- To explore midwifery practices and knowledge, the findings would influence strategies that could promote ssc.
- Pilot an infant feeding checklist document in line with the maternity unit’s breastfeeding strategy (2007) and the recommendations of the NICE guideline for postnatal care. (2006)
- To design a visual reminder for staff and women to raise the profile of the benefits of ssc which would increase all health care professionals’ knowledge that care for postnatal women.
- Promote the project in the midwifery neonatal study days and in breastfeeding training days for MCA’s
Methodology
The practice of ssc would be offered to all women regardless of their feeding method delivering healthy term infants in the maternity unit with the vision of increasing this percentage.
A triangulation of methods was used to increase the reliability of the results, the quantitative methods would provide numerical data and the qualitative methods would provide descriptive in depth information that would influence the change process and completion. Ethical approval was not required as this was promoting best practice from clinical audit and service evaluation and not a research study.
Lewins (1951) three stage process of managing change was followed.
Unfreezing
The need for change was identified by two retrospective audits.
- Postnatal notes audit (2007) – 100 randomly selected postnatal notes were analyzed prior commencing a research study in the unit and information from the section on infant feeding was reviewed to establish documentation availability. There was no area available to record SSC.
- Top up breastfeeding audit (2007) – A review of the percentage (%) of term healthy breastfeeding infants that had received artificial milk on the postnatal ward found babies delivered by Lower Section Caesarian section (LSCS) had the higher intervention rate for no medical reason.
Data was also collected from the CMIS maternity database which is completed at the time of birth by the attending midwife for the months August-October 2007 to determine the % of babies experiencing ssc: the type of delivery was established to identify areas where ssc was lowest and needed creative promotion.
To establish the midwives knowledge and practices 22 randomly selected midwives from all levels were asked to complete a questionnaire, in view of the data gained from the CMIS system and Top up audit it was specific to women experiencing emergency (LSCS). Likert scales were used to determine the level of importance ssc had when caring for a mother following LSCS, what influenced their practice, if they had ever asked a MCA to assist with ssc and knowledge of the length of time advised by UNICEF baby friendly initiative. (30-40 minutes of unhurried SSC 2006) Appendix 1
To review the role of support staff 10 maternity care assistants were asked to complete a questionnaire to establish if they were involved in helping women with ssc and first feed initiation on delivery suite, if they had attended breastfeeding training courses, their confidence levels and if it would affect their job satisfaction. Appendix 2
This unfreezing process identified that the % of SSC was lower than the national average (76%) further analysis of type of birth revealed that women who had delivered by LSCS had a lower SSC rate than a vaginal birth. The barriers to change needed identification prior to strategic planning.
A force field analysis was completed to determine the driving and resisting forces for the change, also SWOT, PEST and temple analysis tools were used to plan and analysis the internal and external environment. Appendix 3 & 4
This planning would determine barriers to change and ensure the objectives were SMART specific / measurable / achievable / realistic and time-based. (Stewart 1994) A Gantt chart was used to plan the project. (Usherwood 1996).
Appendix 5.
The midwives questionnaire identified the main clinical barriers to the change were that the condition of the mother was a priority which is supported by the midwifery rules of practice (2004) that states ‘a midwife must make sure the needs of the woman are the primary focus of her practice’ perhaps research by Erlandsson et al (2007) that found a positive effect on infant behavior if the father carried out ssc could be implemented.
Maternal choice was reflected by insuring the mother was aware of the benefits of ssc although as Cantrill (2004) found even though midwives attempted first feed initiation the practice of ssc was poorly understood. Education and training of support workers to assist in the role of supporting breastfeeding, a key recommendation from the Department of Health document ‘Good practice and innovation in breastfeeding ‘(2004) could aid the barrier of increased workload. As part of the MCA’s role was to assist women in the postnatal period so this role could be utilized. Whilst the issue of time a factor discussed by Richardson (1999) that can effect implementing evidence-based care could be utilized by allowing women a quite period with their family.
These barriers were approached using a combination of normative re-educational and rational-empirical strategies, as these strategies assume that change will flow by promoting the benefits of ssc which would motivate interest and reduce resistance as well as re-educating people acknowledging individual cultures. The ideas to influence practice were to be discussed on the neonatal study days and to be part of an information display on delivery suite.
Change agents were identified to empower ssc promotion and these champions would work within the team on delivery suite, postnatal wards, breastfeeding clinic and leaders on the neonatal study days and training days for MCA’s.(Martin 2003)
Change
An infant feeding checklist was designed with a section to record ssc and first feed initiation; this could be used with the present postnatal notes and would become part of the new individualized booklet for postnatal care that was being developed from the research project at the unit. (HOP 2007) This was piloted by 10 midwives on the delivery suite and was reviewed by the Infant feeding specialist; the consensus of opinion was that a visual reminder would be beneficial in the delivery areas. Appendix 6
An information display was created on the monthly topic board on the delivery suite with the results of the questionnaires from the midwives and MCA’s, the benefits of ssc and effects on breastfeeding were supported by research articles. The board would be used as a teaching aid by the champion infant feeding specialist whilst teaching on the MCA’s breastfeeding days.
