot find any reason why the dyad is struggling. You are left wondering what else you can do. Recalling the education you received about breastfeeding, it
M AN U
seems you have tried every possibility to get breastfeeding going well and still challenges exist. While this instrumental support is an invaluable foundation for effective breastfeeding, other forms of knowledge are required by health professionals to support breastfeeding women effectively (Bernaix, 2000; Patton et al., 1996, Spear, 2006). For example, we know that
TE D
breastfeeding is an embodied experience for women (Ryan et al., 2011; Schmied and Barclay, 1999), making breastfeeding personal, intimate, and value-laden. A woman’s personal values, beliefs, and perceptions influence her breastfeeding experience and her success (Martucci, 2012).
EP
Therefore, in addition to breastfeeding assessment and support tools that emphasize the instrumental elements of breastfeeding, health professionals require knowledge and skills that
AC C
can enable them to effectively work within the personal and contextual realities of women’s lives to help them achieve their unique breastfeeding goals. Health professionals need to be adequately prepared to work within the contextual complexities as they attempt to support women to establish and continue breastfeeding their babies.
2
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding In this paper, we describe how relational inquiry (Hartrick Doane & Varcoe, 2015) offers an approach to breastfeeding support that enables health professionals to optimize women’s experience of breastfeeding and address women’s breastfeeding goals within the complexities of
RI PT
their lives.
BEYOND THE LATCH: TAKING A RELATIONAL INQUIRY ORIENTATION
In practice, health professionals are frequently stymied as to how to proceed in assisting a
SC
woman when “the latch looks good” according to our instrumental assessments yet breastfeeding is not going well according to the woman. As health professionals attempt to meet the needs of
M AN U
women they are faced with limited strategies they can employ to support and empower a woman who is struggling in her efforts to be successful. Since most breastfeeding courses for health professionals today are informed by the principles and foci of the 20 hour WHO/UNICEF course (2009), health professionals usually have a strong foundational knowledge about milk production
TE D
and supply, positioning and latching, and supporting milk supply during maternal-baby separation. The educational requirements for this course as well as those to become an International Board Certified Lactation Consultant (IBCLC) include counselling and
EP
communication skills to enhance interpersonal support. However, even though interpersonal counselling skills and the primary health care framework are considered important in
AC C
breastfeeding practice, a study by Burns et al (2012) found that only 9% of the health professionals positioned relationships as integral to breastfeeding. Moreover, Burns et al. (2012) contend that as science has assumed the dominant position in breastfeeding promotion strategies, women have been relegated away from the center of the breastfeeding experience. They describe most health professionals as operating at two disparate ends: prizing the product and production of breastfeeding while disregarding women or positioning women as simply needing
3
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding the necessary amount of commitment to succeed as breastfeeding is ‘natural.’ Thus, researchers have been calling for a more relational, contextualized approach to breastfeeding support and education to more successfully support breastfeeding women (Chalmers, 2013; Dykes, 2006;
Ayoola, 2012; Schmied et al., 2011; Sheehan et al., 2013).
RI PT
Dykes and Flacking, 2010; Joanna Briggs Institute, 2012; Noel-Weiss et al., 2012; Rossman and
While this instrumental knowledge and interpersonal communication and counseling
SC
skills are important, of vital importance is the ability to offer meaningful, relevant and effective breastfeeding support within the particular context and embodied experiences of breastfeeding
M AN U
woman. Relational Inquiry (Hartrick Doane & Varcoe, 2015) provides this contextual, embodied foundation for breastfeeding support. By explicitly addressing the intrapersonal, interpersonal and contextual levels of women’s breastfeeding experience, relational inquiry enables health professionals to broaden their knowledge and understanding of a woman’s breastfeeding
their breastfeeding goals.
TE D
experience and simultaneously enlist a range of effective strategies to support women to achieve
TAKING A RELATIONAL INQUIRY APPROACH TO BREASTFEEDING
EP
Relational inquiry is a relationally responsive practice that is grounded in inquiry and acknowledges the dynamic complexity of human health experience (Hartrick Doane and Varcoe,
AC C
2005; 2015). The questions in Table 1 illustrate how this inquiry might begin. Overall relational inquiry is an approach to practice that enables health professionals to consider the meaning of any health experience for each individual in his/her unique context, address the complexities of that experience and enlist multiple forms of knowledge simultaneously to enhance the effectiveness of any intervention.
