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Preventing nipple trauma in lactating women in the University Hospital of the University of Sao Paulo: a best practice implementation project 1,3

Gilcéria Tochika Shimoda, RN, PhD

Alda Valeria Neves Soares, RN, PhD

1

Ilva Marico Mizumoto Aragaki, RN, PhD

1

Alexa McArthur, RN, RM, MPHC, MClinSc

2

1. Department of Nursing, University Hospital, University of Sao Paulo, Sao Paulo, Brazil 2. Joanna Briggs Institute, University of Adelaide, South Australia, Australia 3. The Brazilian Centre for Evidence-based Healthcare: an Affiliate center of The Joanna Briggs Institute Primary contact: Gilcéria Tochika Shimoda [email protected]

Key dates Commencement date: April 10, 2013 Completion date: October 18, 2013

Executive summary Background Nipple trauma in lactating women is an important issue in facilitating successful breastfeeding. Evidence suggests that early postnatal education on the positioning and attachment technique, early observation of mothers and correcting breastfeeding techniques at an early stage may reduce nipple trauma. Objectives The aim of this project was to improve breastfeeding practice and thereby reduce nipple trauma in lactating women in a public hospital in Sao Paulo. More specifically the objectives of this project were: firstly, to assess the current practice in nurses’ assistance concerning the prevention of nipple trauma; secondly, to adapt and trial a Breastfeeding Assessment Form to observe and educate the lactating mother during the early post natal period; and thirdly, to assess the impact of introducing the assessment strategy on breastfeeding and nipple trauma rates. Methods

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The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) online tool was utilized for this project. A clinical audit was conducted to assess compliance with best practice in nursing assistance concerning the prevention of nipple trauma. The project concluded with a second audit, which assessed the change in practice following the implementation of strategies to improve practice. Results The project was successful in that there was an improvement across all of the audit criteria following the introduction of the strategy to promote best practice. Criterion 1, concerning nursing staff knowledge, improved in compliance by 73%. Criterion 2 and 4, concerning women’s knowledge about prevention and management of nipple trauma, improved by 53% and 55% respectively. Breastfeeding assessment improved by 26% from baseline to follow-up audit. Moreover, an improvement in women’s satisfaction and exclusive breastfeeding rates was observed; however, nipple trauma rates did not decrease. Conclusions This implementation project had great impact on both nursing staff as well as lactating women’s knowledge of preventing and managing nipple trauma. It also enhanced women’s satisfaction with breastfeeding and exclusive breastfeeding rates. Further research is required into other aspects involved with the onset of nipple trauma. Keywords evidence-based nursing, clinical audit, breastfeeding, nipple trauma, benchmarking, implementation project

Background Nipple trauma in breastfeeding women is a common condition experienced by new mothers and is one that health professionals are frequently required to address. The incidence of nipple pain in 1

breastfeeding women is reported to vary from 34% to 96%, and nipple trauma has been identified as a 2–7

result of ineffective positioning and attachment techniques.

This type of lesion, which may cause pain when breastfeeding, is considered an important factor 8

negatively impacting on the breastfeeding process, and may lead to early weaning. In addition, this kind of nipple injury can be recurrent, especially if an incorrect attachment technique is not corrected. As a result of recurring damage to the nipple skin tissue, rates of epithelialization may be reduced and wound healing delayed, when compared to other types of lesions.

9

Exclusive breastfeeding for up to six months of a child's life is widely regarded as an important intervention for reducing infant and child mortality, and is strongly recommended by the Ministry of Health in Brazil and the World Health Organization.

10

However breastfeeding rates still fall short of

expectations, as shown by the latest national survey conducted in 2008 in the capitals of the Brazilian states, which found a median value of 54.1 days of exclusive breastfeeding in Brazil, and 66.6 days in 11

the south-east region, where this study was conducted.

Current rates of breastfeeding in this region

fall short of the recommended six months of exclusive breastfeeding. As a global strategy to protect, promote and support breastfeeding, the Baby Friendly Hospital Initiative plays an important role in increasing the breastfeeding rates in Brazil.

12

Every certified hospital follows

the ten steps to successful breastfeeding, as follows:

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1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding. 4. Help mothers initiate breastfeeding within half an hour after birth. 5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practice rooming in, that is, allow mothers and infants to remain together 24 hours a day. 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

12

The steps which represent the main resources to improve health professionals’ skills to assist lactating women to breastfeed are: train health care staff on how to demonstrate correct positioning of the baby to breastfeed, and how to assist with any problems due to the breastfeeding process, including clinical 12

and counselling skills (step 2) ; help mothers to initiate breastfeeding within half an hour after birth, which represents the optimal timing for a newborn’s first breastfeed or skin-to-skin contact with the 12

