585977
research-article2015
JHLXXX10.1177/0890334415585977Journal of Human LactationEdwards et al
Insights in Practice
Online Continuing Education for Expanding Clinicians’ Roles in Breastfeeding Support
Journal of Human Lactation 2015, Vol. 31(4) 582–586 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415585977 jhl.sagepub.com
Roger A. Edwards, ScD1, Rachel Colchamiro, MPH, RD, LDN, CLC2, Ellen Tolan, RD, LDN, IBCLC2, Susan Browne, MD3, Mary Foley, RN, BSN, IBCLC4, Lucia Jenkins, RN, IBCLC, RLC4, Kristen Mainello, MPH5, Rohith Vallu, BS6, Lauren E. Hanley, MD, FACOG, IBCLC7, Mary Ellen Boisvert, MSN, RN, CLC, CCE8, Julie Forgit, LDN, CLC2, Kara Ghiringhelli, RD, LDN, CLC2, and Christina Nordstrom, MEd2
Abstract Lack of health professional support is an important variable affecting mothers’ achievement of breastfeeding goals. Online continuing education is a recognized pathway for disseminating content for improving clinicians’ knowledge and supporting efforts to change practices. At the time we developed our project, free, accredited continuing education for physicians related to breastfeeding management that could be easily accessed using portable devices (via tablets/smartphones) was not available. Such resources were in demand, especially for facilities pursuing designation through the Baby-Friendly Hospital Initiative. We assembled a government, academic, health care provider, and professional society partnership to create such a tutorial that would address the diverse content needed for supporting breastfeeding mothers postdischarge in the United States. Our 1.5-hour-long continuing medical and nursing education was completed by 1606 clinicians (1172 nurses [73%] and 434 physicians [27%]) within 1 year. More than 90% of nurses and over 98% of physicians said the tutorial achieved its 7 learning objectives related to breastfeeding physiology, broader factors in infant feeding decisions and practices, the American Academy of Pediatrics’ policy statement, and breastfeeding management/troubleshooting. Feedback received from the tutorial led to the creation of a second tutorial consisting of another 1.5 hours of continuing medical and nursing education related to breast examination and assessment prior to delivery, provision of anticipatory guidance to pregnant women interested in breastfeeding, maternity care practices that influence breastfeeding outcomes, breastfeeding preterm infants, breastfeeding’s role in helping address disparities, and dispelling common myths. The tutorials contribute to achievement of 8 Healthy People 2020 Maternal, Infant and Child Health objectives. Keywords breastfeeding, continuing education, online tutorial
Background Although more than 40 health professional organizations and numerous government agencies and reports recommend that infants be breastfed exclusively for 6 months, only 18.8% of infants in the United States receive breast milk exclusively for the first 6 months of life.1 Lack of health professional support has been consistently identified as an important variable affecting mothers’ achievement of their breastfeeding goals.2 Internet-based e-learning has become a core component of continuing health professional education for a number of years.3 As part of a larger effort to change the climate and resources for postdischarge support of breastfeeding mothers in the commonwealth of Massachusetts,4 we sought to address gaps in clinician education related to postdischarge support of breastfeeding. While materials related to supporting
1 Consultant, Massachusetts Department of Public Health, and formerly Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA 2 Massachusetts Department of Public Health, Boston, MA, USA 3 MA Chapter, American Academy of Pediatrics, Waltham, MA, USA 4 Melrose-Wakefield Hospital, Hallmark Health System, Melrose, MA, USA 5 Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA 6 College of Computer & Information Sciences, Northeastern University, Boston, MA, USA 7 Harvard University School of Medicine, Massachusetts General Hospital, Boston, MA, USA 8 Beth Israel Deaconess Plymouth, Plymouth, MA USA
Date submitted: October 20, 2014; Date accepted: April 9, 2015. Corresponding Author: Christina Nordstrom, MEd, Obesity Prevention Program Director, Division of Prevention and Wellness, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA. Email: [email protected]
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Edwards et al breastfeeding mothers did exist and fulfill useful roles and specific needs, they were not in a form that was readily accessed by portable devices and used by clinicians, especially physicians. For example, the American Academy of Pediatrics (AAP) has a Breastfeeding Residency Curriculum that comprehensively covers important topics and includes valuable case studies, but it cannot be efficiently reviewed by a clinician wanting a succinct overview and attainment of continuing education credits.5 The Wellstart International Lactation Management Self-Study resource is available as a PDF, but it is not formatted as an online “e-learning” tool (with content and pre- and posttests automatically scored) that is accessible using portable devices; continuing education credits are not automatically awarded upon successful completion of the course.6 A number of professional societies (eg, Academy of Breastfeeding Medicine), education organizations (eg, Carolina Global Breastfeeding Institute, University of Virginia), private entities (eg, Lactation Education Resources and Evergreen) offer programs with continuing education credits, but they are offered at specific times or include recorded presentations of prior presentations and not available for free. Links to many of these programs are available at The Breastfeeding Center’s CHAMPS website.7 Others offer free programs, such as New York State, but none have had free continuing education credits and material in a form that was efficiently accessed by the busy clinician on a handheld, portable device. Clinicians are in strong positions to influence mothers due to their frequent contacts and the perception by the mother that the clinicians are the experts in this area. Yet, practical, easily accessible information for interacting and educating patients has been lacking. It was this gap that our project was seeking to fill.
