](I( ;N C L I N I C A L S T U D I E S he American Academy of Pediatrics has stated

that health-care practitioners should encour- age mothers to breastfeed their full-term infants.'"l Neifert stressed the importance of providing expec- tant parents with enough information for them to

E R I N A N D E R S O N , R N , M S make informed decisions about infant feeding.5 Nei- fert also maintained that health-care practitioners

E L I Z A B E T H G E D E N , R N , P H D , F A A N should take a stand on the issue of breastfeeding ver- sus bottle feeding because research has shown that breast milk is the superior infant

Martinez and Krieger found that 61% of infants in

week in 1984, an increase of 36.1% from 1970; how- ever, the increase in breastfeeding from 1982 to 1984 was only 0.5%.6 Although more than 50% of newborns are breastfed when thev leave the hosDital, between

Nurses' Knowledge the United States were breastfed at the age of one

The purpose of this study was to survey nurses' knowledge of breastfeeding and to assess whether nurses' education, clinical experience, or personal experience predicted their breastfeeding knowledge. Results suggest that nurses have limited knowledge of breastfeeding, although no variable consistently predicted b reastfeeding knowledge. Clin leal experience produced the most consistent results, implying that leadership, variety in maternal and newborn nursing experiences, and years of experience result in nurses having more knowledge about breastfeeding.

Accepted: January 1990

30% and 40% are weaned by six weeks of age.'.' The Surgeon General's 1984 Workshop on Breastfeeding and Human Lactation recognized that all health-care practitioners should receive a thorough education in breastfeeding, and therefore, the workshop directed its attention to the issue of increasing the incidence and duration of brea~tfeeding.~ The American Acad- emy of Pediatrics' Committee on Nutrition suggested that hospitals should provide the opportunity for a mother to be successful at lactation by ensuring that the personnel responsible for patient care be well in- formed about breastfeeding manage men^^

Crowder tested 53 maternal-newborn nurses on their knowledge of breastfeeding and found that their level of education correlated positively and their length of experience correlated negatively with their knowledge scores.'o Hayes concluded from her study of 203 hospital staff members that the information gained during nursing school, work experience, and personal experience may not necessarily provide nurses with the knowledge needed to assist new mothers with breastfeeding." Furthermore, Hayes concluded that information about breastfeeding may not be consistent among members of the nursing staff in the same hospital."

An exploration of the relationships among nurses' personal experiences with breastfeeding, as well as of how they acquired and maintained breastfeeding knowledge, was undertaken to provide greater under- standing of nurses' performance on the breastfeeding knowledge test. The researchers sought to determine whether nurses had increased their knowledge about breastfeeding. This information could help staff educa- tors and lactation specialists target their in-service pro- grams.

A descriptive study was designed that focused on breastfeeding knowledge of currently employed ma-

58 J O G N N Volume 20 Number 1

Nurses’ Knowledge ofBreas@eding

Clinical experience produced the most consistent results, implying that leadership, variety in maternal- neonatal nursing experience, and years of experience result in nurses having more knowledge about breastfeeding.

ternal-neonatal nurses. A breastfeeding knowledge test was constructed because Crowder’s tool did not contain items relevant to current breastfeeding self- care practices and Hayes’ tool was unobtainable. The test outcomes were expected to provide data indicat- ing whether education, clinical experience, personal experience, or some combination of these variables would predict nurses’ knowledge of breastfeeding.

Metbodology

Sampling A two-stage sampling design was used to solicit sub- jects. First, 50 hospitals from the western north-central United States having 200 or more live births each year were selected randomly from the 1986 edition of the American Hospital Association Guide to the Health Care Field.I2 Second, after receiving a notice of agreement from each hospital’s nursing director, the researchers sent the coordinators of maternal-child nursing in each institution a maximum of 20 question- naires to distribute to registered staff nurses and li- censed practical nurses working in maternal-neonatal units. The nurse sample was, therefore, a convenient, nonrandom sample.

Instrument The researchers developed a breastfeeding knowl- edge questionnaire with 20 items that reflected the following areas: (1) in-hospital breastfeeding manage- ment, (2) breastfeeding management when a health problem is present, (3) postpartum anticipatory guid- ance, ( 4 ) anatomy and physiology, and (5) nutrition. The researchers chose a multiple-choice format to ease the scoring and management of the data. This format also had the advantage of being one with which the respondents were familiar.

Eleven experts evaluated content validity by re- viewing each item and responding to the following questions:

3) Could there be a better choice in answers? 4 ) Because I am looking at the knowledge that

mothers need in the hospital and the information that new mothers need to go home, are there other questions I should ask?