4
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Using a relational inquiry approach, health professionals recognize the integral relationship between the contextual, interpersonal, and intrapersonal domains and how it is at that intersection that “knowledge is developed and acted upon” (Hartrick Doane and Varcoe,
RI PT
2005, p. 174). By inquiring into these domains of experience and knowledge, health
professionals intentionally and responsively orientate themselves and their actions to build
capacity, self-efficacy, and promote health and wellbeing (Hartrick Doane and Varcoe, 2015).
SC
Explicitly attending to women’s breastfeeding experiences within the three domains enables health professionals to enlist a set of practical and responsive strategies and tools and
M AN U
ensure that the focus of their work is centered on the woman and optimizing her achievement of her goals. By using this three-dimensional approach to breastfeeding support, health professionals using relational inquiry can integrate the necessary instrumental aspects of the act of breastfeeding with the contextual and experiential aspects of the experience for women. For
TE D
instance, when breastfeeding is assessed instrumentally to be going well, yet the mother reports ongoing difficulties, relational inquiry offers strategies to examine and address other aspects of the woman’s breastfeeding experience. Through an inquiry process the instrumental and
Contextual Inquiry
EP
relational aspects of the breastfeeding experience are woven together.
AC C
Within relational inquiry, health professionals consider the effect of contextual elements
on clients, themselves, and on other contextual elements. For example, health professionals engaged in the contextual domain of relational inquiry may examine the support a woman has and/or does not have for breastfeeding, consider other demands on her time, her existing capacities, and the resources she has to draw upon. How is her family and/or community – those present with her and those surrounding her (and not surrounding her) – responding to her
5
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding intention to breastfeed? How is all that is going on around a breastfeeding woman shaping her immediate needs, values, beliefs, assumptions, and her experience of breastfeeding? What other competing concerns may be influencing what is happening? These contextual considerations can
RI PT
range from basic physical needs (food, shelter, etc.) to emotionally-fueled concerns (safety, intimate partner violence, etc.). As an example, health professionals inquiring contextually may develop practical and responsive strategies to support breastfeeding when they learn that a
impeding her capacity to latch her baby independently.
M AN U
Intrapersonal Inquiry
SC
mother’s concern about where she and her infant shall be living in the immediate future may be
Within relational inquiry, health professionals consider the effect of intrapersonal influences, those things going on within clients, themselves, and any other persons involved in the situation. For example, when supporting a breastfeeding woman, this may mean inquiring
TE D
into her goals, motivations, and expectations regarding breastfeeding. It may mean exploring what really matters to her as a mother. It may mean looking to the inner capacities and resources she has to achieve her goals. Has she encountered and overcome challenging and overwhelming
EP
experiences in the past? How has she approached them? What inner resources have supported her success in these situations? Might she draw on these experiences of success to also be
AC C
successful in achieving her breastfeeding goals? What is working for her and where might she need new information or a different level or kind of support? As an example, health professionals inquiring intrapersonally may develop practical and responsive strategies when they learn a mother is deeply committed to exclusively breastfeeding her baby even in the face of illness and separation. Interpersonal Inquiry
6
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Within relational inquiry, health professionals consider the effect of interpersonal influences, those things going on among and between people. For example, when supporting a breastfeeding woman, it means starting with where the woman is in her experience and joining
RI PT
her there. What does the woman need most from the relationship with the health professional? What is going on for this woman right now and how can the health professional most effectively respond? To achieve her breastfeeding goals, does the woman need the health professional to
SC
validate, empathize or normalize her experience? Does she need assistance developing strategies to overcome a particular challenge? Does she need information to make an informed decision?