Approach We wanted to implement an approach that would produce continuing professional education that covers the diverse content associated with supporting successful breastfeeding after discharge from the hospital. Hence, we established a government, academic, health care provider, and professional society partnership to create the content for the online continuing medical education (CME) tutorial. The publication of the newest AAP policy statement on breastfeeding and the use of human milk in 20128 also provided an appropriate impetus for the Massachusetts chapter of the AAP to collaborate with the Massachusetts Department of Public Health to create a new continuing education on breastfeeding. The tutorial covers background on breastfeeding, broader factors in infant feeding decisions and practices, the AAP guidelines, breastfeeding management and troubleshooting, integrative case studies, and a review of available resources. Learning objectives and the sections of the tutorial are available at the CME webpage: http://www.northeastern.edu/breast feedingcme/index.html. The topics and content were selected by a consensus process of the authors, reflecting the partner-
ship noted above, and guided by the principles of adult learning described below. The effort was guided by Malcolm Knowles’s theory of andragogy,9 which describes 5 components that are essential for successful adult learning: 1. Self-concept: Adults are self-directed and seek control in deciding what they are learning and their responsibility in directing and motivating their own learning. 2. Experience: Adults bring their experiences to their learning, and learning should incorporate that aspect. 3. Orientation to learning: Adults learn better when they can apply what they are learning in a problem-centered manner rather than a subject-centered manner. 4. Readiness to learn: Adults learn better when they know they need to learn something. 5. Motivation to learn: Adults learn based on internal motivation associated with perceived relevance and impact in their lives. The theory is consistent with a recent literature review that highlighted 4 key themes for online CME: (1) physicians’ learning preferences (learn at own pace, opportunity to reflect on change and practice implications, permit needs-based, goal-directed learning), (2) physicians’ content preferences (systematic approach to content; clinical problem or case based; interactive with content, experts, and peers; facilitate change and practice improvement), (3) technical aspects (user-friendly, effective use of multimedia, inclusion of linked resources), and (4) evaluation components (allow for learner self-assessment, course evaluates itself and outcomes).10 Our decision to include text and images rather than rely on video clips was based on input that health professionals wanted flexibility to complete the tutorial efficiently and from locations where video might not be easily feasible. In addition to clinical examples throughout the CME, we included a separate section at the end of the tutorial that consisted of case studies that integrate and apply the content, thereby providing the opportunity to see the relevance and how to apply what they are learning in the tutorial. The tutorial provides links to additional resources throughout and in a single location at the end to facilitate access and use of these resources while completing the tutorial and at subsequent times. Our partnership created an online tutorial, “Expanding Clinicians’ Roles in Breastfeeding Support,” that is available free of charge for pediatricians and other health care providers. The CME has been approved for 1.5 American Medical Association Physician’s Recognition Award Category 1 Credit(s) for physicians. Registered nurses receive 1.5 American Nurses Credentialing Center Continuing Nurse Education contact hours for participation in this educational activity. These continuing education authorizations expire in August 2016. The continuing education tutorial has been promoted as a free-of-charge resource for all through announcements sent via
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Table 1. Continuing Medical Education Evaluation Measures Obtained from Physician and Registered Nurse (RN) Participants.a August 2013–August 2014 Learning Objectives Explain implications of breast physiology for achieving exclusive breast milk feeding. Apply the current guidelines regarding duration of breastfeeding, use of supplements, and use of infant formulas. Identify the limited contraindications to breastfeeding. Assess breastfeeding history and lactating mother’s needs. Make appropriate recommendations for referral to lactation services. Recommend medication choices that are aligned with supporting lactating mothers. Describe the populationwide benefits of supporting breastfeeding.
