Evidence-Based Practice Project

Abstract
Breastfeeding is recognized as the gold standard for infant nutrition and is associated with several benefits to the mother and to the baby. Failure to breastfeed is also associated with different risk factors such as breast cancer, endometrial, and ovarian cancers, as well as, other chronic diseases such as diabetes and hypertension for the mother. Some of the benefits associated with breastfeeding include reduced episodes of diarrhea, lower respiratory infections, asthma, diabetes, low infant mortality rates, and childhood obesity among others. Unfortunately, despite the benefits associated with breastfeeding, compliance rates are below the recommended numbers. In an effort to increase breastfeeding rates and duration, UNICEF and the World Health Organization recommend the use of educational interventions to increase awareness and cultivate positive attitudes to improve breastfeeding initiation and duration. In light of this, this study is a proposal to initiate breastfeeding education intervention within the hospital setting to increase breastfeeding initiation rates and breastfeeding duration. The project targets pregnant women visiting the prenatal and obstetrics clinic. Nurses working within the two clinics will be tasked with the responsibility of implementing change. Drawing upon existing literature, we describe the proposed solution and justify why it is consistent with current evidence and the organization culture. Using Roger’s diffusion of innovation theory, we outline a step-by-step implementation process based on diffusion of innovation theory phases. Additionally, we provide a detailed implementation plan, considering the setting and access to potential subjects, time needed, resources, and methods of data collection. Further, we outline the process for delivering the intervention, the data collection plan, strategies to overcome barriers and any challenges, feasibility of the implementation, and the future of the proposed project. Lastly, we present the evaluation plan in a comprehensive and concise way.
Table of Contents
Abstract 2
Section A: Organizational Culture and Readiness Assessment 5
Section B: Problem Description 6
Background of the Problem 6
Stakeholders/Change Agents 7
PICOT Question 7
Purpose and Project Objectives in Specific, Realistic, and Measurable Terms 7
Supportive Rationale on the Importance of the Problem 8
Section C: Literature Support 8
PICOT Question 9
Description of the Search Method 9
Summary of the Research Studies used as Evidence 9
Description of the Validity of Internal and External Search 10
Section D: Solution Description 11
Proposed Solution 12
Applicability of the Intervention in the Organization 12
Organization Culture 12
Expected Outcomes 13
Method to Achieve Outcomes 13
Outcome Impact 13
Section E: Change Model 14
Rogers’ Diffusion of Innovation Theory 14
Section F: Implementation Plan 16
Setting and Access to Potential Subjects 16
Time Needed to Complete the Project 16
Resources 16
Methods and Instruments 17
Delivering the Intervention 17
Outline for Data Collection 17
Strategies to deal with the Management of any Barriers, Facilitators, and Challenges 17
Feasibility of the Implementation Plan 18
Future of the Proposed Solution 18
Section G: Evaluation of Process 18
Rationale for the Data Collection Methods 18
Outcome Measures 19
Validity, Reliability, and Applicability of Outcomes 19
Strategies to Apply if Outcomes do not Provide Positive Results 20
Implications for Practice and Future Research 20
References 21
Appendices 23
Appendix A: Rapid Critical Appraisal of Qualitative Evidence by Radzyminski and Callister article: “Mother’s beliefs, attitudes, and decision making related to infant feeding choices” 23
Appendix B: Rapid Critical Appraisal of Systematic Reviews of Clinical Interventions/ Treatments: “Breastfeeding education: where are we going? A systematic review article” 28
Appendix C: Rapid Critical Appraisal of Systematic Reviews of Clinical Interventions/ Treatments: “Stakeholder views of breastfeeding education in schools: a systematic mixed studies review of the literature” 30
Appendix D: A Conceptual Framework for Prenatal Breastfeeding Educational Intervention for Pregnant Women 32
Appendix E: Informed Consent 33
Appendix F: Timeline for the Project 35
Appendix G: Resource List 36
Appendix H: Questionnaire 37
Appendix I: Breastfeeding self-initiation Scale 39
Appendix J: Data Collection Tools 40
Appendix K: Budget Plan 41

