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Maternity Nurses' Knowledge of Factors Promoting Successful Breastfeeding: A Survey at Two Hospitals
research and studies choice questions, in some of which more than one response could be chosen, were used. T o pretest and refine the tool, a pilot survey was conducted in a maternity unit in a hospital not included in this survey, but with a population similar to the study population. The questionnaire was also submitted separately to three faculty members in maternalchild nursing in a school of nursing to judge clarity and correctness of reDOROTHY SHOLES CRO WDER, RN, MS sponses. A two-week test-retest procedure was used to check reliability. The content remained identical, but at the second testing, the order of An investigator-designed questionnaire was used to survey 53 RNs and LPNs at two urban items was changed due to deletion of hospitals concerning knowledge far support of breastfccding mothers. Maternie nurses one item and rewriting of one disdemonstrated limited knowledge, especially in drugs, maternal emotions, and neonatal physioloo as related to breastfeding. Level of education affected test scores positively; length of experience tractor. The correlation coefficient affected test scores negatively. was calculated from the grades of the two testings with six subjects using the Pearson R. It was 0.86 at Because of increased interest in only clinically based opinions were 95% confidence level. As a result, the breastfeeding, factors that influence expressed. Breastfeeding success fac- final questionnaire consisting of a its success are being investigated. tors, confirmed by Applebauq2 profile sheet and 28 items was deThe items were divided into ~ The literature reveals a low success Newton a n d Newton,’ R a ~ h a e l , signed. r a t e even though breastfeeding K r ~ n and , ~ Sartob were placed in five categories: maternal drugs, prinamong women in America has been categories. The categories included ciples of infant feeding, maternal increasing since the 1960s. Dun- physical, physiological, psychologi- emotions and neonatal physiology, cumbe’ postulates that nurses and cal, sociocultural, and neonatal fac- maternal physiology, and nursing others caring for mothers and neo- tors as well as medical and nursing intervention. The target was a 100% sample of a population that innates today are inadequately trained support and guidance. The review identified variables cluded RNs and LPNs on all three to impart knowledge about breastfeeding. Personal clinical observa- that could affect nurses’ knowledge shifts in newborn nurseries and posttions also revealed that many nurses of the factors. Some authors postu- partal units of one university and demonstrate a lack of knowledge lated that the level of education, one community hospital in a large necessary to assist, support, and in- length of experience in a given area, city in the Southeast. Only 74% of a n d frequency of c o n t a c t with these responded, hence the sample struct mothers who breastfeed. This pilot study was undertaken mothers whose babies were breast- size was 53 out of a possible 72 to determine if maternity nurses feeding were elements that could af- nurses. The data were analyzed using dehave adequate knowledge regarding fect the nurses’ knowledge this method of infant feeding. It was O t h e r variables noted were the scriptive statistics. To summarize the acknowledged that many other vari- nurses’ attitudes, knowledge base, data and make interpretations about ables, both in the nurse and in the a n d nursing intervention. As all the participating nurses, the mean mother, might account for unsuc- variables could not be used, the cri- score (in percent) was used, ie., the cessful breastfeeding or for the deci- teria for choosing items were: 1) the average test score of all participants, sion not to breastfeed, but this sur- frequency of mention by experts and divided by the total score possible, vey examined only breastfeeding- 2) the relevance to success as con- multiplied by 100. related knowledge possessed by ma- firmed through repeated findings. Results ternity nurses. Methodology The literature was reviewed not The total possible test score was only to identify factors that promote A descriptive survey approach was 37, and scores ranged from 8 points successful breastfeeding, but also to used, and a questionnaire had to be to 31 points. The mean score for 26 correlate these with appropriate constructed since no existing appro- subjects at the community hospital nursing intervention. Sometimes priate tool was found. Multiple was 56.1%, while the mean score for
Maternity Nurses’ Knowledge of Factors Promoting Successful Breastfeeding
A Survey at Two Hospitals
28
January/February 198 1 JOCN Nursing 0090-0311/81/01 15-0028$0100
Table 1.
Maternity nurses’ breastfeeding knowledge: Mean scores (in percent) by subject area categories and level of education.