M AN U
As an example, health professionals inquiring interpersonally may develop practical and responsive strategies when they learn that a mother needs to feel in charge of her breastfeeding decisions rather than being instructed on how to breastfeed her baby. CONCLUSION
TE D
Health professionals supporting women with breastfeeding play an important role in women successfully achieving their breastfeeding goals. While discussion in this paper offers a brief introduction to how a relational inquiry approach to breastfeeding practice can extend
EP
health professionals effectiveness in that supportive role, relational inquiry includes specific tools and strategies that can be enlisted to develop this three-dimensional understanding of a
AC C
woman’s breastfeeding experience. These tools provide a concrete orientating structure for assessment, a means of expanding one’s knowledge base to inform action and a way of honing in on effective interventions to meet the needs of women in their own particular life circumstance. A relational inquiry approach enables health professionals to move beyond simply
offering instrumental knowledge and/or interpersonal support, making it possible for them to protect, promote, and support breastfeeding women in the complex circumstances of their lives.
7
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding It offers knowledge and skills to enable health professionals to attend to women’s experiences and position their actions in ways that support and enable breastfeeding women to address their
AC C
EP
TE D
M AN U
SC
RI PT
own specific needs and achieve their individual breastfeeding goals.
8
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Table 1 Inquiry at All Levels Intrapersonally •
What are this woman’s points of reference regarding breastfeeding? (What is she thinking
•
RI PT
and feeling about breastfeeding?)
What are her primary concerns and how are those concerns shaping her attitude and approach to breastfeeding?
What interpersonal and contextual elements are influencing her feelings and attitudes?
•
How are my own values and reference points about breastfeeding similar and/or different
SC
•
M AN U
from hers? Interpersonally •
What is happening between us? (What is she wanting from me? What am I expecting of her?)
What competing concerns and/or obligations might be at play in the situation?
•
What reference points and allegiances are shaping my actions and responses to this particular woman?
TE D
•
Is what I am prioritizing in synch with the priorities of this particular woman?
•
How might I orientate my actions to address her particular priorities and concerns?
AC C
EP
•
Contextually •
What contextual elements are shaping the woman’s priorities and concerns (for example, sociocultural elements, economic and/or structural constraints)?
•
What contextual forces and/or limitations might be shaping her experience?
•
What resources and supports does this woman have to draw upon?
9
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding How can this particular woman best be supported to achieve her breastfeeding goals in
EP
TE D
M AN U
SC
RI PT
her home environment? How can I contribute to this right now?
AC C
•
10
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding REFERENCES Bernaix, L.W., 2000. Nurses attitudes, subjective norms, and behavioral intentions toward support of breastfeeding mothers. Journal of Human Lactation 16(3),201-209.
RI PT
Burns, E., Fenwick, J., Sheehan, A., Schmied, V., 2013. Mining for liquid gold: Midwifery
language and practices associated with early breastfeeding support. Maternal and Child Nutrition, 9(1), 57-73.
SC
Chalmers, B., 2013. Breastfeeding unfriendly in Canada? Canadian Medical Association Journal, 185(5), 375-6.
M AN U
Dykes, F., 2006. The education of health practitioners supporting breastfeeding women: time for critical reflection. Maternal & Child Nutrition, 2(4), 204-216. Dykes, F., Flacking, R., 2010. Encouraging breastfeeding: A relational perspective. Early Human Development, 86(11), 733-736.
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Hartrick Doane, G., Varcoe, C., 2005. Family Nursing as Relational Inquiry: Developing Health Promoting Practice. Philadelphia, Lippincott Williams & Wilkins. Hartrick Doane, G., Varcoe, C., 2015. How to Nurse: Relational Inquiry with Individuals and
EP
Families in Changing Health and Health Care Contexts. Philadelphia, Lippincott Williams &Wilkins.
AC C
Joanna Briggs Institute, 2012. Best practice information sheet: Women's perceptions and experiences of breastfeeding support. Nursing & Health Sciences, 14(1), 133-135.
Martucci, J., 2012. Maternal Expectations: New Mothers, Nurses, and Breastfeeding. Nursing History Review, 20, 72-102.
Noel-Weiss, J., Cragg, B., Woodend, A.K., 2012. Exploring how IBCLCs manage ethical dilemmas: a qualitative study. BMC Medical Ethics, 13, 18.