12

mother (step 4) ; and show mothers how to breastfeed and maintain lactation (step 5). In a maternity ward, omission or unsuccessful demonstration of any of these steps could be directly related to the onset of nipple trauma. The University Hospital of the University of Sao Paulo has been certified as a Baby Friendly Hospital since 2006, and is accredited every two years in order to maintain this certification. Recertification requires all staff to be trained to assist new mothers and to follow the ten steps to successful breastfeeding. Nursing staff, being involved in the care of the mothers and their newborns 24 hours a day, are a major support during the breastfeeding process, and dealing with the difficulties and complications regarding this is a huge challenge. In everyday clinical practice, the most common difficulty experienced by new mothers is nipple trauma, which leads to a painful breastfeeding experience. In June 2012, following concerns regarding this problem, a “Nipple Trauma Indicator” (Appendix 2) was introduced, as a quality of care indicator, to evaluate breastfeeding assistance given. According to this protocol, the nurse evaluates the mother daily and records the presence or absence of nipple trauma and the baby’s ability to latch on to the nipple. After six months of implementation, the primary results of this initiative showed an incidence of 52.0% to 59.2% nipple trauma in a sample of 1672 lactating women, the main cause being trauma, which was, according to nursing staff, largely due 13

to ineffective attachment techniques (44%). This raised concerns regarding insufficient assessment of breastfeeding practice, and a lack of education provided to women related to correct positioning and attachment techniques. In addition, the high level of nipple trauma indicated that there may be an inadequate level of support and education being given to new mothers during the onset of the breastfeeding process. Breastfeeding is a dynamic process, therefore it is important to keep evaluating mothers and newborns each shift. The data collected highlighted that assessments were not always being performed during shifts.

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The University Hospital of the University of Sao Paulo is a public hospital of secondary care complexity with 236 beds, with three main areas: therapeutics, education and scientific research. The hospital serves the residential community of the western area of the city of Sao Paulo, Brazil, which is the community of Butanta, with 376,140 inhabitants including the university community. The maternity ward has 52 beds in total: five assigned to gynecological patients, four to women with pathologic pregnancies, and 43 to mother and newborn dyad. The maternity ward adopts the rooming-in system, and the normal length of stay is 60 hours minimum, irrespective of the type of delivery. All patients are scheduled for an appointment with a nurse, from three to ten days after discharge, at the outpatients unit. The nursing staff of the maternity ward consists of one chief nurse, 12 nurse practitioners and 30 nurse technicians. Staff are distributed over two shifts of six hours duration (morning and afternoon shift). In addition, workers on evening shifts work alternate days of 12 hours. Nurse practitioners are responsible for the supervision of the nursing process (assessing the patient, identifying nursing diagnoses, and planning, implementing and evaluating nursing care). All the registered nurses who work in the maternity ward have a one year specialization in midwifery. This expertise enables them to assist women in the postpartum period, with a more centered focus on their health needs at this very particular life stage. The nurse technicians are responsible for the execution of nursing care. The nursing process enables individualized nursing care according to the needs of each mother and newborn, which includes individualized assistance in breastfeeding. In addition to accessing ward staff, women can attend a one-hour education session, offered by nurses once daily, on breastfeeding (importance and technique), caring for the newborn and self-care in the puerperal period. It was in this context that the author, supported by others on the nursing unit, decided to undertake a best practice implementation project aimed at examining support for early breastfeeding and enhancing the practice, particularly in relation to addressing nipple trauma. The project, which used evidence-based audit and feedback, was implemented by the author/project leader as part of her participation in the Joanna Briggs Institute Evidence Based Clinical Fellowship Program. The audit criteria and strategies implemented to improve practice in the project were informed by a brief review of the literature on best practice for preventing nipple trauma. Evidence from research literature suggests that early postnatal education on positioning and attachment technique is effective in reducing 14

nipple pain and trauma caused by breastfeeding in the postnatal period (Level I),

and by observing

mothers early on and correcting techniques at an early stage; later possible issues can be corrected 15

(Level II).

Objectives The aims of this project were to improve nursing support to lactating women during the early postnatal period, and decrease nipple trauma rates due to incorrect attachment during breastfeeding. By implementing evidence-based practice in breastfeeding assessment and prevention of nipple trauma, the project objectives were to: 

Assess current practices in nurses’ assistance concerning the prevention of nipple trauma using evidence-based audit criteria



Adapt and trial an evidence-based Breastfeeding Assessment Form to observe and educate lactating women during the early post natal period

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Assess the impact of the implementation of the Breastfeeding Assessment Form on support provided to new mothers by nurses during the initial stage of breastfeeding, nipple trauma and exclusive breastfeeding rates.

Methods Using the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES), and Getting Research into Practice (GRIP) tools, the team conducted a clinical audit to assess compliance with best practice in nursing assistance in relation to the prevention of nipple trauma. This project consisted of three phases over a period of six months, from April to October 2013. The three phases of the project are described below.

Phase 1: Baseline audit preparation and conduct

Establishment of the audit team The audit team was established from identified key stakeholders, and coordinated by the project lead who is a Nurse Practitioner at the maternity ward, and coordinator of the Evidence Based Nursing Core at the University Hospital. She was responsible for training the nursing staff on the audit process, developing the tools used as strategies to increase compliance, collecting data and supervising the implementation program. Relevant key stakeholders were appointed and following consultation, involvement was as follows: the Nursing Chief of Maternity Ward and the Director of Maternal-Child Nursing Department helped with the data collection, the training program and the supervision of the best practice implementation; the Director of the Nursing Department helped to provide the resources required for this project; nurses from the out-patient unit helped with data collection at the out-patient appointment; and doctors (obstetricians and pediatricians) were responsible for highlighting this project to their interns and residents. In addition, nursing professionals from the maternity ward implemented the Breastfeeding Assessment Form, and both nursing professionals and women gave their feedback regarding the needs and outcomes of this best practice implementation project. Definition of audit criteria To determine current levels of compliance with best practice recommendations, this project utilized the four evidence-based audit criteria obtained from the JBI PACES program related to the management of nipple pain/or trauma associated with breastfeeding. The related best practice recommendations were: Criterion 1: Healthcare staff received training regarding promotion of breastfeeding, including prevention and management of nipple pain and trauma Criterion 2: Parents received education regarding correct breastfeeding positioning, and prevention of nipple pain and trauma Criterion 3: Assessment of breastfeeding correct positioning and attachment is carried out by the midwife during each shift, as necessary Criterion 4: If a woman has experienced nipple pain, the midwife has provided management options and support for the woman. These recommendations were adapted to our context in the following ways: for Criterion 1, this study considered healthcare staff as nursing staff who carried out this implementation project; Criterion 3