Education
No. subjects
Drugs
Infant feeding
14 23 2
23.8 21.7 16.7
57.2 77.2 100.0
14
33.3
64.2
24.2
69.3
Practical program Diploma program Associate Degree program BS program TOTAL
53
27 subjects at the university hospital was 50.3%. The mean score for all participants was 53.2%. A profile of these subjects included the following characteristics: highest level of education attained, length of experience in years or months in any area of maternity nursing, length of experience in years or months in newborn nursery or postpartal unit, current a r e a of p r a c t i c e , c o n t a c t w i t h mothers whose babies are breastfeeding, number of hours per week usually worked, and floor of hospital employed. The first characteristic reviewed was the educational level of the nurses. R N s scored higher t h a n LPNs. The mean scores ranged from 64.9% to 38.8% as shown in the far right column of Table 1. Overall results could confirm the advantage in depth of knowledge acquired in degree programs versus diploma and especially practical programs or the differences in program emphasis among basic nursing programs. Another characteristic reviewed was length of experience in maternity nursing. T h e median length was 1 to 10 years. Scores were highest when the subject had under 5 years’ experience (far right column, Table Table 2. nursing
Maternal emotions and Newborn physiology 23.8 41.7 50.0 40.3 38.9
Maternal physiology
Nursing intervention
Overall mean
51.8 67.9 87.5
34.2 55.4 57.9
72.3
61.6
38.8 56.6 64.9 60.2 53.2
69.6
2), which might reflect recent increases in breastfeeding and emphasis on breastfeeding support in education. Mean score decreases with increased experience up to 15 years could indicate nurses have not kept up with their knowledge/experience due to leaving nursing perhaps for marriage and family life. The decrease in mean score in the over 20 years group might indicate lack of continuing education due to lack of motivation coupled with the desire to retire from nursing. Little difference in knowledge scores was revealed between the 24 nurses in newborn nurseries (mean 53.5%) and the 29 nurses in postpartum units (mean 52.9%). Likewise, there was little difference between the 38 nurses who had frequent contact with breastfeeding mothers (mean 53.5%) and the 15 who seldom had contact (mean 52.4%). Next, mean scores in each knowledge subject area were derived according to educational level (Table 1). It is readily discernible that the weakest area for all participants was the effect of maternal drugs on breast milk and the infant. Also, it is interesting to note that the area in
51.5
-
which nurses should be most proficient, nursing intervention, ranked only as third highest in total mean scores. This could imply that nurses have knowledge, but fail to apply it within nursing situations. ( T h e length of experience variable could also affect differences in scores among nurses with different levels of education.) Knowledge of subject areas according to years of experience in any area of maternity nursing were also analyzed (Table 2). T h e length of experience in maternity nursing had some bearing on each specific area. While knowledge about drugs increases up to five years, there are subsequent decreases and increases up to 30 years of experience. Could the general increases in knowledge for the first 1-5 years be due to the younger nurses’ motivation and enthusiasm to gain experience along with her knowledge? Could the subsequent rises and falls in successive years be due to efflux and influx of nurses as they move from marriage and family back to nursing?
Conclusions T h e d a t a point out t h a t the nurses’ level of education affected
Breastfeeding knowledge mean scores (in percent) by subject area categories and length of experience in maternlty
Length of Experience Less than 6 mo 6mo-I yr 1 yr-5yr 6 yr-10 yr 11 yr-15 yr 16 yr-20 yr 21 yr-25 yr 26 yr-30 yr TOTAL
No. subjects
Drugs
Infant feeding
Maternal emotions and newborn physiology
5 5 19 6 8 4 3
6.7 26.7 33.3 11.1 29.2 16.7 22.2
60.0 55.0 77.6 70.8 65.6 75.0 66.7
20.0 60.0 42.1 38.9 29.2 25.0 55.5
65.0 67.5 71 .O 68.8 56.2 75.0 54.2
58.9 63.2 46.8 40.4 42.8 52.6 43.8
53.0 60.0 58.9 47.3 45.9 54.7 47.8
3
33.3
58.3
11.1
!%.B
38.6
EL&
53
24.2
69.3
38.9
65.6
51.5
53.2
January/February 1981JOCN Nursing
Maternal physiology
Nursing intervention
Overall mean
29
their knowledge of breastfeeding success factors. However, neither length of experience in maternity nursing nor frequency of contact with mothers whose babies breastfeed appeared to increase the nurses’ knowledge. Nurses in this study showed greatest strengths of principles of infant feeding and maternal physiology. T h e i r greatest weaknesses were drugs and maternal emotions and neonatal physiology. Also, nurses in this study revealed limited knowledge about breastfeeding success factors and concomitant nursing intervention. Further research should attempt to correlate knowledge with motivation a n d ability to support t h e breastfeeding mother effectively. Larger samples from broader geographic areas would be needed before findings could be generalized.