11
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Patton, C.B., Beaman, M., Csar, N., Lewinski, C., 1996. Nurses’ attitudes and behaviors that promote breastfeeding. Journal of Human Lactation 12(2), 111-115. Rossman, L., C., Ayoola, B., A., 2012. Promoting Individualized Breastfeeding Experiences.
RI PT
The American Journal of Maternal Child Nursing. 37(3), 193-199.
Ryan, K., Todres, L., Alexander, J., 2011. Calling, permission, and fulfillment: the
interembodied experience of breastfeeding. Qualitative health research, 21(6), 731.
SC
Schmied, V., Barclay, L., 1999. Connection and pleasure, disruption and distress: women's experience of breastfeeding. Journal of Human Lactation, 15(4), 325.
M AN U
Schmied, V., Beake, S., Sheehan, A., McCourt, C., Dykes, F., 2011. Women's perceptions and experiences of breastfeeding support: A metasynthesis. Birth, 38(1), 49. Sheehan, A., Schmied, V., Barclay, L., 2013. Exploring the Process of Women’s Infant Feeding Decisions in the Early Postbirth Period. Qualitative Health Research, 23(7), 989-998.
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Spear, H. 2006. Baccalaureate nursing students’ breastfeeding
knowledge: A descriptive survey. Nurse Education Today, 26, 332-337. World Health Organization., 2009. Breastfeeding promotion and support in a baby-friendly
EP
hospital: A 20-hour course for maternity staff. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241594981_eng.pdf. Last accessed
AC C
January 18, 2017.
12
ACCEPTED MANUSCRIPT
Table 1 Inquiry at All Levels Intrapersonally •
What are this woman’s points of reference regarding breastfeeding? (What is she thinking
•
RI PT
and feeling about breastfeeding?)
What are her primary concerns and how are those concerns shaping her attitude and approach to breastfeeding?
What interpersonal and contextual elements are influencing her feelings and attitudes?
•
How are my own values and reference points about breastfeeding similar and/or different
SC
•
M AN U
from hers? Interpersonally •
What is happening between us? (What is she wanting from me? What am I expecting of her?)
What competing concerns and/or obligations might be at play in the situation?
•
What reference points and allegiances are shaping my actions and responses to this particular woman?
TE D
•
Is what I am prioritizing in synch with the priorities of this particular woman?
•
How might I orientate my actions to address her particular priorities and concerns?
AC C
EP
•
Contextually •
What contextual elements are shaping the woman’s priorities and concerns (for example, sociocultural elements, economic and/or structural constraints)?
•
What contextual forces and/or limitations might be shaping her experience?
•
What resources and supports does this woman have to draw upon?
ACCEPTED MANUSCRIPT
How can this particular woman best be supported to achieve her breastfeeding goals in
EP
TE D
M AN U
SC
RI PT
her home environment? How can I contribute to this right now?
AC C
•
S1471-5953(17)30048-3
DOI:
10.1016/j.nepr.2017.07.011
Reference:
YNEPR 2251
To appear in:
Nurse Education in Practice
Received Date: 20 January 2017 Revised Date:
27 July 2017
Accepted Date: 31 July 2017
Please cite this article as: Robinson, B.A., Hartrick Doane, G., Beyond the latch: A new approach to breastfeeding, Nurse Education in Practice (2017), doi: 10.1016/j.nepr.2017.07.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
BEYOND THE LATCH: A NEW APPROACH TO BREASTFEEDING Authors & Affiliations: Betty Ann Robinson
RI PT
University of Victoria
Gweneth Hartrick Doane
SC
School of Nursing
PO Box 1700 STN CSC Victoria BC V8W 2Y2 Canada
TE D
Corresponding Author: Betty Ann Robinson
[email protected]
EP
1.902.470.7820 (B) 1.902.220.5090 (C)
AC C
55 Summit Crescent
Upper Tantallon NS B3Z 1P9 Canada
M AN U
University of Victoria
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding ABSTRACT Health professionals supporting breastfeeding play an important role in women successfully achieving their breastfeeding goals. Instrumental knowledge has dominated health
RI PT
professionals’ breastfeeding education and practice. Because breastfeeding is a contextual and embodied experience, a relational orientation is required to identify effective strategies to
support women. A relational inquiry approach to breastfeeding practice offers a practical way to
SC
support women to better achieve their breastfeeding goals within the complexities of their own lives. Incorporating a relational inquiry approach to breastfeeding practice may assist health
M AN U
professionals to more effectively respond and engage with women in practice so that women’s breastfeeding goals are protected; women’s capacity and self-efficacy are promoted; and women feel and experience the support from health professionals that they require to be successful with breastfeeding.