5 ) Are there any “trick” questions that I should not expect a nurse to have the knowledge to answer correctly?

The experts offered several suggestions regarding clarity and readability. The questionnaire subse- quently was revised, based on the suggestions. Scores, which could range from 0 to 20, were constructed by summing the number of correct answers.

In addition to gathering information on nurses’ knowledge of breastfeeding, demographic and per- sonal questions were posed to elicit data to describe the sample and to explicate the findings. These items included the following demographic information: age, gender, race, education, position, area of assign- ment, and length of work experience. The researchers also elicited information about the nurses’ personal experiences with breastfeeding. Questions included the following: Have you ever breastfed? If yes, were you satisfied with the experience? How long did you breastfeed? How many children do you have? All re- spondents were asked to rate their ability to assist mothers in breastfeeding and to indicate how they ob- tained and maintained knowledge about breastfeed- ing. Institutional data also were collected: each re- spondent was asked whether the institution in which he or she worked had a breastfeeding protocol and whether a lactation consultant was on staff.

Procedure The University of Missouri-Columbia Health Science Center Institutional Review Board reviewed the proj- ect and determined it to be exempt from further re- view. N o written consent was required. Initially, the researchers mailed a packet containing a query letter explaining the purpose of the study, a copy of the in- strument, and a postcard to each nursing director of the 50 selected institutions. Each director was asked to fill out and return the postcard, indicating willingness to participate in the study, the name of the maternal- child nursing coordinator who would serve as the con- tact person, and the number of staff nurses on the ma- ternal-neonatal unit(s). Directors who did not re- spond within two weeks received a second packet. The 25 directors who had still not responded were then called. After two mailings and several follow-up

1) Is there a correct answer for each question? 2) Could the question be stated in a clearer way?

telephone calls, 43 institutions agreed to participate in the study, yielding an 86% institutional response rate.

JanuaTv/February 1991 J O G ” 59

C L I N I C A L S T U D I E S

The purpose of this study was to survey nurses’ knowledge of breastfeeding and to assess whetber nurses’ education, clinical experience, or personal experience predicted their breastfeeding knowledge.

The researchers mailed packets of questionnaires to the maternal-child nursing coordinators, who were asked to distribute the questionnaires to their staff nurses. Each coordinator received approximately 9-20 questionnaires, depending on the number of maternal-child staff nurses at the institution. A total of 780 questionnaires was mailed.

The questionnaires were numbered by institution. If a response was not received from an institution within two weeks after the packets were mailed, the researchers called the coordinator to determine whether he or she had received the package. The questionnaires were designed as self-mailers, and the researchers paid the business-reply postage on all questionnaires that were returned.

Results

Demographic Cbaracteristics of sample The researchers received 293 usable questionnaires of the 780 mailed, resulting in a 38% response rate. The respondents’ characteristics are presented in Table 1.

Source of breastfeeding knowledge The respondents were asked where they learned about breastfeeding management, how they updated their breastfeeding knowledge, and whether their hos- pitals had breastfeeding protocols or lactation consul- tants. The results of these questions are presented in Table 2.

Knowledge test psychometrics The number of correct answers on breastfeeding knowledge ranged from 4 to 19, with a mean of 12.2 and a standard deviation of 2.8. The Kuder-Richardson 21 (a measure of internal consistency) was .53.13 Dim- culty indices (i.e., the percent of respondents who an- swered each question correctly) ranged from 22.6% to 95.6%. Item discrimination indices ranged from .03 to .67.13 Six questions had a discrimination index of less than .20 and were dropped from subsequent analyses. The total number of correct answers, or total score for each respondent, was recomputed and ranged from 1 to 14, with a mean of 7.4 and a standard deviation of

Table 1. Cbaracteristics of Respondents

Cbaractertstic n Percent

Gender Female Male No response

290 99.7 1 0.3 2 -

Race White, non-Hispanic 280 96.3 American Indian 5 1.7 Black, non-Hispanic 5 1.7 Asian or Pacific Islander 1 0.3 No response 2 -

Type of License Registered Nurse 236 81.7 Licensed Practical Nurse 53 18.3

- N o response 4

Highest Degree Earned Baccalaureate Associate Master’s N o response

Length of Experience Range: 1 month to 37 years Mean: 8.9 years

A s Range: 20 to 68 years Mean: 36.5 years

70 52.6 59 44.4 4 3.0

160 -

N = 293. Note: Percents were calculated based on the number of

respondents who answered the question.