2 . Applebaum RM: The modern management of successful breast feeding. Pediatr Clin North Am 17:203-223, 1970 3. Newton M, Newton N: The normal course and management of lactation. Clin Obstet Gynecol 5:44-63, 1962 4. Raphael D: The Tender Gift: Breastfeeding. Englewood Cliffs, New Jersey, Prentice-Hall, 1973 5. Kron RE, Stein M, Goddard KE: Newborn sucking behavior affected by obstetric sedation. Pediatrics 37:1012-1016, 1966 6. Sarto SJ: Breast feeding-preparation, practice and professional help. Am J Nurs 63:58-60, 1963 7. Mobbs EJ: Breast feeding and nursing management. Med J Australia 2:392-396, 1972 I 8. Clark J: Lip-service only. Nurs Mirror, Jan 16, 1975, pp 39-40 9. Lesser MS, Keane VR: Nurse Patient Relationships in a Hospital Maternity Service. St. Louis, CV Mosby, 1956
References
Supplementary Bibliography
1. Duncumbe MA: A different kind of famine. Nurs Times May 15, 1975, pp 762-763
Lawson B: Perceptions of degrees of support for the breast feeding mothers. Birth Fam J 32:67-74, 1976
Brian VA: Is breast feeding being discouraged? Nurs Mirror, May 22-29, 1975, p 83 Nichols M: Effective help for the nursing mother. JOGN Nurs 7(2):22-23, Mar/ Apr 1978 Cole E: Breastfeeding: A critique of the literature. Lactation Rev 25, Aug 23, 1977 Esterly NB: The obstetrician and breast feeding: Some views of the women physicians. Keeping Abreast J 1(3):236-251, 1976 Estok PJ: What do nurses know about breastfeeding problems? JOGN Nurs 2(6):36-39, 1973 Address for correspondence: Dorothy S. Crowder, RN, VCU/MCV School of Nursing, MCV Station, Box 567, Richmond. VA 23298. Dorothy Crowder is assistant professor of Maternig Nursing at Virginia Commonwealth University in Richmond. The article is derived from the thesis f o r her M S degreefrom the same institution. She is a member of NAACOG, A N A , N L N , and Sigma Theta Tau and has had varied experience in sta& supervisory, and instructor positions.
CANCER PREVENTIONAND DETECTION The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, in Houston, is sponsoring cancer prevention and detection modules for nurses. The 1981 winter/spring schedule is as follows: Breast module March 2-6 Gynecology module March 9-20 Breast module March 16-20 March 30-April3 Breast module Gynecology module April 6-1 7 Breast module April 13-1 7 Breast module June 8-1 2 Gynecology module June 8-1 9 Fees: Breast module-4100 out-of-state residents, $40 Texas residents; Gynecology module--$200 out-of-state residents, $80 Texas residents. Credits: Breast, 35 hours; Gynecology, 54 hours. For further information contact Judy E. Patterson, RN, Cancer Prevention and Detection Program for Nurses, M.D.Anderson Hospital, 6723 Bertner Avenue, Room PR855, Houston, TX 77030, (713) 792-3427.
30
January/FebruaFy 198 1 JOGN Nursing
Maternity Nurses’ Knowledge of Factors Promoting Successful Breastfeeding
A Survey at Two Hospitals
28
January/February 198 1 JOCN Nursing 0090-0311/81/01 15-0028$0100
Table 1.