Physician Participants Who Reported “Met,”b %
RN Participants Who “Strongly Agree,”c %
RN Participants Who “Strongly Agree” or “Agree,”d %
98.8
60.2
96.0
99.5
63.2
97.1
98.5
62.9
97.3
99.2
63.5
97.9
99.0
60.3
94.5
99.0
55.9
90.2
99.6
61.5
94.0
a
he continuing education questions differ for physicians and nurses. Scale included the following: strongly agree, agree, disagree, strongly disagree, and T NA. Not applicable (NA) evaluation measures have been discounted. b Other choices were “partially met” or “did not meet.” c Other choices were “agree,” “disagree,” and “strongly disagree.” d Other choices were “disagree” and “strongly disagree.”
listservs of the Massachusetts Breastfeeding Coalition, the Massachusetts Baby-Friendly Collaborative, and the Centers for Disease Control and Prevention’s Department of Nutrition, Physical Activity, and Obesity. Additional methods to promote the CME included. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) electronic mailing lists, annual World Breastfeeding Week communication with Massachusetts birth hospitals, the WIC Breastfeeding Focus newsletter for health care providers, and the Massachusetts chapter of the AAP’s fall 2013 forum newsletter. The Northeastern Institutional Review Board (IRB), Northeastern University, Boston, Massachusetts, reviewed the project and agreed that it did not meet the definition of research involving human subjects and that there was no need for additional IRB involvement.
Online Tutorial Use The online tutorial has been available since August 2013. In the first year, 1606 clinicians, of whom 1172 were nurses (73%) and 434 were physicians (27%) from 47 states, received continuing education credit (with an average of 134 health care providers participating per month). Massachusetts clinicians represented 28% of the total. Another 27% were
from North Carolina, New York, New Jersey, and Michigan combined. The other 45% were from 42 states. The tutorial website identified 10 831 unique visitors from more than 30 countries. The posttest was passed by 95% of those who initiated it (no pretest was included). The required evaluation questions were different for the CME than the nurse contact hours. Table 1 shows physician and nurse responses about the tutorial’s achievement of learning objectives. Physicians’ responses ranged from 98.5% to 99.6%, and nurses’ responses ranged from 90.2% to 97.9%. Physician feedback also included the following: (a) 75.5% gave it a 5 (excellent) on a 5-point scale and 98.8% gave it a 4 or 5, and (b) 96.0% agreed that the CME activity was balanced, promoted improvements and/or quality in health care, and was not unduly biased toward a specific commercial interest. Feedback on the tutorial led to a name change for the original tutorial. “Pediatricians” was replaced with “Clinicians,” reflecting input that the content was applicable to a wide array of health care providers and that the title did not convey that aspect accurately. Feedback on the tutorial also led to the creation of a second free online tutorial that is more focused on providers delivering care to pregnant women and new mothers who want to breastfeed. The additional tutorial includes content that would fulfill the 3 hours of required
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Edwards et al training for physicians practicing in hospitals seeking to achieve Baby-Friendly Hospital Designation. The second tutorial covers additional background on breast examination and assessment prior to delivery, provision of anticipatory guidance to pregnant women interested in breastfeeding, maternity care practices that influence breastfeeding outcomes, breastfeeding preterm infants, breastfeeding’s role in helping address disparities, and dispelling common breastfeeding myths. The section on maternity practices includes content on the importance of skin-to-skin contact for the newborn, the role of rooming-in, and the evidence base for the 10 Steps of the Baby-Friendly Hospital Initiative. It also addresses some neonatal circumstances that are often challenges in the care of the breastfeeding mother and her newborn: weight loss, supplementation, hyperbilirubinemia, late preterm infants, breastfeeding for infants in the neonatal intensive care unit, ankyloglossia (tongue-tie), and family planning. It concludes with integrative case studies and resources like the first CME. Learning objectives and the sections of the tutorial are available at the CME webpages: http://www.northeastern.edu/breastfeedingcme/index and www.mass.gov/dph/breastfeeding.html. The second tutorial, “Expanding Clinicians’ Roles in Breastfeeding Support: Focus on Maternal & Infant Care Prenatally and During the Hospital Stay,” became available August 1, 2014; it will be available until July 31, 2017, when the continuing education authorizations expire. Preliminary data are showing good interest in the second tutorial but, as expected, not at the pace of the first tutorial given the expected higher demand for postpartum information by a wider array of health professionals. Additional efforts for promoting the second tutorial are currently being planned. The website address to access both of the online tutorials is www.hriainstitute.org/BreastfeedingCME. (The online tutorials require use of recent versions of common browsers, including Firefox and Google Chrome.) As of March 31, 2015, a total of 2676 have completed the first tutorial for credit (795 physicians and 1881 nurses), and 647 have completed the second tutorial for credit (235 physicians and 412 nurses) in the United States. An additional 13 clinicians from locations outside the United States have completed the first tutorial, and none from locations outside the United States have completed the second tutorial. There have been 20 236 unique visitors to the tutorials’ website since its inception.
facilitates better support for breastfeeding mothers by health professionals. The adult learning orientation of the content is aligned with lifelong education that has always been part of being a dedicated health professional. Further research is needed to better understand how tutorials such as ours affect practices and how they complement and enhance other educational practices and efforts to improve the quality of care. Since we did not include a pretest, we cannot provide an analysis that would include the baseline knowledge of those who have completed the tutorial. In addition, this project was focused on those practicing in the United States; however, it was accessed by English-speaking professionals in other countries, and its applicability in those circumstances required further exploration.