A A3 poster was designed and displayed to obtain comments from staff prior to its display in every delivery room, it would be viewed by all staff and clients, positive feedback was returned and the poster was developed following negotiation between the delivery suite manager / infant feeding specialist/ divisional manager and a member of the lay public. Funding was negotiated from the amenity fund and the poster was sent to the patient information manager for finalizing and printing. Unfortunately the pictures had been obtained from the World Wide Web and due to changes in the NHS license for the Copyright Licensing Agency (CLA) the pictures could not be authorized. So it was back to the beginning, a decision matrix is an ideal tool to investigate and think about a problem (Usherwood 1996) this identified time as an issue and 4 options were considered. Appendix 7.
A hospital in the midlands had promoted ssc recently and contact was made to negotiate purchasing photographs for the poster, this involved the skills of communication, tact and diplomacy and after 4 weeks of negotiating a decision was made by the project leader, using a process of identification analysis and planning to chose another option (Tinsley 2005), as the Gantt chart was lagging behind. A chance conversation with a press officer lead the project to a web site and a new poster was redesigned, authorized and printed within a week. This was then displayed in all delivery rooms, in the birth centre and breastfeeding clinic and was used on the training days as a visual aid and learning tool. Appendix 8
Strategies for overcoming barriers to implementing SSC were discussed on neonatal training days and as low structured interviews on the delivery suite with midwives and MCA’s. This conversational type of approach was an effective way of assessing progress, using the motivational theories of content and process to analyze and create a positive and motivational environment. Motivation as Cubbon (2000) discusses is multifaceted and concerns the internal and external forces that influence a person’s behavior, as a leader understanding these forces can increase performance and implement the change process.
The project leader was continually aware of the importance of leadership the qualities of a transformational leader who inspires the team and shares the vision by communicating where considered ideal. Being visible throughout the change allowed identification of the resisters as Martin (2002) writes ‘those who doubt that improvement will result from the proposal often challenge it.’ Being perceptive to situations, providing strategies and reviewing problems as they are encountered can aid progress of the project.
Refreezing
An essential part of a project is evaluating the outcomes of the change so that Lewins refreezing stage can be achieved;
Data was collected from the CMIS database for the months Feb – March 2008 to determine the % of women experiencing ssc this was produced on excel as pie chart.
A random selection of 22 midwives were asked to complete a repeat
Questionnaire about their knowledge and practice as were 10 MCA’s. The main themes were displayed in charts such as knowledge of the advised length of time for SSC, MCA breastfeeding training progress, and if midwives had utilized the suggested methods to overcome the barriers to implementing SSC for all women especially following LSCS.
Women were asked on the postnatal ward if they had enjoyed the experience of SSC, women attending the antenatal training breastfeeding days and breastfeeding clinic were asked about the posters content appeal and relevance to themselves.
Results
Before project audit of CMIS
The rates of SSC for 989 women were analyzed from August to Oct 2007
Yes = 643
No = 315
Missing values = 29
(Chart 1)
Chart 1 shows a 65% SSC prior to the project for all types of delivery.
This was broken down into type of delivery which found that LSCS had a low SSC % 15%
Spontaneous vaginal deliveries (svd) 67%
After Project audit of CMIS.
The rates of SSC for 883 women were analyzed from January to March 2008.
Yes = 613
No = 250
Missing values = 20
(Chart 2)
Chart 2 shows a 70 % SSC after 2 months of implementing the project this is a 5% increase in the number of babies experiencing SSC.
Type of delivery showed LSCS = 17% (2% INCREASE)
SVD = 70% (3% INCREASE)
Information gathered from midwives questionnaires showed.
Chart 3 shows prior to project 6/22 midwives thought the recommended time for SSC was 30-40 mins,
12/22 midwives did not know the recommended time
(Chart 3)
Following the project see chart 4 -18/22 midwives knowledge had increased and thought the recommended time for SSC was 30-40 mins, 2 longer only 2 did not know.
(Chart 4)
Midwives factors – mothers comfort and privacy most important, followed by temperature of baby and breastfeeding initiation which could indicate that SSC has a lower importance factor. Following project slight change in practice only.
The main influences on practice were considered by midwives and strategies to aid implementing ssc.
(Chart 6)
Information from MCA questionnaires
(Chart 7) (Chart 8)
2 more MCA’s had been trained to assist with breastfeeding, chart 9 shows a slight increase in assisting with feeding, SSC and a higher increase in confidence and job satisfaction.
(Chart 9)
MCA’S factors – breastfeeding initiation most important and temperature of baby, this did not change after the project.
(Chart 10)
Discussion
So it seems appropriate that the Unicef baby friendly accreditation (2007) step 3 and 4 suggests all mothers should have a period of unhurried SSC after birth.Mikiel-Kostyra et al (2002) concluded SSC increases the duration of exclusive breastfeeding whilst the experience of women from Finnegan’s (2004) study showed that SSC was valued and increased the women’s confidence with their babies which may explain why early SSC increases the success of breastfeeding.
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