Maternity nurses’ breastfeeding knowledge: Mean scores (in percent) by subject area categories and level of education.
Education
No. subjects
Drugs
Infant feeding
14 23 2
23.8 21.7 16.7
57.2 77.2 100.0
14
33.3
64.2
24.2
69.3
Practical program Diploma program Associate Degree program BS program TOTAL
53
27 subjects at the university hospital was 50.3%. The mean score for all participants was 53.2%. A profile of these subjects included the following characteristics: highest level of education attained, length of experience in years or months in any area of maternity nursing, length of experience in years or months in newborn nursery or postpartal unit, current a r e a of p r a c t i c e , c o n t a c t w i t h mothers whose babies are breastfeeding, number of hours per week usually worked, and floor of hospital employed. The first characteristic reviewed was the educational level of the nurses. R N s scored higher t h a n LPNs. The mean scores ranged from 64.9% to 38.8% as shown in the far right column of Table 1. Overall results could confirm the advantage in depth of knowledge acquired in degree programs versus diploma and especially practical programs or the differences in program emphasis among basic nursing programs. Another characteristic reviewed was length of experience in maternity nursing. T h e median length was 1 to 10 years. Scores were highest when the subject had under 5 years’ experience (far right column, Table Table 2. nursing
Maternal emotions and Newborn physiology 23.8 41.7 50.0 40.3 38.9
Maternal physiology
Nursing intervention
Overall mean
51.8 67.9 87.5
34.2 55.4 57.9
72.3
61.6
38.8 56.6 64.9 60.2 53.2
69.6
2), which might reflect recent increases in breastfeeding and emphasis on breastfeeding support in education. Mean score decreases with increased experience up to 15 years could indicate nurses have not kept up with their knowledge/experience due to leaving nursing perhaps for marriage and family life. The decrease in mean score in the over 20 years group might indicate lack of continuing education due to lack of motivation coupled with the desire to retire from nursing. Little difference in knowledge scores was revealed between the 24 nurses in newborn nurseries (mean 53.5%) and the 29 nurses in postpartum units (mean 52.9%). Likewise, there was little difference between the 38 nurses who had frequent contact with breastfeeding mothers (mean 53.5%) and the 15 who seldom had contact (mean 52.4%). Next, mean scores in each knowledge subject area were derived according to educational level (Table 1). It is readily discernible that the weakest area for all participants was the effect of maternal drugs on breast milk and the infant. Also, it is interesting to note that the area in
51.5
-
which nurses should be most proficient, nursing intervention, ranked only as third highest in total mean scores. This could imply that nurses have knowledge, but fail to apply it within nursing situations. ( T h e length of experience variable could also affect differences in scores among nurses with different levels of education.) Knowledge of subject areas according to years of experience in any area of maternity nursing were also analyzed (Table 2). T h e length of experience in maternity nursing had some bearing on each specific area. While knowledge about drugs increases up to five years, there are subsequent decreases and increases up to 30 years of experience. Could the general increases in knowledge for the first 1-5 years be due to the younger nurses’ motivation and enthusiasm to gain experience along with her knowledge? Could the subsequent rises and falls in successive years be due to efflux and influx of nurses as they move from marriage and family back to nursing?