Conclusion The tutorials contribute to the achievement of 8 Healthy People 2020 Maternal, Infant, and Child Health objectives11 and 1 key indicator for the National Prevention Strategy (Healthy Eating Section).12 Preventive health behaviors such as breastfeeding require support at all levels, and the role of health professionals is crucial in supporting these healthy behaviors. The tutorials, especially the second one, also support achievement of better quality of care through supporting implementation of The Joint Commission’s Perinatal Care Core Measure Set.13 If we, as a society, are going to attain our national prevention goals, then it is essential for individuals across organizations to work together and provide widely accessible resources in pursuit of these preventive health goals. Our collaborative effort was one of many that are directed toward creating a healthier population by improving the healthy starts for our infants and healthy lifestyles for women and families. Acknowledgments We are grateful to all those who contributed to the tutorials in various ways and who have provided feedback on the tutorials. We also acknowledge students Emily Russell and Katherine MacLean for their contributions.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Discussion
Funding
The widespread use of the tutorials and the feedback received about them demonstrate the value of a multiorganizational and interprofessional team working together to provide a needed resource. The goal of free-of-charge educational content inspired cooperation and effective collaborative dynamics among the various stakeholders to generate material that
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the first online tutorial has been received from the Centers for Disease Control and Prevention (CDC) on the grant that funded the work (CDC DNPAO Supplemental Funding to Support Breastfeeding Promotion and Support Activities, Award 3U58DP001400-05W1). Funding for the second online tutorial has
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been received from Cooperative Agreement CDC-RFA-DP13-1305, “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health,” from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily reflect the official views of the CDC, the Department of Health and Human Services, or the federal government.
References 1. Centers for Disease Control and Prevention. CDC breastfeeding report card 2014. http://www.cdc.gov/breastfeeding/pdf/ 2014breastfeedingreportcard.pdf. Accessed September 5, 2014. 2. US Department of Health and Human Services, Office of the Surgeon General. The Surgeon General’s Call to Action to Support Breastfeeding. http://www.surgeongeneral.gov/library/ calls/breastfeeding/. Published January 20, 2011. Accessed August 27, 2014. 3. Wutoh R, Boren SA, Balas EA. eLearning: a review of Internet-based continuing medical education. J Contin Educ Health Prof. 2004;24(1):20-30. 4. Edwards RA, Tolan ER, Colchamiro R, Nordstrom C. Massachusetts: enabling continuity of care for breastfeeding support. https://apha.confex.com/apha/141am/webprogram/ Paper294679.html. Accessed October 18, 2014. 5. American Academy of Pediatrics. Breastfeeding Residency Curriculum. http://www2.aap.org/breastfeeding/curriculum/ tools.html#preparedPresentations. Accessed January 15, 2015.
6. Wellstart International website. http://www.wellstart.org/SelfStudy-Module.pdf. Accessed January 15, 2015. 7. CHAMPS: Communities and Hospitals Advancing Maternity Practices. The Breastfeeding Center at Boston Medical Center website. http://www.champsbreastfeed.org/training-for-healthcare-professionals.html. Accessed January 15, 2015. 8. American Academy of Pediatrics. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2012;129:e827-e841. 9. Knowles M. The Adult Learner: A Neglected Species. 3rd ed. Houston, TX: Gulf Publishing; 1984. 10. Shortt SED, Guillemette J, Duncan AM, Kirby F. Defining quality criteria for online continuing medical education modules using modified nominal group technique. J Continuing Educ Health Professions. 2010;30(4):246-250. 11. Centers for Disease Control and Prevention. HealthyPeople. gov 2020 Topics and Objectives Maternal, Infant, and Child Health website. http://www.healthypeople.gov/2020/topicsobjectives/topic/maternal-infant-and-child-health/objectives. Accessed August 31, 2014. 12. National Prevention Council. National Prevention Strategy website. http://www.surgeongeneral.gov/initiatives/prevention/ strategy/report.pdf. Accessed August 27, 2014. 13. US Breastfeeding Committee. Toolkit: implementing TJC perinatal care core measure on exclusive breast milk feeding. http://www. usbreastfeeding.org/HealthCare/HospitalMaternityCenter Practices/ToolkitImplementingTJCCoreMeasure/tabid/184/ Default.aspx. Accessed September 16, 2014.