Evidence-Based Practice Project
Section A: Organizational Culture and Readiness Assessment
Evidence-based practice has been widely recognized as a key to the delivery of high quality healthcare and enhancing patient outcomes at significantly lower costs. Unfortunately, as Melnyk and Fineout-Overholt (2015) elaborate, although there is a wide range of evidence to guide clinical practice, the integration of evidence-based care by healthcare providers is significantly low in a majority of the health care organizations. Drawing upon survey on the organizational culture and readiness assessment, the organization is moderately ready to implement EBP. Ideally, the organization’s readiness is based upon the philosophy of EBP, presence of EBP mentors, and administrative support. The presence of EBP mentors includes healthcare providers such as Advanced Practice Nurses, who are academically prepared to implement EBP. Administrative support is in form fiscal resources such as conferences, workshops, and education programs focusing on training nurses on EBP. Focusing on possible project barriers and facilitators, lack of EBP knowledge and skills in the organization is one of the major barriers to EBP implementation. The librarians within the organization do not have sufficient knowledge and skills to help with searching for EBP evidence.
Clinical inquiry is a process where clinicians collect data using narrowly defined clinical parameters to enhance treatment options. Within the healthcare organizational setting, cultivation of clinical inquiry is necessary. Melnyk and Fineout-Overholt (2015) recommend that one of the ways to integrate clinical inquiry into the organization is by cultivating a level of uncertainty, which is the inability to predict the outcome of an experience and provides the basis for developing foreground questions.
Section B: Problem Description
Background of the Problem
Evidently, breastfeeding is associated with several health benefits such as reduced risk of breast cancer, endometrial, and ovarian cancers, as well as, other chronic conditions such as hypertension and diabetes for the mother. Along with that, breastfeeding is associated with numerous benefits for the baby such as reduced episodes of diarrhea, lower respiratory infections, low infant mortality rates, asthma, diabetes, and childhood obesity among others (Anstey et al., 2017). For mothers who know and understand the numerous health benefits associated with breastfeeding, they are more likely to breastfeed. On the other hand, research indicates that although mothers believe that breastfeeding is important for their babies, those who do not understand the specific benefits and possible health risks of not breastfeeding are unable to make truly informed decisions about initiating and the duration of breastfeeding (Radzyminski & Callister, 2016). Additionally, mothers who do not how to initiate and continue breastfeeding are likely to be afraid it will be painful or they will be unable to produce enough milk to feed the baby. In essence, pregnant mothers who do not understand breastfeeding including initiating, benefits, and possible health risks are less likely to breastfeed their babies. Nonetheless, an article by Singletary, Chetwynd, Goodell, and Fogleman (2016) indicates that formal prenatal breastfeeding education can be helpful in informing women about the health advantages of breastfeeding and increase a mother’s ability to initiate breastfeeding and the breastfeeding duration.
Stakeholders/Change Agents
The prenatal breastfeeding education program to enhance a mother’s ability to initiate breastfeeding and increase breastfeeding duration is targeted at pregnant. Some of the identified stakeholders include:
The community health centers including healthcare providers who provide clinical and support services for pregnant women
Staff and volunteers in programs/agencies such as World Health Organization and UNICEF that offer support services during prenatal period for pregnant women
Pregnant women and their families.
PICOT Question
For pregnant women (P), how does formal prenatal breastfeeding education (I) compared to no education or informal individual research (C) affect a mother’s ability to initiate breastfeeding (O) and increase breastfeeding duration (T)?
Purpose and Project Objectives in Specific, Realistic, and Measurable Terms
As earlier identified, breastfeeding is associated with several health benefits for both mother and baby. Unfortunately, statistics indicate that global breastfeeding rates are below the recommended numbers (Singletary et al., 2016). In an effort to increase breastfeeding initiation and duration, UNICEF and the World Health Organization recommend use of educational interventions to increase awareness and cultivate positive attitudes among mothers towards breastfeeding. Drawing upon the PICOT question, the purpose of the project is to examine the impact of education intervention vs. lack of education interventions on a mother’s ability to initiate breastfeeding and increase breastfeeding duration.
Supportive Rationale on the Importance of the Problem
According to the United Nations International Children’s Emergency Fund and World Health Organization, if all infants breastfed for at least six months of their lives, this would reduce the morbidity and malnutrition, as well as, other health-related problems (Burgio et al., 2016). Nurses play a significant role in encouraging pregnant women to initiate breastfeeding. Understanding how education interventions can help initiate breastfeeding can help nurses achieve their objectives in helping mothers to initiate breastfeeding, and increase breastfeeding duration. The issue is an important one for nurses to resolve using relevant professional literature sources in that, it will help nurses acquire knowledge on evidence-based practices that are appropriate and effective for mothers. It will also help them understand how to implement the educational interventions to enhance compliance of breastfeeding among mothers.
Section C: Literature Support