Conclusions T h e d a t a point out t h a t the nurses’ level of education affected
Breastfeeding knowledge mean scores (in percent) by subject area categories and length of experience in maternlty
Length of Experience Less than 6 mo 6mo-I yr 1 yr-5yr 6 yr-10 yr 11 yr-15 yr 16 yr-20 yr 21 yr-25 yr 26 yr-30 yr TOTAL
No. subjects
Drugs
Infant feeding
Maternal emotions and newborn physiology
5 5 19 6 8 4 3
6.7 26.7 33.3 11.1 29.2 16.7 22.2
60.0 55.0 77.6 70.8 65.6 75.0 66.7
20.0 60.0 42.1 38.9 29.2 25.0 55.5
65.0 67.5 71 .O 68.8 56.2 75.0 54.2
58.9 63.2 46.8 40.4 42.8 52.6 43.8
53.0 60.0 58.9 47.3 45.9 54.7 47.8
3
33.3
58.3
11.1
!%.B
38.6
EL&
53
24.2
69.3
38.9
65.6
51.5
53.2
January/February 1981JOCN Nursing
Maternal physiology
Nursing intervention
Overall mean
29
their knowledge of breastfeeding success factors. However, neither length of experience in maternity nursing nor frequency of contact with mothers whose babies breastfeed appeared to increase the nurses’ knowledge. Nurses in this study showed greatest strengths of principles of infant feeding and maternal physiology. T h e i r greatest weaknesses were drugs and maternal emotions and neonatal physiology. Also, nurses in this study revealed limited knowledge about breastfeeding success factors and concomitant nursing intervention. Further research should attempt to correlate knowledge with motivation a n d ability to support t h e breastfeeding mother effectively. Larger samples from broader geographic areas would be needed before findings could be generalized.
2 . Applebaum RM: The modern management of successful breast feeding. Pediatr Clin North Am 17:203-223, 1970 3. Newton M, Newton N: The normal course and management of lactation. Clin Obstet Gynecol 5:44-63, 1962 4. Raphael D: The Tender Gift: Breastfeeding. Englewood Cliffs, New Jersey, Prentice-Hall, 1973 5. Kron RE, Stein M, Goddard KE: Newborn sucking behavior affected by obstetric sedation. Pediatrics 37:1012-1016, 1966 6. Sarto SJ: Breast feeding-preparation, practice and professional help. Am J Nurs 63:58-60, 1963 7. Mobbs EJ: Breast feeding and nursing management. Med J Australia 2:392-396, 1972 I 8. Clark J: Lip-service only. Nurs Mirror, Jan 16, 1975, pp 39-40 9. Lesser MS, Keane VR: Nurse Patient Relationships in a Hospital Maternity Service. St. Louis, CV Mosby, 1956
References
Supplementary Bibliography
1. Duncumbe MA: A different kind of famine. Nurs Times May 15, 1975, pp 762-763
Lawson B: Perceptions of degrees of support for the breast feeding mothers. Birth Fam J 32:67-74, 1976
Brian VA: Is breast feeding being discouraged? Nurs Mirror, May 22-29, 1975, p 83 Nichols M: Effective help for the nursing mother. JOGN Nurs 7(2):22-23, Mar/ Apr 1978 Cole E: Breastfeeding: A critique of the literature. Lactation Rev 25, Aug 23, 1977 Esterly NB: The obstetrician and breast feeding: Some views of the women physicians. Keeping Abreast J 1(3):236-251, 1976 Estok PJ: What do nurses know about breastfeeding problems? JOGN Nurs 2(6):36-39, 1973 Address for correspondence: Dorothy S. Crowder, RN, VCU/MCV School of Nursing, MCV Station, Box 567, Richmond. VA 23298. Dorothy Crowder is assistant professor of Maternig Nursing at Virginia Commonwealth University in Richmond. The article is derived from the thesis f o r her M S degreefrom the same institution. She is a member of NAACOG, A N A , N L N , and Sigma Theta Tau and has had varied experience in sta& supervisory, and instructor positions.
CANCER PREVENTIONAND DETECTION The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, in Houston, is sponsoring cancer prevention and detection modules for nurses. The 1981 winter/spring schedule is as follows: Breast module March 2-6 Gynecology module March 9-20 Breast module March 16-20 March 30-April3 Breast module Gynecology module April 6-1 7 Breast module April 13-1 7 Breast module June 8-1 2 Gynecology module June 8-1 9 Fees: Breast module-4100 out-of-state residents, $40 Texas residents; Gynecology module--$200 out-of-state residents, $80 Texas residents. Credits: Breast, 35 hours; Gynecology, 54 hours. For further information contact Judy E. Patterson, RN, Cancer Prevention and Detection Program for Nurses, M.D.Anderson Hospital, 6723 Bertner Avenue, Room PR855, Houston, TX 77030, (713) 792-3427.
30
January/FebruaFy 198 1 JOGN Nursing