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research-article2015
JHLXXX10.1177/0890334415585977Journal of Human LactationEdwards et al
Insights in Practice
Online Continuing Education for Expanding Clinicians’ Roles in Breastfeeding Support
Journal of Human Lactation 2015, Vol. 31(4) 582–586 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0890334415585977 jhl.sagepub.com
Roger A. Edwards, ScD1, Rachel Colchamiro, MPH, RD, LDN, CLC2, Ellen Tolan, RD, LDN, IBCLC2, Susan Browne, MD3, Mary Foley, RN, BSN, IBCLC4, Lucia Jenkins, RN, IBCLC, RLC4, Kristen Mainello, MPH5, Rohith Vallu, BS6, Lauren E. Hanley, MD, FACOG, IBCLC7, Mary Ellen Boisvert, MSN, RN, CLC, CCE8, Julie Forgit, LDN, CLC2, Kara Ghiringhelli, RD, LDN, CLC2, and Christina Nordstrom, MEd2
Abstract Lack of health professional support is an important variable affecting mothers’ achievement of breastfeeding goals. Online continuing education is a recognized pathway for disseminating content for improving clinicians’ knowledge and supporting efforts to change practices. At the time we developed our project, free, accredited continuing education for physicians related to breastfeeding management that could be easily accessed using portable devices (via tablets/smartphones) was not available. Such resources were in demand, especially for facilities pursuing designation through the Baby-Friendly Hospital Initiative. We assembled a government, academic, health care provider, and professional society partnership to create such a tutorial that would address the diverse content needed for supporting breastfeeding mothers postdischarge in the United States. Our 1.5-hour-long continuing medical and nursing education was completed by 1606 clinicians (1172 nurses [73%] and 434 physicians [27%]) within 1 year. More than 90% of nurses and over 98% of physicians said the tutorial achieved its 7 learning objectives related to breastfeeding physiology, broader factors in infant feeding decisions and practices, the American Academy of Pediatrics’ policy statement, and breastfeeding management/troubleshooting. Feedback received from the tutorial led to the creation of a second tutorial consisting of another 1.5 hours of continuing medical and nursing education related to breast examination and assessment prior to delivery, provision of anticipatory guidance to pregnant women interested in breastfeeding, maternity care practices that influence breastfeeding outcomes, breastfeeding preterm infants, breastfeeding’s role in helping address disparities, and dispelling common myths. The tutorials contribute to achievement of 8 Healthy People 2020 Maternal, Infant and Child Health objectives. Keywords breastfeeding, continuing education, online tutorial
Background Although more than 40 health professional organizations and numerous government agencies and reports recommend that infants be breastfed exclusively for 6 months, only 18.8% of infants in the United States receive breast milk exclusively for the first 6 months of life.1 Lack of health professional support has been consistently identified as an important variable affecting mothers’ achievement of their breastfeeding goals.2 Internet-based e-learning has become a core component of continuing health professional education for a number of years.3 As part of a larger effort to change the climate and resources for postdischarge support of breastfeeding mothers in the commonwealth of Massachusetts,4 we sought to address gaps in clinician education related to postdischarge support of breastfeeding. While materials related to supporting
1 Consultant, Massachusetts Department of Public Health, and formerly Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA 2 Massachusetts Department of Public Health, Boston, MA, USA 3 MA Chapter, American Academy of Pediatrics, Waltham, MA, USA 4 Melrose-Wakefield Hospital, Hallmark Health System, Melrose, MA, USA 5 Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA 6 College of Computer & Information Sciences, Northeastern University, Boston, MA, USA 7 Harvard University School of Medicine, Massachusetts General Hospital, Boston, MA, USA 8 Beth Israel Deaconess Plymouth, Plymouth, MA USA
Date submitted: October 20, 2014; Date accepted: April 9, 2015. Corresponding Author: Christina Nordstrom, MEd, Obesity Prevention Program Director, Division of Prevention and Wellness, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA. Email: [email protected]
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Edwards et al breastfeeding mothers did exist and fulfill useful roles and specific needs, they were not in a form that was readily accessed by portable devices and used by clinicians, especially physicians. For example, the American Academy of Pediatrics (AAP) has a Breastfeeding Residency Curriculum that comprehensively covers important topics and includes valuable case studies, but it cannot be efficiently reviewed by a clinician wanting a succinct overview and attainment of continuing education credits.5 The Wellstart International Lactation Management Self-Study resource is available as a PDF, but it is not formatted as an online “e-learning” tool (with content and pre- and posttests automatically scored) that is accessible using portable devices; continuing education credits are not automatically awarded upon successful completion of the course.6 A number of professional societies (eg, Academy of Breastfeeding Medicine), education organizations (eg, Carolina Global Breastfeeding Institute, University of Virginia), private entities (eg, Lactation Education Resources and Evergreen) offer programs with continuing education credits, but they are offered at specific times or include recorded presentations of prior presentations and not available for free. Links to many of these programs are available at The Breastfeeding Center’s CHAMPS website.7 Others offer free programs, such as New York State, but none have had free continuing education credits and material in a form that was efficiently accessed by the busy clinician on a handheld, portable device. Clinicians are in strong positions to influence mothers due to their frequent contacts and the perception by the mother that the clinicians are the experts in this area. Yet, practical, easily accessible information for interacting and educating patients has been lacking. It was this gap that our project was seeking to fill.