2.5. Subsequent analyses were made using the re- maining 14 valid items.

Analyses of total score and selected demographic variables A significant relationship did not exist between total score and age ( r = .02, p = .75). A one-way analysis of variance did not produce a significant effect between total score and education, F(3,285) = 197, p = .1167. A weak, although significant, positive correlation oc- curred between total score and length of experience ( r = .30, p = .0049).

60 J O G N N Volume 20 Number 1

Nurses' Knowledge of Breas@edhg

Table 2. Sources of Breastfeeding Knowledge Available at Respondents' Hospitals

Source n

Received Breastfeeding Knowledge

On-the-job 259 Personal experience 188 Hospital in-service 109 Nursing school 82 Family or friends 63 Other (books or workshops) 70 No response 1

Percent

88.7 64.4 37.3 28.1 21.6 24.0 -

Keep Current on Breastfeeding Knowledge Journals or books 226 79.3 Workshops or conferences 150 52.6 Hospital in-service 112 39.3 Other lay sources 21 7.4 No response 8 -

Breastfeeding Protocol Available Yes 211 73.8 No 57 19.9 Do not know 18 6.3 No response 7 -

Lactation Consultant Available Yes No Do not know No response

35 12.1 251 86.6

4 1.4 3 -

N = 293. Note: Respondents were able to select more than one

response. The percentages were calculated based on the number of respondents who answered the auestion.

Analyzing test scores by position using a one-way ANOVA produced a significant result, H4, 284) = 4.69, p = .0011. Bonferroni pairwise comparisons revealed that respondents who were head nurses scored significantly higher than respondents who were registered staff nurses. The mean difference be- tween these groups was 2.11. No other pairwise com- parisons were significantly different. As may be seen in Table 3, those who breastfed (n = 196) scored sig- nificantly higher ( M = 7.76) than those who did not breastfeed (n = 51) ( M = 6.53, F(1, 246) = 9.85, p = ,0019). Using a one-way ANOVA, no differences were found between the scores of the nurses who

worked in hospitals with fewer than 1,000 live births per year and those working in hospitals with more than 1,000 live births per year, F(1, 259) = 2.16, p = 0.1426.

Discussion

The researchers sought to determine whether educa- tion, clinical experience, or personal experience pre-

Table 3. Mean Breastfeeding Knowledge Scores by Education and Selected Variables

~ ~

Cbaracteristlc n Mean total score

Education Licensed practical nurse Diploma RN Associate RN Bachelors RN

No response

Position LPN RN staff RN charge nurse Head nurse Other No response

Primary Assignment Postpartum Labor 8r delivery Newborn nursery All of the above Labor lb delivery and

newborn nursery Newborn nursery and

postpartum Labor lb delivery and

postpartum Other No response

Personal Experience Breastfeeding

Yes No No response

53 115 62 59 4

50 165 37 20 17 4

35 35

101 60

1

19

20 20 2

196 51 46

* Scores could range from 1 to 14. N = 293.

7.45 7.34 7.15 8.15 -

7.52 7.09 7.81 9.20 8.59 -

6.69 7.03 7.08 8.32

9.00

7.74

7.60 8.50 -

7.76 6.53 -

JOG" 61

C L I N I C A L S T U D I E S

Nurses need to acquire more information about breastfeeding to assist their patients with this important skill.

dicted maternal-neonatal nurses’ knowledge of breastfeeding. The answer to this research question proved complex. No single predictor variable consis- tently distinguished between nurses who were knowl- edgeable and nurses who were less knowledgeable regarding breastfeeding. Perhaps the finding of the low mean score ( M = 7.4, 53.2%) is most revealing. This finding, coupled with similar findings of Crowder and Hayes, suggests that knowledge of breastfeeding by the maternity practitioner has not in- creased since 1981.10*11 Although, in the current study, RNs scored higher than LPNs, nurses’ generic nursing education was not significantly correlated with their total scores. This result is consistent with Crowder’s findings (i.e., RNs scored higher than LPNs), but Crowder did not report a test of significance.”

Collectively, the variable clinical experience pro- duced some consistent results, which may suggest that leadership, breadth of experience, and years of experi- ence result in nurses having more knowledge about breastfeeding. Head nurses scored significantly higher than the RN staff nurses. This could be due to head nurses traditionally having more clinical experi- ence or feeling greater clinical responsibility for up- dating their skills. Nurses who were assigned to more than one area of maternal-neonatal nursing scored higher than nurses who worked in a newborn nursery or a postpartum area only. This finding may be ex- plained by the possibility that nurses who worked on combined maternal-neonatal units were confronted with the breastfeeding dyad more directly than nurses who worked in the newborn nursery or postpartum area only. Length of experience correlated weakly, al- though significantly, with the total score, as contrasted with Crowder’s 1981 study, which found that scores were higher for subjects with 0-5 years of experience and lower for those with 5-15 years of experience.’O

The researchers included the number of deliver- ies per institution as a variable, expecting that nurses who worked in institutions with a greater number of deliveries would have had more experience and would have developed a greater knowledge of breast- feeding. This expectation was not supported when comparing hospitals with more than 1,000 live births per year with hospitals with fewer than 1,000 live births per year.