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related to nurse midwives, resident nurses and nursing technicians, as all of them assessed breastfeeding techniques, and Criterion 4 related to nursing professionals as well, as all of them provided education about correct breastfeeding technique and both nurse midwives and nurse residents prescribe nursing care to mothers with nipple trauma. For Criterion 4, we considered nipple trauma instead of nipple pain, as women can experience pain without visible trauma or trauma without pain. Other outcomes of interest to this project were: 

Rates of nipple trauma on discharge and on follow-up appointment at the out-patient unit, occurring from three to ten days after discharge



Rates of exclusive breastfeeding on discharge and on follow-up appointment



Women’s satisfaction with the care/help they have received during breastfeeding.

Sample size For this project, the sample comprised women and newborns together who were breastfeeding throughout their whole hospitalization time in the maternity ward. Women separated from their babies or who did not breastfeed were excluded. The mean number of births in the University Hospital is 287 per month, and most women remain with their newborn full time during their hospitalization (about 80.9%).

13

The majority of women were eligible for inclusion in this project. We evaluated 227 patients in the baseline audit, and 217 patients in the post-implementation audit. At the outpatient appointment, the sample size varied, as 19 women were absent for the baseline audit, and 21 for the post-implementation audit. Therefore, for data after discharge, the sample comprised 208 women at baseline, and 196 women at follow-up. The sample also comprised nursing staff from the maternity ward. Nurses or technicians on holiday from work or on sick leave were excluded. We evaluated eight nurses and 29 technicians in the baseline audit, and nine nurses and 29 technicians in the post-implementation audit. Ethical considerations This project was submitted and approved by the Ethics Committee of the University Hospital of the University of Sao Paulo (CAAE number 1700513.1.0000.0076) and was conducted in agreement with 16

Resolution 196/96 of the Brazilian Health Council. A Post Informed Consent Form was not applied due to the nature of the study. Baseline audit A baseline audit was conducted prior to the best practice implementation over one month, from May to June 2013. In addition, an assessment tool was used to collect data, as shown in Appendix 1. In relation to the audit criteria, for Criterion 1, nursing staff were interviewed about their knowledge concerning the prevention and management of nipple trauma. The criterion was considered fulfilled when the staff member understood correct positioning and attachment of the baby during a breastfeed and how to manage nipple trauma. It was also noted which staff had undergone the Baby Friendly Initiative Training Program which was run by the hospital. For Criterion 2 and 3, women were interviewed at discharge regarding their knowledge about the prevention and management of nipple trauma, and if nursing staff had assessed them during breastfeeding, a minimum of one time per shift, during their hospitalization period. Criterion 2 was considered fulfilled when the women knew about correct positioning and attachment of the baby during breastfeeding. Criterion 3 was considered fulfilled when the women reported at least one observation of

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the breastfeed by the nursing professional per shift. Also, the hospital records were checked to verify which patients had participated in the educational program during their hospital stay. For Criterion 4, the Nipple Trauma Indicator Form (Appendix 2) was checked, as this instrument provided all the information regarding the presence of nipple trauma, and the nursing care prescribed if this occurred. Women were also interviewed about their knowledge concerning management of nipple trauma. It was considered fulfilled when nursing care was prescribed, the form completed in full, and the women knew how to manage nipple trauma. Data related to the exclusive breastfeeding rates at discharge was collected from the newborn’s report, and data related to exclusive breastfeeding and nipple trauma rates at the follow-up appointment were collected from nursing reports in the outpatient section. This enabled us to assess the short term impact of this project. Phase 2: Implementation of best practice Results of the baseline audit, analyzed using the JBI-PACES software, showed poor performance in compliance with three of the four audit criteria (less than 35% compliance). Only one criterion (Criterion 4) demonstrated moderate to high compliance (61%). (See Figure 1 in the Results section.) The gaps between current practice and best practice were discussed with the project team, and barriers to compliance were identified. The Getting Research into Practice framework was used to document barriers, strategies and resources required to address these barriers in order to improve compliance (Table 1 in the Results section). The strategies and resources to overcome each barrier were discussed with the project team, and an action plan was formulated and interventions for improving compliance implemented. The strategies were: (i) an educational program, (ii) a Breastfeeding Assessment Form (Appendix 3), and (iii) a Consumer Information Sheet given to the women (Appendix 4). The GRIP strategies are presented in the Results section. Both the Breastfeeding Assessment Form and the consumer leaflet were modified in response to stakeholders’ feedback, and were tested over one week. The follow-up audit was conducted one week following implementation of the form. Phase 3: Follow-up audit The post-strategy implementation audit was conducted over one month (August - September 2013) using the same audit criteria as used in the baseline. Data was collected by the primary auditor and the co-leader of this project. Additional data was also collected at this time, as the Breastfeeding Assessment Form had been introduced. More specifically, for Criterion 3, newborn nursing notes were examined, and this criterion was considered fulfilled when the Breastfeeding Assessment Form had been completed at least once per shift (day and evening shift).