Approach We wanted to implement an approach that would produce continuing professional education that covers the diverse content associated with supporting successful breastfeeding after discharge from the hospital. Hence, we established a government, academic, health care provider, and professional society partnership to create the content for the online continuing medical education (CME) tutorial. The publication of the newest AAP policy statement on breastfeeding and the use of human milk in 20128 also provided an appropriate impetus for the Massachusetts chapter of the AAP to collaborate with the Massachusetts Department of Public Health to create a new continuing education on breastfeeding. The tutorial covers background on breastfeeding, broader factors in infant feeding decisions and practices, the AAP guidelines, breastfeeding management and troubleshooting, integrative case studies, and a review of available resources. Learning objectives and the sections of the tutorial are available at the CME webpage: http://www.northeastern.edu/breast feedingcme/index.html. The topics and content were selected by a consensus process of the authors, reflecting the partner-
ship noted above, and guided by the principles of adult learning described below. The effort was guided by Malcolm Knowles’s theory of andragogy,9 which describes 5 components that are essential for successful adult learning: 1. Self-concept: Adults are self-directed and seek control in deciding what they are learning and their responsibility in directing and motivating their own learning. 2. Experience: Adults bring their experiences to their learning, and learning should incorporate that aspect. 3. Orientation to learning: Adults learn better when they can apply what they are learning in a problem-centered manner rather than a subject-centered manner. 4. Readiness to learn: Adults learn better when they know they need to learn something. 5. Motivation to learn: Adults learn based on internal motivation associated with perceived relevance and impact in their lives. The theory is consistent with a recent literature review that highlighted 4 key themes for online CME: (1) physicians’ learning preferences (learn at own pace, opportunity to reflect on change and practice implications, permit needs-based, goal-directed learning), (2) physicians’ content preferences (systematic approach to content; clinical problem or case based; interactive with content, experts, and peers; facilitate change and practice improvement), (3) technical aspects (user-friendly, effective use of multimedia, inclusion of linked resources), and (4) evaluation components (allow for learner self-assessment, course evaluates itself and outcomes).10 Our decision to include text and images rather than rely on video clips was based on input that health professionals wanted flexibility to complete the tutorial efficiently and from locations where video might not be easily feasible. In addition to clinical examples throughout the CME, we included a separate section at the end of the tutorial that consisted of case studies that integrate and apply the content, thereby providing the opportunity to see the relevance and how to apply what they are learning in the tutorial. The tutorial provides links to additional resources throughout and in a single location at the end to facilitate access and use of these resources while completing the tutorial and at subsequent times. Our partnership created an online tutorial, “Expanding Clinicians’ Roles in Breastfeeding Support,” that is available free of charge for pediatricians and other health care providers. The CME has been approved for 1.5 American Medical Association Physician’s Recognition Award Category 1 Credit(s) for physicians. Registered nurses receive 1.5 American Nurses Credentialing Center Continuing Nurse Education contact hours for participation in this educational activity. These continuing education authorizations expire in August 2016. The continuing education tutorial has been promoted as a free-of-charge resource for all through announcements sent via
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Table 1. Continuing Medical Education Evaluation Measures Obtained from Physician and Registered Nurse (RN) Participants.a August 2013–August 2014 Learning Objectives Explain implications of breast physiology for achieving exclusive breast milk feeding. Apply the current guidelines regarding duration of breastfeeding, use of supplements, and use of infant formulas. Identify the limited contraindications to breastfeeding. Assess breastfeeding history and lactating mother’s needs. Make appropriate recommendations for referral to lactation services. Recommend medication choices that are aligned with supporting lactating mothers. Describe the populationwide benefits of supporting breastfeeding.