TE D
HIGHLIGHTS
Current breastfeeding approaches limit health professionals’ capacity to support women
•
A relational approach provides more opportunities and strategies to provide support
•
Relational inquiry is a breastfeeding practice and education framework
•
Relational inquiry develops practical and responsive practice
AC C
EP
•
KEY WORDS
Breastfeeding; relational practice; relational inquiry
This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.
1
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding INTRODUCTION When supporting breastfeeding women and babies there are times when all goes well. However, there are also times when challenges are encountered. Stop for a moment and think
RI PT
about how you respond when working with a mother to initiate breastfeeding and things are not going smoothly. Most often positioning and latch are checked. Nipples and breasts are
inspected. Milk transfer is assessed. Sometimes, babies are also checked for tongue ties.
SC
Everything looks good and you cannot find any reason why the dyad is struggling. You are left wondering what else you can do. Recalling the education you received about breastfeeding, it
M AN U
seems you have tried every possibility to get breastfeeding going well and still challenges exist. While this instrumental support is an invaluable foundation for effective breastfeeding, other forms of knowledge are required by health professionals to support breastfeeding women effectively (Bernaix, 2000; Patton et al., 1996, Spear, 2006). For example, we know that
TE D
breastfeeding is an embodied experience for women (Ryan et al., 2011; Schmied and Barclay, 1999), making breastfeeding personal, intimate, and value-laden. A woman’s personal values, beliefs, and perceptions influence her breastfeeding experience and her success (Martucci, 2012).
EP
Therefore, in addition to breastfeeding assessment and support tools that emphasize the instrumental elements of breastfeeding, health professionals require knowledge and skills that
AC C
can enable them to effectively work within the personal and contextual realities of women’s lives to help them achieve their unique breastfeeding goals. Health professionals need to be adequately prepared to work within the contextual complexities as they attempt to support women to establish and continue breastfeeding their babies.
2
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding In this paper, we describe how relational inquiry (Hartrick Doane & Varcoe, 2015) offers an approach to breastfeeding support that enables health professionals to optimize women’s experience of breastfeeding and address women’s breastfeeding goals within the complexities of
RI PT
their lives.
BEYOND THE LATCH: TAKING A RELATIONAL INQUIRY ORIENTATION
In practice, health professionals are frequently stymied as to how to proceed in assisting a
SC
woman when “the latch looks good” according to our instrumental assessments yet breastfeeding is not going well according to the woman. As health professionals attempt to meet the needs of
M AN U
women they are faced with limited strategies they can employ to support and empower a woman who is struggling in her efforts to be successful. Since most breastfeeding courses for health professionals today are informed by the principles and foci of the 20 hour WHO/UNICEF course (2009), health professionals usually have a strong foundational knowledge about milk production
TE D
and supply, positioning and latching, and supporting milk supply during maternal-baby separation. The educational requirements for this course as well as those to become an International Board Certified Lactation Consultant (IBCLC) include counselling and
EP
communication skills to enhance interpersonal support. However, even though interpersonal counselling skills and the primary health care framework are considered important in
AC C
breastfeeding practice, a study by Burns et al (2012) found that only 9% of the health professionals positioned relationships as integral to breastfeeding. Moreover, Burns et al. (2012) contend that as science has assumed the dominant position in breastfeeding promotion strategies, women have been relegated away from the center of the breastfeeding experience. They describe most health professionals as operating at two disparate ends: prizing the product and production of breastfeeding while disregarding women or positioning women as simply needing
3
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding the necessary amount of commitment to succeed as breastfeeding is ‘natural.’ Thus, researchers have been calling for a more relational, contextualized approach to breastfeeding support and education to more successfully support breastfeeding women (Chalmers, 2013; Dykes, 2006;
Ayoola, 2012; Schmied et al., 2011; Sheehan et al., 2013).