Results The results from baseline and follow-up audits, with the percentage of compliance for the four audit criteria generated by JBI-PACES, are presented in Figure 1.

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Criteria legend 1. Healthcare (Nursing) staff received training regarding promotion of breastfeeding, including prevention and management of nipple pain and trauma (considered knowledge). 2. Parents (Mothers) received education regarding correct breastfeeding positioning, and prevention of nipple pain and trauma (considered knowledge). 3. Assessment of breastfeeding (correct positioning and attachment) is carried out by the midwife (nursing professionals) each shift, as necessary. 4. If a woman experienced nipple pain (trauma), the midwife (nursing professionals) provided management options and support for the woman.

Figure 1: Compliance with best practice audit criteria in follow up audit compared to baseline audit (%)

Figure 1 shows the percentage compliance with best practice regarding preventing nipple trauma for the four audit criteria at baseline and at post-GRIP strategy implementation audits. Baseline audit results (yellow bars in graph) identified the lowest compliance in nursing staff’s knowledge on the prevention and management of nipple trauma (22%), followed by the women’s knowledge on how to manage nipple pain/trauma (27%), and women’s knowledge on the correct breastfeeding positioning and prevention of nipple pain and trauma (35%). The highest compliance was in the breastfeeding process being observed by nursing professionals in all shifts (61%), as reported by women, but it was not performed in a systematic way. The GRIP results are presented in Table 1.

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Table 1: Getting Research Into Practice – identified barriers to best practice implementation and strategies for improving compliance. Barriers Lack

of

Strategies

human

resources to assess the

Resources

- Request the University to provide

- Vacancies have

extra staff via Nursing Department

nott been filled

breastfeeding

process

in

systematic

way

as yet

a in

-

Assess

breastfeeding

in

a

each shift (morning,

systematic way every 12 hours (day

afternoon

and evening shift)

and

Outcome

-Nurses Nursing education

are

assessing breastfeeding every day and

evening shift)

evening from

shift,

admission

to discharge time

Lack

of

time

observe breastfeed

to the

in

a

systematic way

- Develop a practical and useful

- A Breastfeeding

-Breastfeeding

breastfeeding

Assessment Form

Assessment

assessment

form,

attached to the newborn’s nursing

Form developed

notes

- Nursing staff were orientated to a

Training program

systematic way, give education to

on how to assess

the mothers and return at the end of

breastfeeding

the breastfeed, if it was not possible

using the form

assess

breastfeeding

in

-Training program implemented

to observe the entire process

Lack of knowledge or

- Educational programs about the

skills on the part of

positioning and attachment of the

the professionals

baby

during

breastfeeding

and

- Multimedia - Meeting room

management of nipple trauma

35

education

sessions - 100% of nursing staff trained

Lack of knowledge or

- Develop a leaflet about correct

-

skills on the part of

positioning and attachment of the

information sheet

the patients

baby during breastfeeding

Consumer

-Information sheet distributed to and approved by the mothers

For improving compliance for Criterion 1, an educational program was delivered to the nursing staff via a PowerPoint presentation and a video, on all shifts, of approximately one hour duration. As not all staff on a shift were able to attend a session at the same time, this component took approximately two weeks, with 35 meetings to be implemented to cover 100% of the staff. In total, 10 nurse/midwives, 30 technicians and two nurse residents were trained.

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Implementing a Breastfeeding Assessment Form (Appendix 3) to observe this process in a systematic way at least once per shift (day and evening shifts) was a strategy to ensure that women had been correctly assessed and educated by nursing staff, and that they understood the importance of correct positioning and attachment of the baby during a breastfeed and how to manage nipple trauma. This strategy was implemented to improve compliance in Criteria 2, 3 and 4. In addition, for improving compliance in Criterion 2, a consumer leaflet (Appendix 4) was developed which was visual and used simple language, so that all women attending the service could understand the information, regardless of their educational level. This information sheet was distributed to women at the time of admission by the nurse/midwife who was responsible to give a brief orientation about correct positioning and attachment of the baby to the breast, using this tool. Following commencement of the action plan, the follow-up audit was conducted over one month, and the results are shown in Figure 1 (blue bars in graph). Data demonstrated an improvement in all criteria after the best practice implementation program was introduced. For Criterion 1, the audit team considered not only participation of the nursing professionals in a training program (the Baby Friendly training program in baseline audit and the implementation training program in post-implementation audit), but also knowledge of the nursing professionals regarding prevention and management of nipple trauma. It was important to understand the extent to which the nurses had sufficient knowledge to be able to educate the women. Table 2 shows the items evaluated in Criterion 1.

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Table 2: Items evaluated to measure compliance in Criterion 1 Criterion 1 - Have nursing staff received training

Baseline audit

Post-implementation audit

(N= 37)

(N= 38)

regarding promotion of breastfeeding, including prevention and management of nipple pain and N

trauma? 1.1.

Participation

in

Baby Friendly training

%

N

%

35

94.6

38

100

8

21.6

36

94.7

1.2.1- correct positioning of mother and baby

36

97.3

38

100

1.2.2- correct attachment of the baby to the

37

100

38

100

1.2.3- pattern suction of the baby

35

94.6

38

100

1.2.4- how to detach the baby from the breast to

37

100

37

97.4

11

29.7

37

97.4

1.2.6- evaluate pain

35

94.6

38

100

1.2.7- evaluate if areola is soft and flexible before

25

67.6

38

100

33

89.2

37

97.4

30

81.1

38

100

program

(baseline-audit)

or

implementation

project training program (post-implementation audit) 1.2.