When carrying out a focused search for a clinical topic based on a PICOT question, researchers can enter multiple elements into the search system. Unfortunately, Melnyk and Fineout-Overholt (2015) elaborate that, this method makes it hard to determine the concept with the most evidence. In view of this, it is recommended to enter the terms from a PICOT question one at a one, identify the number of hits, and ensure that evidence is available to answer the clinical question. In addition, databases can be very large making it hard to retrieve only the desired articles even after using the best search strategies. In light of this, a limit function is used to help the researcher narrow down from a large list of citations to find relevant studies to the PICOT question. Search limits are several forms including limiting the search to a type of study design, availability of the study article, or subject headings. Along with that, clinicians use conditions called inclusion and exclusion criteria based on specific conditions set to determine the most relevant evidence. With this knowledge, we provide a description of the search method used with the research studies. Secondly, we summarize the research studies used as evidence and the essential components of the studies. Lastly, we provide a description of the validity of both internal and external research.
PICOT Question
For pregnant women, how does formal prenatal breastfeeding education compared to no education or informal individual research (C) affect a mother’s ability to initiate breastfeeding (O) and increase breastfeeding duration (T)?
Description of the Search Method
For the purpose of the study, we searched the EBSCOHost database. The following keywords were used for the search criteria; “prenatal breastfeeding education”, AND “mother’s ability to initiate breastfeeding”, AND “increase breastfeeding duration”. The inclusion and exclusion criteria considered studies from January 2015 to January 2019. The search criteria generated a hit of 469 results, which were evaluated based on their relevance and applicability to the PICOT question.
Summary of the Research Studies used as Evidence
The studies reviewed helped to inform the background of the problem. The study sought to explain why addressing the PICOT question was important and why it deserves attention. The review of literature considered articles between 2015 and 2019. Two articles were systematic reviews, one a review, and the last one was a qualitative study. Out of the two articles that were based systematic reviews, one article by focused on stakeholder views of breastfeeding education in schools. The article by Singletary, Chetwynd, Goodell, and Fogleman (2016) informed the background of the problem by providing an overview of the current state on global breastfeeding rates. The strength of the study was in the quality appraisal tool that was used to test for validity, efficiency, and reliability of the articles reviewed. The limitation of the study was identified as its inability to include studies published in other languages apart from English.
The second systematic review was by Burgio et al. (2016) and focused on evaluating the importance and success rate of breastfeeding education. The strength of the review was based on the research databases, which included Scopus, PubMed, MEDLINE, Google scholar, and Science Direct. The limitation or the weakness of the study was in the lack of a critical appraisal tool to evaluate the article. Besides, the article considered studies dating back several years back to 1980.
The third article by Anstey et al. (2017) was a review that focused on understanding breastfeeding and breast cancer risk reduction. The article informed the research about the risks associated with failure to breastfeed, as well as, benefits associated with breastfeeding. The strength of the article was based on the fact that majority of the references cited within the article were recent and within the past five years from the date of publication. A limitation of the study was using older sources to gather information to support the research.
The article used was a qualitative study by Radzyminski and Callister (2016), that collected data using interviews. The study sought to find out the impact of mother’s beliefs, attitudes, and decisions on infant feeding choices, with a special focus on breastfeeding and formula feeding. The strength of the article was based on the number of participants interviewed and the fact that they were randomly selected from a large tertiary medical center.
Description of the Validity of Internal and External Search
Evidence-Based Practice experts have outlined various ways to rate the varying levels of evidence and strength of evidence. The assessments provide a mechanism to help clinicians and health care providers in evaluating evidence for its applicability to healthcare decision making (Melnyk & Fineout-Overholt, 2015). Ideally, when searching for evidence, it is important to consider the internal and external validity of the search. Considering quality as the domain used to measure internal validity, the review methods used were of high quality. In particular, the review methods considered articles within the last five years and considered the strengths of the studies. On the other hand, and considering the external validity of the search, the selected sample of articles that were used were representative of the articles from which they were drawn. The articles were identified from 469 hits, which were searched using the same criteria.
Section D: Solution Description
Breast milk is the optimal source of nutrients for babies and confers multiple health benefits to mothers and babies. According to Anstey et al. (2017), breastfeeding is associated with numerous benefits for the baby including reduced episodes of diarrhea, lower respiratory infections, asthma, diabetes, low infant mortality rates, diabetes, and childhood obesity. Along with benefits to the baby, breastfeeding is also associated with numerous benefits to the mothers such as reduced risk of endometrial, breast, and ovarian cancer among other conditions such as diabetes and hypertension. The World Health Organization, the United Nations International Children’s Emergency Fund, the Healthy People 2020, and the American Academy of Pediatrics encourages mothers to breastfeed and recommends exclusive breastfeeding for the first six months of a baby’s life (Jacobsen, 2018). Unfortunately, Ann et al. (2016) elaborate, despite the multiple benefits associated with breastfeeding and the call to initiate breastfeeding, breastfeeding rates in the United States lag behind the US Healthy People 2020 objectives.
