Evidence-based practice indicates the universal need for the implementation of better maternal and newborn infant care, especially with regard to breastfeeding support and encouragement. This is evidenced by countless research works that both report the optimized goals of better rates of exclusive breastfeeding among infants 0-6 months and the evidence of current trends and practices (AAP, 2010; Scanlon et. al, 2007; Naylor, 2010; Grummer-Strawn & Shealy 2009). These researchers, reviewers an experts base their observations on a need that is well documented in the literature, i.e. both the current state of breastfeeding support in maternity settings and clinical short- and long-term health related outcomes associated with breastfeeding and lack of breastfeeding. The literature associated with this need is demonstrative of many issues regarding breastfeeding and support that the best overall scenario for maternal and infant health is exclusive breastfeeding of infants till six months of age with supplements or other age appropriate foods added after that age marker. This protocol demonstrates a reduction in incidence and severity of several infectious diseases, noted above and reduces infant mortality rates by more than 21% (AAP, 2005, p. 596) This emphasis on breastfeeding is further supported in many policy statements and bodies of research as well as other organization sources that exclusive breastfeeding is demonstrative of overall better health outcomes for infants and mothers with regard to diabetes (both type 1 and type 2) "lymphoma, leukemia, and Hodgkin disease, overweight and obesity, hypercholesterolemia, and asthma in older children and adults who were breastfed, compared with individuals who were not breastfed" (AAP, 2005, pp. 496-497). Additionally, the research indicates that breastfed infants demonstrate more advanced neurodevelopment (AAP, 2005, p. 497) have greater health outcomes even when maternal health is compromised, and there is also important evidence that breastfeeding supports maternal physical and mental health and well being (AAP, 2005, p. 497). Contraindications of breastfeeding, on the other hand are much more limited than once believed, and include only a few maternal disease states or physical states, such as HIV / AIDS infection in the mother, certain types of tuberculosis, recent exposure to radioactivity, chemotherapeutic or harmful pharmaceutical exposure (AAP, 2005, p. 497). One previously viewed contraindication for breastfeeding, that is both common and largely accepted should be eliminated from consideration, maternal smoking. In fact maternal smoking effects on the infant may be partly mitigated by breastfeeding, even if smoking continues after birth, especially when compared to once supported options of formula feeding (Dorea, 2007). According to the CDC Division of Nutrition, Physical Activity, and Obesity hospital and institutional routines can either help support or can create barriers to breastfeeding (2009). Some examples that are extreme include the fact that 98% of all births in the U.S. occur in institutions without the Baby-Friendly Hospital Designation and about 50% of those infants receive formula supplements in the hospital regardless of medical need, and 1 in 4 receive it before 2 days of age (Younger Meek, 2010, p. 253). This statistic needs to change as cultural and institutional settings have become much more aware of what a disruption it is in the breastfeeding cycle to supplement with an inferior product and Baby-Friendly Hospital Designation at Brookdale will be an important step for change in this community and as another example for other U.S. hospitals.
Resources for Implementation
Resources needed for the implementation of the Baby Friendly Hospital designation are relatively limited, due in large part to the extensive work the Brookdale Hospital has recently done to begin to implement better breastfeeding and maternal practices, as noted at the close of the Problem statement section of this work. The hospital must implement additional changes, file the proper application for assessment and designation and prove and justify implementation of the 10 steps associated with the designation over a period of five years. The resources needed for this process will include participation by existing staff including nurses, nurse managers and the hiring of a certified lactation specialist. The most costly of all the implementation strategies will be hiring of a certified lactation specialist, other costs will be further detailed in the budget section of this work and will include administrative, office supplies, additional signage and support training of nursing and support staff.
Barriers to Change
Barriers to change must begin with a clear understanding and elimination of the kinds of hospital practices that are shown in evidence-based research to be particularly contraindicative of early, long-duration and successful breastfeeding including the; use of artificial nipples (pacifiers), bottles, and even nipple shields in mainly healthy newborns (McKechnie & Eglash, 2010) supplementation that is unneeded for natal nutrition, limitations in the practice of rooming in (infant stays with mother as much as possible over the first 24 hours after birth to ensure on demand nursing opportunities), limitations in skin to skin contact of infant with both mother and father, and other institutionally practiced barriers are not only common but traditionally accepted as standards of practice in most hospitals and birthing centers ("Breastfeeding-related maternity practices…" 2008 ). The Baby-Friendly Hospital Designation, and all the steps to prepare and implement it will go far to demonstrate change in hospitals including but not limited to Brookdale Hospital in NYC.
Barriers to change, that are specific to Brookdale hospital have been briefly developed in the problem statement of this work and demonstrate mostly institutional practices that are not only accepted but supported by the hospital and L&D and neonatal staff. Rooming in, where the newborn infant spends as much time as possible with the mother during the first 24-48 hours of life, leaving the bedside of the mother only when absolutely necessary is essential to change. The existence of a highly staffed and large newborn nursery, where infants spend a good deal of time and receive a great deal of care from staff rather than the mother is one of the first institutional issues that needs to change. This reduction of reliance on the newborn nursery may offset some of the costs of implementing change, as stricter rooming in policies and practices would indicate the need for fewer staff resources in the newborn nursery. Skin-to-skin contact of mother to infant should begin at the moment of birth, as is indicated by the hospital's new policies and procedures for breastfeeding support. Newborns should be given screening tests in the presence of the mother, and if at all possible while the mother is holding and/or nursing the child during skin to skin contact. Breastfeeding education should be continuous, beginning in prenatal clinics, extending throughout the hospital stay and supported and supplemented by follow up care with a certified lactation specialist and/or nursing staff that has taken CEC courses in breastfeeding support, and the number class offerings per week should be increased to every other day to support the usual uncomplicated discharge of mother and baby at 48-72 hours post delivery and the course for mothers should be a condition for discharge. L&D and nursery nurses should continue to be encouraged to take the available course with a first year goal of 100% completion. Lastly, cultural barriers to breastfeeding in the patient population should be mitigated with culturally sensitive training and breastfeeding support, long-term breastfeeding follow up and a sensitive but essential reiteration of the many benefits of breastfeeding for both child and mother, reiteration, for those who qualify, of the benefits of the Women Infant Children program which supports breastfeeding mothers with additional food and benefits for the mother not just by supplying formula or food for the infant after birth.
Role of Nurse Executive
The nurse executive and especially the administrative and charge nurses in L&D and the maternal baby care aspects of the hospital will be required to achieve buy in from all other nursing staff with regard to the implementation of the Baby-Friendly Hospital Designation goals and standards. Nurse executives will also be likely to be the main source of impetus for implementation standards as a detailed implementation plan will need to be developed and then adhered to, to create the possibility of certification. The nurse executive will also be responsible for early implementation strategies including community-based support and contacts for improving breastfeeding support in the hospital and advocating for change through bedside checks and by making his/her observing presence known on the nursing floor. The nurse executive may in fact need to downsize staffing in the nursery