Knowledge

about

prevention

and

management of nipple pain and trauma

breast

break suction 1.2.5 - nipple should not be compressed after the completion of the feed

breastfeed 1.2.8- express breast milk and offer to the baby by cup feeding if the mother decided to rest her nipple 1.2.9- use of modified Lanolin, in presence of trauma

In Table 2, the audit team observed an improvement in nursing staff knowledge from 21.6% from baseline audit to 94.7% after the implementation of the project training program. The greatest improvement in compliance was seen in knowledge about nipple shape after breastfeeding and areola assessment before a breastfeed (67.7% improvement), and evaluation of the flexibility and softness of the areola before a breastfeed (32.4% improvement). The items relating to positioning and attachment of the baby to the breast showed good compliance in the baseline audit, as these aspects were promoted as part of the Baby Friendly Hospital Initiative training. For Criterion 2, the audit team observed that although participation in the educational program offered by the nurses during hospitalization had not increased, the knowledge of women regarding prevention of nipple trauma had greatly improved with the implementation of the evaluation of breastfeeding, and the distribution of the leaflet provided at the time of admission, from 35.2% in the baseline audit to

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88.5% in the post-implementation audit. Table 3 shows the items evaluated to measure compliance regarding women’s knowledge of prevention of nipple trauma.

Table 3: Items evaluated to measure compliance in Criterion 2 Criterion 2 - Have parents (mothers) received education

regarding

correct

Baseline audit

Post-implementation audit

(N= 227)

(N= 217)

breastfeeding

positioning, and prevention of nipple pain and trauma? 2.1 - Participation in educational program during

N

%

N

%

166

73.1

154

71.0

80

35.2

192

88.5

222

97.8

216

99.5

223

98.2

216

99.5

169

74.4

207

95.4

192

84.6

216

99.5

120

52.9

203

93.5

166

73.1

212

97.7

hospitalization 2.2 - Knowledge about

correct breastfeeding

positioning and prevention of nipple pain and trauma 2.2.1- knowledge about correct positioning of herself and baby 2.2.2 - knowledge about correct attachment of the baby 2.2.3 -knowledge about the pattern suction of the baby 2.2.4 - how to detach the baby from the breast to break suction 2.2.5 - nipple should not be compressed after the completion of the feed 2.2.6 - breastfeeding should be pain free

The major improvement regarding women’s knowledge was related to the evaluation of the nipple shape after breastfeeding (40.6% improvement), the evaluation of pain (24.6%), and the pattern suction of the baby (21%), from baseline to post-implementation audit. For Criterion 3, which focused on observing the actual breastfeed, compliance improved by 25.4% (from 61.2% in baseline audit to 86.6% in post-implementation audit). The mean number of breastfeeding assessments from admission to discharge time was 5.35, with a minimum of two, and a maximum of eight systematic breastfeeding observations.

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93.1

90 80

73.3

70 60 50 40

30

30 20 10 0 First breastfeed observed

Anytime breastfeed observed

Last breastfeed observed

Figure 2: Problems with positioning/attachment observed during the breastfeeding process (during hospitalization) (%) Figure 2 shows the percentage of women with inadequate positioning and/or attachment of the baby to the breast, during the systematic observation by nursing staff. Many women experienced inadequate positioning and/or attachment during their hospitalization (93.1%), and at the first observed breastfeed (73.3%). However at the last breastfeed observed (close to their time of discharge), the inadequacy of the positioning and/or attachment during breastfeeding decreased to 30.0%. Criterion 4 focused on women who presented with nipple trauma, with an improvement in compliance after best practice implementation (55.5%) being observed, from 26.7% at baseline audit to 82.2% at the follow-up audit. The items evaluated to measure compliance for this criterion are presented in Table 4. Table 4: Items evaluated to measure compliance in Criterion 4 Criterion 4. If a woman has experienced nipple pain

(trauma),

professionals)

the has

midwife

provided

Baseline Audit

Post-implementation Audit

(N= 146)

(N= 146)

(nursing

management

N

%

N

%

4. If a woman has experienced nipple trauma,

39

26.7

120

82.2

61

41.8

132

90.4

104

71.2

137

93.8

74

135

92.5

options and support for the woman. have

the

management

nursing options

professionals and

support

provided for

the

woman? 4.1. Has the woman known how to express breast milk to offer to the baby by cup feeding (in presence of trauma if she decided to rest her nipple)? 4.2. Has the woman been educated about the use of modified Lanolin (or colostrum), in presence of trauma? 4.3. Has the nurse midwife filled in the “Nipple Trauma

Indicator

management

Form”

options

and

according

108

provided to

the

cause(s) of the trauma?