Physician Participants Who Reported “Met,”b %
RN Participants Who “Strongly Agree,”c %
RN Participants Who “Strongly Agree” or “Agree,”d %
98.8
60.2
96.0
99.5
63.2
97.1
98.5
62.9
97.3
99.2
63.5
97.9
99.0
60.3
94.5
99.0
55.9
90.2
99.6
61.5
94.0
a
he continuing education questions differ for physicians and nurses. Scale included the following: strongly agree, agree, disagree, strongly disagree, and T NA. Not applicable (NA) evaluation measures have been discounted. b Other choices were “partially met” or “did not meet.” c Other choices were “agree,” “disagree,” and “strongly disagree.” d Other choices were “disagree” and “strongly disagree.”
listservs of the Massachusetts Breastfeeding Coalition, the Massachusetts Baby-Friendly Collaborative, and the Centers for Disease Control and Prevention’s Department of Nutrition, Physical Activity, and Obesity. Additional methods to promote the CME included. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) electronic mailing lists, annual World Breastfeeding Week communication with Massachusetts birth hospitals, the WIC Breastfeeding Focus newsletter for health care providers, and the Massachusetts chapter of the AAP’s fall 2013 forum newsletter. The Northeastern Institutional Review Board (IRB), Northeastern University, Boston, Massachusetts, reviewed the project and agreed that it did not meet the definition of research involving human subjects and that there was no need for additional IRB involvement.
Online Tutorial Use The online tutorial has been available since August 2013. In the first year, 1606 clinicians, of whom 1172 were nurses (73%) and 434 were physicians (27%) from 47 states, received continuing education credit (with an average of 134 health care providers participating per month). Massachusetts clinicians represented 28% of the total. Another 27% were
from North Carolina, New York, New Jersey, and Michigan combined. The other 45% were from 42 states. The tutorial website identified 10 831 unique visitors from more than 30 countries. The posttest was passed by 95% of those who initiated it (no pretest was included). The required evaluation questions were different for the CME than the nurse contact hours. Table 1 shows physician and nurse responses about the tutorial’s achievement of learning objectives. Physicians’ responses ranged from 98.5% to 99.6%, and nurses’ responses ranged from 90.2% to 97.9%. Physician feedback also included the following: (a) 75.5% gave it a 5 (excellent) on a 5-point scale and 98.8% gave it a 4 or 5, and (b) 96.0% agreed that the CME activity was balanced, promoted improvements and/or quality in health care, and was not unduly biased toward a specific commercial interest. Feedback on the tutorial led to a name change for the original tutorial. “Pediatricians” was replaced with “Clinicians,” reflecting input that the content was applicable to a wide array of health care providers and that the title did not convey that aspect accurately. Feedback on the tutorial also led to the creation of a second free online tutorial that is more focused on providers delivering care to pregnant women and new mothers who want to breastfeed. The additional tutorial includes content that would fulfill the 3 hours of required
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Edwards et al training for physicians practicing in hospitals seeking to achieve Baby-Friendly Hospital Designation. The second tutorial covers additional background on breast examination and assessment prior to delivery, provision of anticipatory guidance to pregnant women interested in breastfeeding, maternity care practices that influence breastfeeding outcomes, breastfeeding preterm infants, breastfeeding’s role in helping address disparities, and dispelling common breastfeeding myths. The section on maternity practices includes content on the importance of skin-to-skin contact for the newborn, the role of rooming-in, and the evidence base for the 10 Steps of the Baby-Friendly Hospital Initiative. It also addresses some neonatal circumstances that are often challenges in the care of the breastfeeding mother and her newborn: weight loss, supplementation, hyperbilirubinemia, late preterm infants, breastfeeding for infants in the neonatal intensive care unit, ankyloglossia (tongue-tie), and family planning. It concludes with integrative case studies and resources like the first CME. Learning objectives and the sections of the tutorial are available at the CME webpages: http://www.northeastern.edu/breastfeedingcme/index and www.mass.gov/dph/breastfeeding.html. The second tutorial, “Expanding Clinicians’ Roles in Breastfeeding Support: Focus on Maternal & Infant Care Prenatally and During the Hospital Stay,” became available August 1, 2014; it will be available until July 31, 2017, when the continuing education authorizations expire. Preliminary data are showing good interest in the second tutorial but, as expected, not at the pace of the first tutorial given the expected higher demand for postpartum information by a wider array of health professionals. Additional efforts for promoting the second tutorial are currently being planned. The website address to access both of the online tutorials is www.hriainstitute.org/BreastfeedingCME. (The online tutorials require use of recent versions of common browsers, including Firefox and Google Chrome.) As of March 31, 2015, a total of 2676 have completed the first tutorial for credit (795 physicians and 1881 nurses), and 647 have completed the second tutorial for credit (235 physicians and 412 nurses) in the United States. An additional 13 clinicians from locations outside the United States have completed the first tutorial, and none from locations outside the United States have completed the second tutorial. There have been 20 236 unique visitors to the tutorials’ website since its inception.
facilitates better support for breastfeeding mothers by health professionals. The adult learning orientation of the content is aligned with lifelong education that has always been part of being a dedicated health professional. Further research is needed to better understand how tutorials such as ours affect practices and how they complement and enhance other educational practices and efforts to improve the quality of care. Since we did not include a pretest, we cannot provide an analysis that would include the baseline knowledge of those who have completed the tutorial. In addition, this project was focused on those practicing in the United States; however, it was accessed by English-speaking professionals in other countries, and its applicability in those circumstances required further exploration.