Proposed Solution
In order to increase a mother’s ability to initiate breastfeeding and improve breastfeeding duration, we proposed prenatal breastfeeding education for pregnant mothers. Ideally, the use of education intervention to improve breastfeeding has been evaluated in several studies and found effective. For instance according to an integrative review by Ugurlu and Yavan (2016), results indicated that education during prenatal period was more effective in affecting a mother’s ability to initiate breastfeeding and improve the breastfeeding duration. In another study carried out at an Urban Academic Hospital, quality improvement initiatives in form of education resulted in higher number of mothers initiating exclusive breastfeeding (Ward, Williamson, Burke, Crawford-Hemphill, & Thompson, 2017). Additionally, a study by Kellams, Gurka, Hornsby, Drake, and Conaway (2018) that sought to evaluate the effectiveness of breastfeeding education videos in a prenatal clinic found that it was not effective. However, the study noted that the video is not sufficient, but was a useful component of a comprehensive program to promote breastfeeding.
Applicability of the Intervention in the Organization
Considering that the education intervention programs are offered to pregnant mothers, the intervention is not unrealistic to my organization. The education intervention will be offered at the prenatal clinic and at the obstetrics. The nurses and the obstetricians will be trained with the necessary skills and knowledge to initiate this skill.
Organization Culture
My organization recognizes the importance of breastfeeding, and the importance of an optimal environment for appropriate breastfeeding and mother-baby bonding. The organization is committed to pediatric care. Introducing breastfeeding education intervention at the prenatal clinic and the obstetrics will enhance the health outcomes at the pediatrics.
Expected Outcomes
After initiating the breastfeeding education at the prenatal clinic and the obstetrics, it is expected that breastfeeding initiation and increased breastfeeding duration will be realized among mothers visiting the hospital.
Method to Achieve Outcomes
In order to initiate breastfeeding education intervention at the prenatal clinic and the obstetrics, the following plan will be followed.
Step 1: Have a clearly written breastfeeding policy and routinely communicate it to staff members involved in the initiative.
Step 2: train nursing professionals attending the prenatal clinic and obstetric providers. The training program will include online breastfeeding education modules, breastfeeding policy, breastfeeding skills.
Step 3: initiate breastfeeding education for pregnant women visiting the prenatal clinic and the obstetrics, as well as, their families. The education programs will be delivered individually or in group form.
Outcome Impact
Breastfeeding has several health benefits to the baby and the mother. The ability of the nurses and the providers at the obstetrics to help mother initiate breastfeeding and increase the breastfeeding duration will reflect improved quality care. It will reflect the ability of the organization and health care providers to provide quality care. The outcomes will provide a basis for evidence-based practice to improve quality of care, enhance the delivery of patient-centered quality care, and enhance efficiency in initiating breastfeeding after mothers have delivered newborns.
Section E: Change Model
In recent years, clinical practitioners have adopted the concept of EBP in their clinical practice to deliver quality and safe patient care. However, despite the emergence and development of EBP, its implementation is limited to a degree due to various implementation barriers as elaborated by Barría (2014), failing to provide evidence-based practice care to a significant percentage of patients. The failure to implement EBP means that the effect of subjective errors, use of obsolete information, and exercising practices based on unsubstantiated experiences increases (Mohammadi, Poursaberi, & Salahshoor, 2018). Roger’s diffusion of innovation theory is a good theoretical framework that will be used to identify factors that will be applied to advance EBP adoption, determine the process, and develop an EBP adoption model.
Rogers’ Diffusion of Innovation Theory
Roger’s theory of diffusion of innovation has been applied to enable the implementation of new practices in clinical settings. According to Scott and McGuire (2017), the theory seeks to answer the how and under what circumstances changes are acceptable. Evidence-based practice is considered an innovation and using the four elements the diffusion of innovation theory we outline the implementation of EBP within the organizational practice.
Innovation. In the diffusion of innovation theory, innovation encompasses a new idea, object, or a practice. Innovation can include an emerging medical practice or a new educational policy, or a technology. Focusing on the element of innovation, scholars have found that individuals are more likely to implement an innovation based on the following perceptions. If individuals believe that it has some relative advantage compared to the current practice, is compatible with current needs and values, or it is not too complex to implement. In addition, individuals are likely to implement a change is they believe the practice can be tested for a certain period before adoption or has observable outcomes or results (Scott & McGuire, 2017). In this case, the innovation is the implementation of prenatal breastfeeding education in the organization to improve breastfeeding initiation and duration. The implementation of prenatal breastfeeding education at the prenatal and obstetrics clinic is perceived as having sole relative advantage and the ability to improve breastfeeding. The proposed practice change is compatible with the organization values and is not too complex in its mode of implementation. Besides, the education will be implemented during the prenatal period and has observable results.
