Retraining Hospital Staff to Prioritize Breastfeeding

About 80 percent of the women giving birth at CHRISTUS Hospital - St. Elizabeth in Beaumont, TX breastfeed with 50 percent exclusively breastfeeding during their stay. The exclusive rate is up 13 percent from just two years ago. The increase is a result of considerable efforts to retrain staff, eliminate formula giveaways, prioritize skin-to-skin bonding between mother and baby, and educate pregnant women about the benefits of breastfeeding.

Stacie Jones, a neonatal nurse and lactation consultant at CHRISTUS - St. Elizabeth who leads the hospital’s breastfeeding initiative, says the hospital was motivated to act for three reasons: the culture of breastfeeding in Southeast Texas was changing and the need for lactation support was drastically growing; the Joint Commission’s new perinatal care core measures regarding exclusive breastfeeding; and the assistance available through the Texas Ten Step Star Achiever Breastfeeding Learning Collaborative. The state-wide quality improvement project is a collaboration between the Texas Department of State Health Services (DSHS) Nutrition Services Branch (Texas WIC) and NICHQ, which focuses on helping participating birthing hospitals follow the evidence-based Ten Steps to Successful Breastfeeding as outlined by WHO/UNICEF to improve their maternity care practices.

One of the major changes at CHRISTUS - St. Elizabeth was implementing immediate skin-to-skin contact (Step 4) between mother and baby to make way for a good initial feeding. The benefits, Jones says, go beyond the nutritional benefits of the milk itself. Research indicates that immediate skin-to-skin contact also helps the infant to regulate its temperature, blood glucose level and heart rate.

But leaving the baby on the mother’s chest immediately after delivery—as long as mother and baby are both stable—has required major procedural changes. Previous standard practice included initial separation between mother and baby. CHRISTUS is currently taking steps to initiate immediate skin-to-skin contact to eliminate mother/baby separation by delaying infant weight, measurement and initial bath during the “golden hour” right after birth.

CHRISTUS - St. Elizabeth followed guidelines learned in the learning collaborative to implement the system changes methodically. Testing new procedural changes started with just one champion OBGYN, one labor and delivery nurse, one charge nurse and one mom. The hospital also created a breastfeeding task force that helped to develop the protocol by reviewing the results of these small tests. Jones says the task force was critical to their success because it ensured there was buy-in from several different units at the hospital. These breastfeeding champions became the driving force behind the broad implementation of the new standard of care.

“After getting feedback from all parties involved, we addressed the procedural concerns, supply and equipment issues, and safety concerns that were raised. We continued to test the process eight more times to bring in more physicians and nurses on the practice change process,” explains Jones.

Ultimately the hospital conducted nine such trials before they created a new standard of care and developed training for all maternal child staff.

“I learned best from the in-person, hands-on training,” says Kelli Huebel, who is a neonatal program manager. Huebel said going on rounds with the lactation consultants, observing their positioning and process and hearing the scripts they used was the most effective aspect of the training program.

Jones notes that some training regarding the new breastfeeding protocol is provided for all staff—not just those in labor and delivery. Staff have to complete an online training session and a breastfeeding competency checklist each year, “so someone in the ER will have an idea of how to address and help a breastfeeding mother,” Jones says.

She admits that not all staff members are eager to accept system changes initially. Some team members are very reluctant to delay the first full baby assessment in favor of skin-to-skin contact. Nurses are generally task oriented so educating and reprioritizing nursing care has been a great challenge. Jones hopes that in time they will come round to the new standards of care. She posts the hospital’s breastfeeding statistics on each unit as a regular reminder of the effectiveness of the skin-to-skin protocol and other changes.

“Positive reinforcement is the key to keeping momentum going during the change process,” advises Jones.