Conclusion The tutorials contribute to the achievement of 8 Healthy People 2020 Maternal, Infant, and Child Health objectives11 and 1 key indicator for the National Prevention Strategy (Healthy Eating Section).12 Preventive health behaviors such as breastfeeding require support at all levels, and the role of health professionals is crucial in supporting these healthy behaviors. The tutorials, especially the second one, also support achievement of better quality of care through supporting implementation of The Joint Commission’s Perinatal Care Core Measure Set.13 If we, as a society, are going to attain our national prevention goals, then it is essential for individuals across organizations to work together and provide widely accessible resources in pursuit of these preventive health goals. Our collaborative effort was one of many that are directed toward creating a healthier population by improving the healthy starts for our infants and healthy lifestyles for women and families. Acknowledgments We are grateful to all those who contributed to the tutorials in various ways and who have provided feedback on the tutorials. We also acknowledge students Emily Russell and Katherine MacLean for their contributions.
Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Discussion
Funding
The widespread use of the tutorials and the feedback received about them demonstrate the value of a multiorganizational and interprofessional team working together to provide a needed resource. The goal of free-of-charge educational content inspired cooperation and effective collaborative dynamics among the various stakeholders to generate material that
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for the first online tutorial has been received from the Centers for Disease Control and Prevention (CDC) on the grant that funded the work (CDC DNPAO Supplemental Funding to Support Breastfeeding Promotion and Support Activities, Award 3U58DP001400-05W1). Funding for the second online tutorial has
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Journal of Human Lactation 31(4)
been received from Cooperative Agreement CDC-RFA-DP13-1305, “State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors and Promote School Health,” from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily reflect the official views of the CDC, the Department of Health and Human Services, or the federal government.
References 1. Centers for Disease Control and Prevention. CDC breastfeeding report card 2014. http://www.cdc.gov/breastfeeding/pdf/ 2014breastfeedingreportcard.pdf. Accessed September 5, 2014. 2. US Department of Health and Human Services, Office of the Surgeon General. The Surgeon General’s Call to Action to Support Breastfeeding. http://www.surgeongeneral.gov/library/ calls/breastfeeding/. Published January 20, 2011. Accessed August 27, 2014. 3. Wutoh R, Boren SA, Balas EA. eLearning: a review of Internet-based continuing medical education. J Contin Educ Health Prof. 2004;24(1):20-30. 4. Edwards RA, Tolan ER, Colchamiro R, Nordstrom C. Massachusetts: enabling continuity of care for breastfeeding support. https://apha.confex.com/apha/141am/webprogram/ Paper294679.html. Accessed October 18, 2014. 5. American Academy of Pediatrics. Breastfeeding Residency Curriculum. http://www2.aap.org/breastfeeding/curriculum/ tools.html#preparedPresentations. Accessed January 15, 2015.
6. Wellstart International website. http://www.wellstart.org/SelfStudy-Module.pdf. Accessed January 15, 2015. 7. CHAMPS: Communities and Hospitals Advancing Maternity Practices. The Breastfeeding Center at Boston Medical Center website. http://www.champsbreastfeed.org/training-for-healthcare-professionals.html. Accessed January 15, 2015. 8. American Academy of Pediatrics. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2012;129:e827-e841. 9. Knowles M. The Adult Learner: A Neglected Species. 3rd ed. Houston, TX: Gulf Publishing; 1984. 10. Shortt SED, Guillemette J, Duncan AM, Kirby F. Defining quality criteria for online continuing medical education modules using modified nominal group technique. J Continuing Educ Health Professions. 2010;30(4):246-250. 11. Centers for Disease Control and Prevention. HealthyPeople. gov 2020 Topics and Objectives Maternal, Infant, and Child Health website. http://www.healthypeople.gov/2020/topicsobjectives/topic/maternal-infant-and-child-health/objectives. Accessed August 31, 2014. 12. National Prevention Council. National Prevention Strategy website. http://www.surgeongeneral.gov/initiatives/prevention/ strategy/report.pdf. Accessed August 27, 2014. 13. US Breastfeeding Committee. Toolkit: implementing TJC perinatal care core measure on exclusive breast milk feeding. http://www. usbreastfeeding.org/HealthCare/HospitalMaternityCenter Practices/ToolkitImplementingTJCCoreMeasure/tabid/184/ Default.aspx. Accessed September 16, 2014.
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