Communication Channels. Distribution of information regarding an innovation is a social and dynamic process. Different communication methods are effective based on the stage of the adoption process (p. 121). Within the organization, the communication method that will be used is a formal meeting to inform all relevant stakeholders about the implementation of the new practice. The face-to-face communication, workshops, professional conferences will be used to persuade individuals to embrace the innovation.
Time. Time represents a number of elements in the adoption of innovation. For instance, it considers the innovation-decision process, individual innovativeness, and the rate of adoption (p. 121). Within the organization, some individuals are more likely to adopt to a new idea more readily than others.
Social systems. Under this element, it is assumed that the diffusion of an innovation occurs within a social system where members share the same objective (p. 122). This may be professional organizations or groups of individuals. Members in a particular form of social system or structure are likely to behave in a predictable manner and influence the implementation of change. At the organization, change will be implemented at the prenatal and obstetric clinic where members share the same objectives.
Section F: Implementation Plan
Setting and Access to Potential Subjects
The proposed solution is to incorporate evidence-based hospital practices in the form of prenatal breastfeeding educational interventions to improve the rate of breastfeeding initiation and increase breastfeeding duration. The exercise will take place at the prenatal clinic and the obstetric clinic of my organization. In order to implement the proposed solution, a multidisciplinary team will be assembled, which will include an administrative leader, obstetrics, and prenatal clinic nurses. The educational intervention targets pregnant women visiting the prenatal clinic and the obstetrics. Considering the type of intervention to be implemented, an informed consent will be obtained from pregnant mothers to participate in the breastfeeding educational intervention program.
Time Needed to Complete the Project
The project will run for a period of 6 months as trial and will follow a three-step program as outlined in section D of solution description. At the end of every training program, there will be mock assessment and patient interviews to determine whether the subjects have understood the breastfeeding interventions. During this time, expected outcomes include overall increased mother’s ability to initiate breastfeeding rate by the end of the training period.
Resources
In order to implement the breastfeeding educational intervention programs, there will be a need to obtain certain resources. The human resources include nurses at the prenatal clinic and obstetricians, as well as, other staff at the obstetric clinic. The fiscal resources will be required to cover the training program for the staff who will be offering the educational interventions at the two clinics. The other resources are educational materials that will be used to train the pregnant women on breastfeeding.
Methods and Instruments
Two methods for monitoring implementation will be used. The first one is a questionnaire to measure pregnant women understanding of the benefits of breastfeeding and their willingness to initiate breastfeeding. The second method will be a scale to test the rate of breastfeeding initiation after delivery, where infant charts will be reviewed.
Delivering the Intervention
In order to deliver the educational intervention program, nurses, obstetrics, and other health care staff involved will be trained on skills necessary to implement the policy.
Outline for Data Collection
For a period of six months, pregnant mothers who have participated in the training programs will be provided with questionnaires. Infant charts will be reviewed to measure compliance and rate of breastfeeding initiation. Data management will involve three key members – data manager, database administrator, and clinical data associate, and will be stored in a clinical database awaiting analysis. Statistical process control charts will be used to evaluate the impact of interventions for the period of six months. Additionally, statistical questionnaire analysis will be used to evaluate the questionnaires administered to pregnant mothers.
Strategies to deal with the Management of any Barriers, Facilitators, and Challenges
Virtually, the success of any intervention depends on the consideration of various barriers and challenges and use of adequate strategies to overcome them. In order to deal with the management of barriers, facilitators, and challenges, the following strategies will be implemented. The first strategy is coordination within teams and across teams to ensure cohesion and success of the program. The second strategy is to ensure sufficient infrastructure to implement the intervention. The third strategy is to ensure sufficient leadership support from the organization and within the team.
Feasibility of the Implementation Plan
The intervention plan consists of prenatal lecture on the benefits of breastfeeding and mock demonstrations. Nurses and obstetric staff will implement the intervention within the clinical setting. The hospital has an IT department that will be responsible for the management of computer related costs. Other costs that will be incurred include development of presentations and staff training program. Fiscally, the intervention is feasible.
Future of the Proposed Solution
After the six months duration has elapsed, successful implementation of the intervention will see the plan proceed to the next level, where all health care providers will be involved. The plan will be continued and become a daily routine for the organization. In case the plan is not successful, the intervention will be revised and put on trial for another six months.
Section G: Evaluation of Process
Rationale for the Data Collection Methods