Personal experience proved to be a meaningful variable. Nurses who had breastfed an infant scored significantly higher than nurses who had never breastfed. Possibly, nurses who had breastfed were more interested in the subject of breastfeeding than nurses who had not breastfed.

Only three of the questions were answered correctly by 90% or more of the respondents. These questions dealt with how one knows whether an infant is receiving enough fluid, whether or not breast milk can be heated in a microwave oven, and what causes sore nipples. High item difficulty scores (i.e., ques- tions that most respondents answered correctly, 290%) coupled with low discrimination indices could indicate that the material covered in these questions is general knowledge or that the distracters (possible answers) were poor, making the correct answer obvi- ous. Because the three questions also had low discrim- ination indices (i.e., - d o ) , they were among the six questions dropped prior to analyses examining group differences.

stacdy Limitations

The study respondents were a self-selected sample. Without knowing the characteristics of nurses who did not respond, the researchers cannot reasonably deter- mine whether the sample consisted of nurses who re- alistically perceived themselves as experts in their re- spective institutions or whether it consisted of nurses who considered themselves knowledgeable when, in fact, they were not. In either case, the mean total score was low.

The adequacy of the questionnaire to appropri- ately sample breastfeeding knowledge could be chal- lenged. Fourteen items represent a meager sample of this domain; however, the items reflected general- practice issues (e.g., frequency with which newborns feed, proper newborn suck, and treatment of plugged milk ducts and mastitis) and represented questions that all maternal-neonatal nurses should be able to an- swer. Subsequent researchers using this questionnaire or method of testing should increase the number of

The low mean score ts the most revealtng Jinding and suggests tbat knowledge of breastfeeding by maternal-neonatal nurses bas not increased in the 10 years since Crowder and Hayes reported tbetr jindtngs.

62 J O G ” Volume 20 Number 1

Nurses’ Knowledge of Breastfeeding

Although hospitals were randomly selected, the nwse respondents represented a convenient, nonrandom sample.

questions, thereby increasing the likelihood of a more reliable measure.

Nursing Implications

Nursing schools may want to reevaluate the amount of emphasis placed on teaching nurses about breastfeed- ing, considering that 69% ( n = 201) of the respon- dents reported that they had not been taught breast- feeding management in nursing school or did not re- member having been taught.

Once nurses are in practice, they have a profes- sional responsibility to update their nursing skills so that they can incorporate current nursing care prac- tices. Consistent and accurate breastfeeding informa- tion is essential to a new mother who is breastfeeding, especially during the taking-in phase. At this time, mothers have difficulty sorting right from wrong infor- mation. The low test scores suggest the likelihood of nurses not giving consistent and accurate information. Institutions need to be held accountable for the infor- mation their patients receive. Only 38%, or 112, of the 293 respondents who answered the item indicated that they update their skills and knowledge of breast- feeding from hospital in-service programs. Patient care managers need to be assured that their staffs are kept informed about current clinical knowledge by providing in-service programs and changing protocols in response to research findings. The breastfeeding knowledge test may be helpful to staff nurses and pa- tient care managers and could be used as a screening or diagnostic measure. An analysis of correct and incor- rect items could serve as a stimulus for revising the content of in-service programs or self-instructional ef- forts.

Several studies have reported that lactation con- sultants positively influence breastfeeding duration. Consequently, it is likely that lactation consultants have a positive effect on increasing staff nurses’ knowl- edge of breastfeeding.14-17 A certified lactation con- sultant could help direct and support changes in nurs- ing practice regarding breastfeeding mothers.

Conclusion The results of this study suggest that nurses have lim- ited knowledge of breastfeeding, but no single vari- able consistently proved to be a powerful predictor of

nurses’ knowledge of breastfeeding. The variable of clinical experience produced the most significant re- sults, suggesting that leadership, variety in maternal- newborn nursing experiences, and years of experi- ence result in nurses having more knowledge about breastfeeding.

References

1.

2.

3.

4.

5.

6.

7.