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The major improvement in compliance was the knowledge of women regarding breastmilk expression, with 48.6% improvement after best practice implementation. Other outcomes of interest As mentioned in the objectives, extra outcome data was collected at various points during the project, relating to: Women’s satisfaction with the care/help they have received during breastfeeding, Rates of nipple trauma on discharge and on follow-up appointment at the out-patient unit, occurring from three to ten days after discharge; Rates of exclusive breastfeeding on discharge and on follow-up appointment; These outcomes are presented below in Figure 3. 100

93.8

80

99.5

94.2 98

85.9 87.1 64.3 67.3

60 40 20

13 16.8

0

Figure 3: Women’s satisfaction with breastfeeding care/help they received (at baseline and follow-up audits) (%)

The audit team observed an improvement in women’s satisfaction, and in the exclusive breastfeeding rates during hospitalization and at the out-patients unit appointment after the implementation of best practice. However, nipple trauma rates did not decrease following the implementation of best practice, both in hospital and following discharge.

Discussion This implementation project resulted in improvements in breastfeeding practice in line with the best available evidence. The implementation of a Breastfeeding Assessment Form to observe and educate the lactating mother in a systematic way, and distribution of consumer information sheets to the women contributed to an increase in the knowledge and skills of both the nursing professionals and the lactating women involved in this project. Considering acquired knowledge, instead of just participating in an educational program was a good strategy to measure compliance, as it was demonstrated that training didn’t necessarily mean appropriating knowledge for both nursing professionals and the women. There was

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commitment by the nursing staff in improving their knowledge by participating in the training program and giving feedback during the implementation phase to improve and refine the observation form and strategies used in the implementation of the project. Women, in general, had great acceptance of the leaflet, reporting that it was easy to understand and the content useful for their breastfeeding practice. A systematic observation of the breastfeeding process was further opportunity for the nursing staff to verify the real needs of the lactating mothers, and offer education during the breastfeed. From the results, the majority of women experienced some inadequacy with positioning and/or attachment of the baby to breastfeed. This highlighted the importance of having a professional with appropriate skills and knowledge to educate and assist women in overcoming any obstacles to successful breastfeeding. The first observed breastfeed represented, most of the time, the first breastfeed after admission to the maternity ward. Most women were assisted by the nursing staff to position and attach the baby to the breast following labor. Babies frequently had difficulties sucking effectively initially, and positioning the baby to breastfeed was not favored during the immediate post-partum period, based on 73.3% of the observations. The project team also observed that the number of women who experienced difficulties with positioning and/or attachment during hospitalization was high (93.1%). However, at the final observed breastfeed, this value decreased to 30.0%, indicating a great improvement in the women’s skills. This data reinforces the importance of health professionals’ assistance during the breastfeeding process at the point-of-care. The project team initially planned to implement the breastfeeding assessment during every shift (morning, afternoon and evening), but due to staffing shortages related to unfilled vacancies, and sick, maternity land holiday leave, it was decided to

observe breastfeeding in a systematic way every 12

hours so as not to overload the nursing staff. For this reason, 100% compliance in Criterion 3 was not achieved. This finding highlights the importance of having an adequate number of health professionals provide adequate care for women during the breastfeeding process. The perceptions reported by nursing professionals involved in this project highlighted the need to be with the women throughout the whole breastfeeding process, as even after the initial orientation and correction of problems with breastfeeding techniques, there were mothers who could not maintain the proper technique throughout the process. The duration for each feed varied, depending on the performance of the baby, highlighting the difficulty in monitoring breastfeeding at all times. On the management of nipple trauma during this project, an increase in compliance from both nursing staff and lactating women was observed, especially in relation to how to express breast milk. Empowering the nursing staff improved their capacity to transmit this knowledge to the women, improving the necessary skills to overcome these problems. The impact of this improvement was demonstrated in increased rates of exclusive breastfeeding during hospitalization and after discharge, and in the increase in women’s satisfaction with the assistance received with breastfeeding during their hospital stay. Nipple trauma rates did not decrease during this project, as expected, both during hospitalization and after discharge. This was discussed with the project team, and it was noted that many other factors contribute to the onset of nipple trauma, such as the frequency of breastfeeding and the intensity of sucking of the newborn, the parity of women, and others. Further studies are needed to clarify these other aspects involved in the prevention and onset of nipple trauma. The Breastfeeding Assessment Form and the information sheet have already been incorporated into our clinical practice, and added to the “Nipple Trauma Prevention Protocol”. However, it will be

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important to conduct further clinical audits periodically to ensure quality of care and sustainability of these outcomes.

Conclusion The impact of this best practice implementation project on exclusive breastfeeding rates was positive, both during hospitalization and following discharge, showing an improvement even with the increased rates of nipple trauma observed in the post-implementation audit. Improving women’s skills regarding breastfeeding practice and management of nipple trauma may contribute to extending the period of exclusive breastfeeding in lactating women. Ongoing commitment to implementing best practice with regards to breastfeeding practice is imperative in sustaining these improvements in the future.

Conflict of interest There was no conflict of interest in this project.

Acknowledgements Special thanks to Professor Alan Pearson and Associate Professor Zoe Jordan for the invitation to take part in the Evidence-Based Clinical Fellowship program, to Dr Suzi Robertson-Malt, and my facilitators, Alexa McArthur (co-author) and Dr Sarahlouise White, and all the staff of Joanna Briggs Institute. To the other clinical fellow participants, Alinafe, Garumma, Henry, Khin Sandar, Gyaami, War War, Jarred and Rachel;

to the Department of Nursing, the University Hospital, the University of Sao Paulo, and

the Brazilian Center for Evidence-based Healthcare: an Affiliate Center of the Joanna Briggs Institute; to the nursing staff of the University Hospital for their efforts and contribution in making this project a reality; and to the lactating mothers, who are the major reason why we do this work, I thank you for your support.

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References 1.