The outcome data collection method that will be used is a questionnaire administered to pregnant women to measure their understanding of the education program. The second data collection that was identified was the use of scale by reviewing infant charts to evaluate the rate of breastfeeding initiations. For the purpose of this paper, this data collection will be identified as reviewing patient data records, in this case, infant chart data records. The study opted to use a questionnaire because the sample study is large and questionnaires are relatively cheap and easy to administer, easy to analyze, familiar with most respondents, allows information to be collected in a standardized way, and can be used to address sensitive questions. Besides, they allow respondents to skip some questions they feel may violate their rights as an individual. On the other hand, review of infant chart data records is a gold standard that will provide accurate data as recorded by nurses after delivery.
Outcome Measures
The project objective is to improve the rate of breastfeeding initiation and increase the duration of breastfeeding based on a prenatal educational program. The outcome measures will evaluate the pregnant women’s understanding of the benefits of breastfeeding and the rate of breastfeeding initiation after delivery. The outcome measures will evaluate the extent to which the project objectives were achieved using pre-set SMART goals. In this case, Specific goals include increased breastfeeding initiation rates after delivery. Measurable –this include indicators to help stay on track to achieving goals, which in this case is participant’s increased understanding on benefits of breastfeeding. Attainable – the organization must commit resources and necessary support to attain the goals. Realistic – the organization has the capacity to implement educational breastfeeding intervention, and lastly; timely – the objectives will be grounded within a six month pre-trial duration.
Validity, Reliability, and Applicability of Outcomes
The validity of the results tests whether the results were obtained using sound scientific methods (Melnyk & Fineout-Overholt, 2015). In order to ensure validity, the study will eliminate bias. For instance, when selecting participants for the study, bias will be reduced by randomly providing questionnaires to the participants. Secondly, to ensure the reliability of the outcomes the numerical study results will be examined carefully, and consider various factors that could influence a mother’s ability to initiate breastfeeding apart from the educational intervention. The reliability will also consider the clinical significance of the outcomes. Lastly, the applicability will be evaluated based on the study design questions. If the outcomes answer the study design questions, then they are applicable in the clinical setting.
Strategies to Apply if Outcomes do not Provide Positive Results
In case outcomes do not provide positive results, an analysis of what caused the failure will be implemented. In particular, the methodology will be evaluated and probably start all over again using different methods. However, if there is no problem with the methodology, then we will conclude that the intervention was unsuccessful and implement a different intervention.
Implications for Practice and Future Research
Nursing education does not offer adequate training on breastfeeding support, which results in making personal breastfeeding experience an important element for nurses to support breastfeeding for new mothers and at the pediatric unit. Breastfeeding education will provide nurses with the necessary knowledge and skills to help mothers initiate breastfeeding and improve the health outcomes at the pediatric unit. Future research should be completed to determine the relationship between nursing assistance and success in breastfeeding initiation and duration.
References
Ann, L. K., Paige, P. H., Valerie, C., Mark, R., Kelly, K. G., Gauri, G., Emily, D., … Daphne, G. (2016). The impact of a prenatal education video on rates of breastfeeding initiation and exclusivity during the newborn hospital stay in a low-income population. Journal of Human Lactation, 32(1), 152-159.
Anstey, E. H., Shoemaker, M. L., Barrera, C. M., O’Neil, M. E., Verma, A. B., & Holman, D. M. (2017). Breastfeeding and Breast Cancer Risk Reduction: Implications for Black Mothers. American Journal of Preventive Medicine, 53(3), S40-S46.
Barría, P. RM. (July 01, 2014). Implementing Evidence-Based Practice: A challenge for the nursing practice. Investigación Y Educación En Enfermería, 32(2), 191-193.
Burgio, M. A., Laganà, A. S., Sicilia, A., Prosperi, P. R., Porpora, M. G., Ban, F. H., DI, V. G., … Triolo, O. (2016). Breastfeeding Education: Where Are We Going? A Systematic Review Article. Iranian Journal of Public Health, 45(8), 970-977.
Jacobsen, N. (2018). Antenatal breastfeeding education and support: summary and analysis of 2 cochrane publications. The Journal of Perinatal & Neonatal Nursing, 32(2), 144-152.
Kellams, A. L., Gurka, K. K., Hornsby, P. P., Drake, E., & Conaway, M. R. (2018). A randomized trial of prenatal video education to improve breastfeeding among low-income women. Breastfeeding Medicine, 13(10), 666-673.
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Wolters Kluwer.
Mohammadi, M. M., Poursaberi, R., & Salahshoor, M. R. (2018). Evaluating the adoption of evidence-based practice using Rogers’s diffusion of innovation theory: a model testing study. Health Promotion Perspectives, 8(1), 25-32.
Radzyminski, S., & Callister, L. C. (2016). Mother’s Beliefs, Attitudes, and Decision Making Related to Infant Feeding Choices. The Journal of Perinatal Education, 25(1), 18-28.
Scott, S., & McGuire, J. (2017). Using Diffusion of Innovation Theory to Promote Universally Designed College Instruction. International Journal of Teaching and Learning in Higher Education, 29(1), 119-128.
Singletary, N., Chetwynd, E., Goodell, L. S., & Fogleman, A. (2016). Stakeholder views of breastfeeding education in schools: a systematic mixed studies review of the literature. International Breastfeeding Journal, 12(1), 1-13.
Ugurlu, M., & Yavan, T. (2016). The effectiveness of breastfeeding education: An integrative review. Journal of Behavioral Health, 5(4), 182-190.
Ward, L. P., Williamson, S., Burke, S., Crawford-Hemphill, R., & Thompson, A. M. (2017). Improving exclusive breastfeeding in an Urban Academic Hospital. Pediatrics, 139(2), e1-e11.