RI PT
Dykes and Flacking, 2010; Joanna Briggs Institute, 2012; Noel-Weiss et al., 2012; Rossman and
While this instrumental knowledge and interpersonal communication and counseling
SC
skills are important, of vital importance is the ability to offer meaningful, relevant and effective breastfeeding support within the particular context and embodied experiences of breastfeeding
M AN U
woman. Relational Inquiry (Hartrick Doane & Varcoe, 2015) provides this contextual, embodied foundation for breastfeeding support. By explicitly addressing the intrapersonal, interpersonal and contextual levels of women’s breastfeeding experience, relational inquiry enables health professionals to broaden their knowledge and understanding of a woman’s breastfeeding
their breastfeeding goals.
TE D
experience and simultaneously enlist a range of effective strategies to support women to achieve
TAKING A RELATIONAL INQUIRY APPROACH TO BREASTFEEDING
EP
Relational inquiry is a relationally responsive practice that is grounded in inquiry and acknowledges the dynamic complexity of human health experience (Hartrick Doane and Varcoe,
AC C
2005; 2015). The questions in Table 1 illustrate how this inquiry might begin. Overall relational inquiry is an approach to practice that enables health professionals to consider the meaning of any health experience for each individual in his/her unique context, address the complexities of that experience and enlist multiple forms of knowledge simultaneously to enhance the effectiveness of any intervention.
4
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Using a relational inquiry approach, health professionals recognize the integral relationship between the contextual, interpersonal, and intrapersonal domains and how it is at that intersection that “knowledge is developed and acted upon” (Hartrick Doane and Varcoe,
RI PT
2005, p. 174). By inquiring into these domains of experience and knowledge, health
professionals intentionally and responsively orientate themselves and their actions to build
capacity, self-efficacy, and promote health and wellbeing (Hartrick Doane and Varcoe, 2015).
SC
Explicitly attending to women’s breastfeeding experiences within the three domains enables health professionals to enlist a set of practical and responsive strategies and tools and
M AN U
ensure that the focus of their work is centered on the woman and optimizing her achievement of her goals. By using this three-dimensional approach to breastfeeding support, health professionals using relational inquiry can integrate the necessary instrumental aspects of the act of breastfeeding with the contextual and experiential aspects of the experience for women. For
TE D
instance, when breastfeeding is assessed instrumentally to be going well, yet the mother reports ongoing difficulties, relational inquiry offers strategies to examine and address other aspects of the woman’s breastfeeding experience. Through an inquiry process the instrumental and
Contextual Inquiry
EP
relational aspects of the breastfeeding experience are woven together.
AC C
Within relational inquiry, health professionals consider the effect of contextual elements
on clients, themselves, and on other contextual elements. For example, health professionals engaged in the contextual domain of relational inquiry may examine the support a woman has and/or does not have for breastfeeding, consider other demands on her time, her existing capacities, and the resources she has to draw upon. How is her family and/or community – those present with her and those surrounding her (and not surrounding her) – responding to her
5
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding intention to breastfeed? How is all that is going on around a breastfeeding woman shaping her immediate needs, values, beliefs, assumptions, and her experience of breastfeeding? What other competing concerns may be influencing what is happening? These contextual considerations can
RI PT
range from basic physical needs (food, shelter, etc.) to emotionally-fueled concerns (safety, intimate partner violence, etc.). As an example, health professionals inquiring contextually may develop practical and responsive strategies to support breastfeeding when they learn that a
impeding her capacity to latch her baby independently.