The Joanna Briggs Institute. The management of nipple pain and/or trauma associated with breastfeeding. Best Practice Information Sheet. 2009.

2.

Woolridge MW. An etiology of sore nipples. Midwifery. 1986;2:172-6.

3.

Righard L. Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles. Birth. 1998;25:40-4.

4.

Shimoda GT, Silva IA, Santos JLF. Characteristics, frequency and factors present in nipples damage occurrence in lactating women. Rev Bras Enferm. 2005;58(5):529-34.

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Weigert EM, Giugliani ER, França MC, de Oliveira LD, Bonilha A, do Espírito Santo LC, et al. The influence of breastfeeding technique on the frequencies of exclusive breastfeeding and nipple trauma in the first month of lactation. J Pediatr (Rio J). 2005;81:310-6.

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Coca KP, Gamba MA, Silva RS, Abrão ACFV. Does breastfeeding position influence the onset of nipple trauma? Rev Esc Enferm USP. 2009a;43(2):446-52.

7.

Coca KP, Gamba MA, Silva RS, Abrão ACFV. Factors associated with nipple trauma in the maternity unit. J Pediatr. 2009b;85(4):341-5.

8.

Page T, Lockwood C, Guest K. Management of nipple pain and/or trauma associated with breast feeding. JBI Reports. 2003;1(4):127-47.

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Ziemer MM, Cooper DM, Pigeon JG. Evaluation of a dressing to reduce nipple pain and improve nipple skin condition in breast-feeding women. Nurs Res.1995;44:347-51.

10.

Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012;8.

11.

Brazil. Ministry of Health. Department of Health Care. Department of Programmatic and Strategic Actions. II Survey of the Prevalence of Breastfeeding in Brazilian Capitals and DC – Brasilia: Ministry of Health; 2009.

12.

UNICEF. United Nations Children’s Fund. Baby Friendly Hospital Initiative: updated and expanded magazine for integrated care - self-assessment and monitoring of hospital / UNICEF, the World Health Organization - Brasilia: Ministry of Health Publisher; 2009.

13.

Cirico MOV, Oliveira RNG Shimoda, GT. Nipple Trauma Indicator in a Maternity ward with Rooming-in system. 2013 (study under way).

14.

Morland-Schultz Kristine, Hill Pamela D. Prevention of and therapies for nipple pain: a systematic review. JOGN Nurs. 2005; 34(4):428-37.

15.

Kronborg H, Vaeth M. How are effective breastfeeding and pacifier use related to breastfeeding problems and duration? Birth, 2009;36(1):34-42.

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Brazil. Ministry of Health. Brazilian Health Council. Guidelines and regulatory standards for research involving humans. Resolution 196. Brasilia: CNS; 1996.

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Appendix 1: Audit assessment tool Criterion 1.

YES NO N/A

Have nursing staff received training regarding promotion of breastfeeding, including

prevention and management of nipple pain and trauma? 1.1. Participation in Baby Friendly Training Program (baseline audit) or Implementation Training Program (follow-up audit) 1.2. Knowledge about prevention and management of nipple pain and trauma: 1.2.1 - correct positioning of mother and baby 1.2.2 - correct attachment of the baby 1.2.3 - pattern suction of the baby 1.2.4 - how to detach the baby from the breast to break suction 1.2.5 - nipple should not be compressed after the completion of the feed 1.2.6 - evaluate pain 1.2.7- evaluate if areola is soft and flexible before breastfeed 1.2.8 - express breast milk and offer to the baby by cup feeding if the mother decide to rest her nipple 1.2.9- use of modified Lanolin, in presence of trauma 2. Have mothers received education regarding correct breastfeeding positioning, and prevention of nipple pain and trauma? 2.1 - Participation in educational program during hospitalization 2.2 - Knowledge about prevention and management of nipple pain and trauma 2.2.1 - knowledge about correct positioning of herself and baby 2.2.2 – knowledge about correct attachment of the baby 2.2.3 - knowledge about the pattern suction of the baby 2.2.4 - how to detach the baby from the breast to break suction 2.2.5 - nipple should not be compressed after the completion of the feed 2.2.6 - breastfeeding should be pain free 2.2.7- how to express breast milk and offer to the baby by cup feeding in presence of trauma and she decided to rest her nipple 2.2.8- how to use modified Lanolin (or colostrum), if presence of trauma 3. Has assessment of breastfeeding correct positioning and attachment carried out by the nursing professional during each shift, as necessary? 4. If a woman has experienced nipple pain, have the nursing professional provided management options and support for the woman? 4.1. Has the woman known how to express breast milk to offer to the baby by cup feeding (in presence of trauma if she decided to rest her nipple)? 4.2. Has the woman being educated about the use of modified Lanolin (or colostrum), in presence of trauma? 4.3. Has the nurse midwife filled in the “Nipple Trauma Indicator Form” and provided management options according to the cause(s) of the trauma? 5. Has the woman presented nipple trauma during hospitalization time? 6. Has the woman breastfed exclusively during hospitalization time? 7. Was the woman satisfied with the care/help she has received during breastfeeding? 8. Has the woman reported exclusive breastfeeding at the follow-up appointment? 9. Has the woman presented nipple trauma at the follow-up appointment?

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Appendix 2: Nipple Trauma Indicator Form – University Hospital, Sao Paulo

NIPPLE TRAUMA INDICATOR FORM

IDENTIFICATION

ADMISSION DATA: Date: ____/____/_____ Parity: ______________ Breastfed previously? No / Yes.