Appendices
Appendix A: Rapid Critical Appraisal of Qualitative Evidence by Radzyminski and Callister article: “Mother’s beliefs, attitudes, and decision making related to infant feeding choices”
Are the results of the study valid (i.e., trustworthy and credible)?

How were the study participants chosen?
The principal investigator and the research assistant approached the participants in a postpartum clinic, informed consent obtained, and demographic forms obtained in preparation for the interview.
Howe were accuracy and completeness of data assured?
The researchers used audio recording, which was later transcribed to ensure accuracy and completeness.
How plausible/ believable are the results?
The results are plausible
Are implications of the research stated
yes

May new insights increase sensitivity to others’ needs?
yes

May understandings enhance situational competence
yes

What is the effect on the reader?
It informs the reader on mother’s beliefs, attitudes, and decisions concerning breastfeeding and formula feeding.

Are results plausible or believable?
yes

Is the reader imaginatively drawn into the experience?
yes

What were the results?

Does the research approach fit the purpose of the study?
yes

How does the researcher identify the study approach?
yes

Are language and concepts consistent with the approach
yes

Are data collection and analysis techniques appropriate?
yes

Is the significance/importance of the explicit?
yes

Does review of the literature support a need for the study?
yes

What is the study’s potential contribution?
Contribute to existing research on the beliefs, attitudes, and decisions of breastfeeding and formula feeding.

Is the sampling strategy clear and guided by study needs?
Yes

Does the researcher control selection of the sample?
Yes

Do sample composition and size reflect study needs?
yes

Is the phenomenon (human experience) clearly identified?
Yes the human experience is clearly identified.

Are data collection procedures clear?
Yes

Are sources and means of verifying data explicit?

unknown
Are researcher roles and activities explained?
Yes

Are data analysis procedures described?

No

Does analysis guide direction of sampling and when it ends?

Unknown
Are data management processes described?

No

What are the reported results (description or interpretation?
Interpretation

How are specific findings presented?
The research findings are presented in a step by step interpretation based on answers from respondents.

Is presentation logical, consistent, and easy to follow?
yes

Do quotes fit the findings they are intended to illustrate?
Yes

How are the overall results presented?
The overall results are consistent with the data collection and analysis.