M AN U
Intrapersonal Inquiry
SC
mother’s concern about where she and her infant shall be living in the immediate future may be
Within relational inquiry, health professionals consider the effect of intrapersonal influences, those things going on within clients, themselves, and any other persons involved in the situation. For example, when supporting a breastfeeding woman, this may mean inquiring
TE D
into her goals, motivations, and expectations regarding breastfeeding. It may mean exploring what really matters to her as a mother. It may mean looking to the inner capacities and resources she has to achieve her goals. Has she encountered and overcome challenging and overwhelming
EP
experiences in the past? How has she approached them? What inner resources have supported her success in these situations? Might she draw on these experiences of success to also be
AC C
successful in achieving her breastfeeding goals? What is working for her and where might she need new information or a different level or kind of support? As an example, health professionals inquiring intrapersonally may develop practical and responsive strategies when they learn a mother is deeply committed to exclusively breastfeeding her baby even in the face of illness and separation. Interpersonal Inquiry
6
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Within relational inquiry, health professionals consider the effect of interpersonal influences, those things going on among and between people. For example, when supporting a breastfeeding woman, it means starting with where the woman is in her experience and joining
RI PT
her there. What does the woman need most from the relationship with the health professional? What is going on for this woman right now and how can the health professional most effectively respond? To achieve her breastfeeding goals, does the woman need the health professional to
SC
validate, empathize or normalize her experience? Does she need assistance developing strategies to overcome a particular challenge? Does she need information to make an informed decision?
M AN U
As an example, health professionals inquiring interpersonally may develop practical and responsive strategies when they learn that a mother needs to feel in charge of her breastfeeding decisions rather than being instructed on how to breastfeed her baby. CONCLUSION
TE D
Health professionals supporting women with breastfeeding play an important role in women successfully achieving their breastfeeding goals. While discussion in this paper offers a brief introduction to how a relational inquiry approach to breastfeeding practice can extend
EP
health professionals effectiveness in that supportive role, relational inquiry includes specific tools and strategies that can be enlisted to develop this three-dimensional understanding of a
AC C
woman’s breastfeeding experience. These tools provide a concrete orientating structure for assessment, a means of expanding one’s knowledge base to inform action and a way of honing in on effective interventions to meet the needs of women in their own particular life circumstance. A relational inquiry approach enables health professionals to move beyond simply
offering instrumental knowledge and/or interpersonal support, making it possible for them to protect, promote, and support breastfeeding women in the complex circumstances of their lives.
7
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding It offers knowledge and skills to enable health professionals to attend to women’s experiences and position their actions in ways that support and enable breastfeeding women to address their
AC C
EP
TE D
M AN U
SC
RI PT
own specific needs and achieve their individual breastfeeding goals.
8
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Table 1 Inquiry at All Levels Intrapersonally •
What are this woman’s points of reference regarding breastfeeding? (What is she thinking
•
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and feeling about breastfeeding?)
What are her primary concerns and how are those concerns shaping her attitude and approach to breastfeeding?
What interpersonal and contextual elements are influencing her feelings and attitudes?
•
How are my own values and reference points about breastfeeding similar and/or different
SC
•
M AN U
from hers? Interpersonally •
What is happening between us? (What is she wanting from me? What am I expecting of her?)
What competing concerns and/or obligations might be at play in the situation?
•
What reference points and allegiances are shaping my actions and responses to this particular woman?
TE D
•
Is what I am prioritizing in synch with the priorities of this particular woman?
•
How might I orientate my actions to address her particular priorities and concerns?
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EP
•
Contextually •
What contextual elements are shaping the woman’s priorities and concerns (for example, sociocultural elements, economic and/or structural constraints)?
•
What contextual forces and/or limitations might be shaping her experience?
•
What resources and supports does this woman have to draw upon?
9
ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding How can this particular woman best be supported to achieve her breastfeeding goals in
EP
TE D
M AN U
SC
RI PT
her home environment? How can I contribute to this right now?
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•
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ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding REFERENCES Bernaix, L.W., 2000. Nurses attitudes, subjective norms, and behavioral intentions toward support of breastfeeding mothers. Journal of Human Lactation 16(3),201-209.
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Burns, E., Fenwick, J., Sheehan, A., Schmied, V., 2013. Mining for liquid gold: Midwifery
language and practices associated with early breastfeeding support. Maternal and Child Nutrition, 9(1), 57-73.
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Chalmers, B., 2013. Breastfeeding unfriendly in Canada? Canadian Medical Association Journal, 185(5), 375-6.