If Yes, had experienced nipple trauma before? No / Yes

Skin colour: White / Brown / Black / Yellow Colour of nipple-areola area: light pink / light brown / dark brown / black Type of nipple Right and Left: Protruded (

)

Semi protruding (

)

Pseudo-inverted (

Newborn in: Maternity Ward / Nursery/ ICU

)

Inverted (

)

Flat (

)

Is newborn premature? No / Yes

Daily evaluation: ___ PP

___ PP

___ PP

___ PP

Newborn: MW / N / ICU

Newborn: MW / N / ICU

Newborn: MW / N / ICU

Newborn: MW / N / ICU

If MW, suction pattern is:

If MW, suction pattern is:

If MW, suction pattern is:

If MW, suction pattern is:

- adequate

- adequate

- adequate

- adequate

- inadequate

- inadequate

- inadequate

- inadequate

- not observed

- not observed

- not observed

- not observed

Received EBM / Formula

Received EBM / Formula

Received EBM / Formula

Received EBM / Formula

Cup / Trans lactation

Cup / Trans lactation

Cup / Trans lactation

Cup / Trans lactation

Trauma: No

Trauma: No

Trauma: No

Trauma: No

/ Yes

/ Yes

/ Yes

/ Yes

Type*:______________

Type*:______________

Type*:______________

Type*:______________

Cause(s):__________

Cause(s):__________

Cause(s):__________

Cause(s):__________

Evolution**:_________

Evolution**:_________

Evolution**:_________

Evolution**:_________

Observations

Observations

Observations

Observations

Sign:. ____________

Sign. ____________

Sign. ____________

Sign. ____________

* Excoriation - Erythema - Fissure - Blister - Erosion – other **P (Present) I (Improved) W (Worsened) U (Unchanged) S (Solved) POSSIBLE CAUSES Related to mothers: 1) inadequate breast support 2) hardened areola 3) engorged breasts 4) lack of colostrum 5) unfavourable nipples 6) inadequate positioning 7) inadequate behaviour 8) inadequate use of syringe 9) Pain 10) milking pump Related to Newborn 11) inadequate attachment 12) Frequent suckling 13) strong suckling 14) suckling problems 15) drowsiness 16) bite 17) Irritation 18) pain 19) nasal obstruction 20) non-nutritive suckling 21) malformation Other(s)______________________________________ NURSING ACTIVITIES Supervise / Assist breastfeeding / Orientate positioning and attachment / feeding time / adequate breast support / different position / exercises of nipple protrusion / ask for help in Nursery or ICU / Offer and orientate use of Lanolin / Shell / Nipple shield / electric massager / Encourage breast milk expression / use of colostrum Offer EBM / Formula AMP Instill Saline / Dexamethasone AMP; Other(s):

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Appendix 3: Breastfeeding Observation Form This form will be used to collect data in addition to the audit criteria. Date: -----/-----/-----

Beginning time: _____h

End time: _____ h

( ) Mother sitting, relaxed and comfortable, with

( ) Mother sitting, shoulders tense, leaning over

shoulders

baby OR lying down and improperly positioned

supported

OR

lying

down

and

well-positioned ( ) Baby’s body is aligned with, and facing, the

(

) Baby’s body far from mother and/or not

breast (belly to belly)

aligned

( ) Mother supports the breast with “C-hold” or it

( ) Mother supports the breast in “scissor hold”

was not necessary to support ( ) Baby’s bottom supported

( ) Only shoulder or head supported

( ) Baby calm and alert at the breast

(

) Baby restless or crying at the breast, or

drowsy ( ) Baby’s mouth wide open

( ) Baby’s mouth not open wide

( ) Baby’s lower lip turned outwards

( ) Baby’s lower lip turned inward

( ) Baby’s chin touching the breast

( ) Baby’s chin not touching the breast

( ) Baby’s nose is free to breathe

( ) Baby’s nose is not free for breathing

( ) Baby’s cheeks are rounded

( ) Baby’s cheeks tense or pulled in

( ) Baby latches onto the nipple and areola, and

( ) Baby does not latch onto the nipple or remain

remains attached

attached, slips off breast

( ) Baby maintains slow and deep suction, with

(

pauses

difficulty sucking

( ) Mother feels no pain

( ) Mother feels pain

(

( ) Nipple is compressed after breastfeeding

) Nipple maintains original shape after

) Baby’s sucking fast and shallow, or has

breastfeeding ( ) Baby releases breast or mother detach the

(

baby by inserting a finger in the corner of baby’s

releasing pressure

) Mother removes baby from breast without

mouth Actions: (

) Guidance on latching and/or positioning and/or how to remove baby from the breast

(

) Breastfeeding assistance

(

) Manual pumping

(

) Other ___________________________________

Signature: Adapted from: WHO/UNICEF. Baby-friendly hospital initiative: revised, updated and expanded for integrated care. Section 3, Breastfeeding promotion and support in a baby-friendly hospital: a 20-hour course for maternity staff. 2009. Available in: http://whqlibdoc.who.int/publications/2009/9789241594981_eng.pdf

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Appendix 4: Information sheet given to the mothers

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Preventing nipple trauma in lactating women in the University Hospital of the University of Sao Paulo: a best practice implementation project.

Nipple trauma in lactating women is an important issue in facilitating successful breastfeeding. Evidence suggests that early postnatal education on t...
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