American Academy of Pediatrics, Committee on Nutri- tion. 1976. Commentary on breastfeeding and infant formulas, including proposed standards for formulas. Pediatrics 57:278-85. American Academy of Pediatrics, Nutrition Committee of the Canadian Paediatric Society and the Committee on Nutrition of the American Academy of Pediatrics. 1978. Breastfeeding: A commentary in celebration of the international year of the child, 1979. Pediatrics. 62 :59 1-601. American Academy of Pediatrics, Committee on Nutri- tion. 1980. Encouraging breastfeeding. Pediatrics. 65:657-58. American Academy of Pediatrics, Policy Statement Based on Task Force Report. 1982. The promotion of breastfeeding. Pediatrics. 69654-61. Neifert, M.R. 1980. Returning of breastfeeding. Clin 06- stet Gynecol. 23:1061-71. Martinez, G., and F. Krieger. 1985. 1984 milk-feeding patterns in the United States. Pediatrics. 76:1004-8. Evans, C., N. Lyons, and M. Killien. 1986. The effects of infant formula samples on breastfeeding practice. IOGNN. 15:401-5.

8. Reiff, M., and S. Essock-Vitale. 1985. Hospital influ- ences on early infant-feeding practices. Pediatrics. 76:872-79.

9. U.S. Department of Health and Human Services. 1984. Report of the Surgeon General’s Workshop on Breast- feeding and Human Lactation. DHHSHRS-D-MC 84-2.

10.

11.

12.

13.

14.

15.

Washington, D.C.: U.S. Government Printing Office. Crowder, D.S. 1981. Maternity nurses’ knowledge of factors promoting successful breastfeeding. JOGNNurs.

Hayes, B. 1981. Inconsistencies among nurses in breastfeeding knowledge and counseling. JOGN Nun.

American Hospital Association. 1986. American Hospi- talAssociation Guide to the Health Care Field. 1986 ed. Chicago: American Hospital Association. Tenbrink, T.D. 1974. Evaluation: A Practical Guide for Teachers. New York: McGraw-Hill Book Company. Bloom, K., R.B. Goldbloom, S.C. Robinson, and F.E. Stevens. 1982. Factors affecting the continuance of breastfeeding. Acta Paediatr Scund. 3OO(Suppl):9-13. Townsend, J . 1982. Effects of nursing guidance and support, and information on success of breastfeeding. Master’s thesis. University of Missouri-Columbia, School of Nursing.

10:28-30.

10:430-33.

Januuq@ebruuty 1991 J O C N N 63

C L I N I C A L S T U D I E S

16. Jones, D.A., and R.R. West. 1986. Effect of a lactation nurse on the success of breastfeeding: A randomized controlled trial. J Epidemiol Community Health. 40:45- 49.

17. Lynch, S. , A. Koch, T. Hislop, and A. Coldman. 1986. Evaluating the effect of a breastfeeding consultant on the duration of breastfeeding. Can J Public Health. 77: 190-95.

Address for correspondence: Elizabeth Geden, RN, PhD, FAAN, University of Missouri-Columbia, School of Nursing, S317 Nursing School Building, Columbia, MO 6521 1.

Ertn Anderson ts a research associate in the School of Nurstng at the University of Missourt in Columbla, Mtssouri. She is also a lactation consultant In private practice. Ms. Anderson is a member of NAACOG, the International lactation Consultant’s Assoctatton, and Stgma Theta Tau.

Elizabeth Geden is a professor of nurstng, the interim associate dean for research, and director of graduate studies In the School of Nursing at the Untverstty of Missourl in Columbia, Missouri. Dr. Geden is a member of the Council of Nurse Researchers, the Midwest Nursing Research Soctety, and Sigma Theta Tau.

Keeping up with the latest developments in obstetric, gynecologic, and neonatal (OGN) nursing can be a full-time job. Let NAACOG, the Organization for Obstetric, Gynecologic, and Neonatal Nurses, do the work for you. Subscribe to the NAACOG Newsletter and you will receive

in-depth reports on the latest trends in OGN nursing practice, personal profiles of the women and men shaping the future of OGN nursing, details on the latest resources available to OGN nurses and their clients, facts about new OGN technology and treatment recommendations, notes on legislation and policy-making affecting OGN nursing, updates on NAACOG activities, notices of upcoming professional meetings, and job listings from across the country.

To order, complete the form below and mail as directed. Don’s miss another issue. Subscribe today!

One-year subscriptions to the NAACOG Newsletter (1 2 issues) are available for $30.00. To start receiving your newsletters, complete the form below and mail it with your check or money order (made payable to NAACOG) to NAACOG, Communications Department, 409 12th Street, S.W., Washington, DC 20024- 2191.

Subscriber Information

Name

Address

City State Zip Code

(54 J O G N N Volume 20 Number 1