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Dykes, F., 2006. The education of health practitioners supporting breastfeeding women: time for critical reflection. Maternal & Child Nutrition, 2(4), 204-216. Dykes, F., Flacking, R., 2010. Encouraging breastfeeding: A relational perspective. Early Human Development, 86(11), 733-736.
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Hartrick Doane, G., Varcoe, C., 2005. Family Nursing as Relational Inquiry: Developing Health Promoting Practice. Philadelphia, Lippincott Williams & Wilkins. Hartrick Doane, G., Varcoe, C., 2015. How to Nurse: Relational Inquiry with Individuals and
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Families in Changing Health and Health Care Contexts. Philadelphia, Lippincott Williams &Wilkins.
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Joanna Briggs Institute, 2012. Best practice information sheet: Women's perceptions and experiences of breastfeeding support. Nursing & Health Sciences, 14(1), 133-135.
Martucci, J., 2012. Maternal Expectations: New Mothers, Nurses, and Breastfeeding. Nursing History Review, 20, 72-102.
Noel-Weiss, J., Cragg, B., Woodend, A.K., 2012. Exploring how IBCLCs manage ethical dilemmas: a qualitative study. BMC Medical Ethics, 13, 18.
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ACCEPTED MANUSCRIPT Beyond the Latch: A New Approach to Breastfeeding Patton, C.B., Beaman, M., Csar, N., Lewinski, C., 1996. Nurses’ attitudes and behaviors that promote breastfeeding. Journal of Human Lactation 12(2), 111-115. Rossman, L., C., Ayoola, B., A., 2012. Promoting Individualized Breastfeeding Experiences.
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The American Journal of Maternal Child Nursing. 37(3), 193-199.
Ryan, K., Todres, L., Alexander, J., 2011. Calling, permission, and fulfillment: the
interembodied experience of breastfeeding. Qualitative health research, 21(6), 731.
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Schmied, V., Barclay, L., 1999. Connection and pleasure, disruption and distress: women's experience of breastfeeding. Journal of Human Lactation, 15(4), 325.
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Schmied, V., Beake, S., Sheehan, A., McCourt, C., Dykes, F., 2011. Women's perceptions and experiences of breastfeeding support: A metasynthesis. Birth, 38(1), 49. Sheehan, A., Schmied, V., Barclay, L., 2013. Exploring the Process of Women’s Infant Feeding Decisions in the Early Postbirth Period. Qualitative Health Research, 23(7), 989-998.
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Spear, H. 2006. Baccalaureate nursing students’ breastfeeding
knowledge: A descriptive survey. Nurse Education Today, 26, 332-337. World Health Organization., 2009. Breastfeeding promotion and support in a baby-friendly
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hospital: A 20-hour course for maternity staff. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241594981_eng.pdf. Last accessed
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January 18, 2017.
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ACCEPTED MANUSCRIPT
Table 1 Inquiry at All Levels Intrapersonally •
What are this woman’s points of reference regarding breastfeeding? (What is she thinking
•
RI PT
and feeling about breastfeeding?)
What are her primary concerns and how are those concerns shaping her attitude and approach to breastfeeding?
What interpersonal and contextual elements are influencing her feelings and attitudes?
•
How are my own values and reference points about breastfeeding similar and/or different
SC
•
M AN U
from hers? Interpersonally •
What is happening between us? (What is she wanting from me? What am I expecting of her?)
What competing concerns and/or obligations might be at play in the situation?
•
What reference points and allegiances are shaping my actions and responses to this particular woman?
TE D
•
Is what I am prioritizing in synch with the priorities of this particular woman?
•
How might I orientate my actions to address her particular priorities and concerns?
AC C
EP
•
Contextually •
What contextual elements are shaping the woman’s priorities and concerns (for example, sociocultural elements, economic and/or structural constraints)?
•
What contextual forces and/or limitations might be shaping her experience?
•
What resources and supports does this woman have to draw upon?
ACCEPTED MANUSCRIPT
How can this particular woman best be supported to achieve her breastfeeding goals in
EP
TE D
M AN U
SC
RI PT
her home environment? How can I contribute to this right now?
AC C
•