Are meanings derived from data described in context?
yes

Does the writing effectively promote understanding?
yes

Will the results help me in caring for my patients?

Are the results relevant to persons in similar situations?
Yes

Are the results relevant to patient values and/ or circumstances?
Yes

How may the results be applied in clinical practice?
To understand what prompts mother’s decisions, beliefs, and attitudes to initiate breastfeeding or consider formula feeding.

Appendix B: Rapid Critical Appraisal of Systematic Reviews of Clinical Interventions/ Treatments: “Breastfeeding education: where are we going? A systematic review article”
Are the results of the review valid?

Are the studies contained in the review randomized controlled trials?

No
Does the review include a detailed description of the search strategy to find all relevant studies?

No
Does the review describe how validity of the individual studies was assessed (e.g., methodological quality, including the use of random assignment to study groups and complete follow-up of the subjects)?

No
Were the results consistent across studies?
Yes

Were individual patient data or aggregate data used in the analysis?
Aggregate data

What were the results?
The results confirm that healthcare providers play a critical role in education and encouraging mothers to initiate breastfeeding and extend the breastfeeding duration.

How large is the intervention or treatment effect (OR, RR, effect size, level of significance)?
The size of the intervention was not indicated.

How precise is the intervention or treatment (CI)?
unknown

Will the results assist me in caring for my patients?
yes

Are my patients similar to the ones included in the review
yes

Is it feasible to implement the findings in my practice setting?
yes

Were all clinically important outcomes considered, including risks and benefits of the treatment?

No
What is my clinical assessment of the patient and are there any contradictions or circumstances that would inhibit me from implementing the treatment?

No
What are my patient’s and his or her family’s preferences and values about the treatment that is under consideration?
yes

Appendix C: Rapid Critical Appraisal of Systematic Reviews of Clinical Interventions/ Treatments: “Stakeholder views of breastfeeding education in schools: a systematic mixed studies review of the literature”
Are the results of the review valid?
yes

Are the studies contained in the review randomized controlled trials?

unknown
Does the review include a detailed description of the search strategy to find all relevant studies?
yes

Does the review describe how validity of the individual studies was assessed (e.g., methodological quality, including the use of random assignment to study groups and complete follow-up of the subjects)?
yes

Were the results consistent across studies?
yes

Were individual patient data or aggregate data used in the analysis?

aggregate
What were the results?
Adolescents have a deficient in breastfeeding knowledge and have negative perception about breastfeeding.

How large is the intervention or treatment effect (OR, RR, effect size, level of significance)?
unknown

How precise is the intervention or treatment (CI)?
The intervention is precise based on the number of articles reviewed.

Will the results assist me in caring for my patients?
yes

Are my patients similar to the ones included in the review
yes

Is it feasible to implement the findings in my practice setting?
yes

Were all clinically important outcomes considered, including risks and benefits of the treatment?

no
What is my clinical assessment of the patient and are there any contradictions or circumstances that would inhibit me from implementing the treatment?
Yes

What are my patient’s and his or her family’s preferences and values about the treatment that is under consideration?
Yes

Appendix D: A Conceptual Framework for Prenatal Breastfeeding Educational Intervention for Pregnant Women

Appendix E: Informed Consent
The purpose of this form is to inform you as a potential participant about the project and help you decide whether you want to participate in this research or not.
Invitation: XYZ hospital would like to invite you to participate in a research study.
Purpose and Description of the Research Study: The purpose of this study is to implement prenatal breastfeeding educational intervention to determine its impact on a mother’s ability to initiate breastfeeding and increase breastfeeding duration. The study attempts to identify the relationship between breastfeeding education and breastfeeding initiation and duration. As a participant, if you decide to participate you will be requested to complete an attached questionnaire, with questions regarding your understanding of breastfeeding benefits after attending a short breastfeeding education program at the prenatal or obstetric clinic.
Risks and Benefits: The research study poses little to no risk for the participants. The benefits of this research is that it will help in identifying the impact of breastfeeding education on a mother’s ability to initiate breastfeeding and increase breastfeeding duration.
Confidentiality: all information obtained in this research study is strictly private and confidential unless mandated by law. The results of this report may be used in presentations, publications, presentations. However, details of the participants will remain strictly confidential and will not be revealed. Completing the study implies your consent to participate. To maintain and protect your privacy, all record of your participation will be assigned a group number to ensure that even the researcher does not identify you. Following the completion of this study, all data will be entered in a computer system and hard copies locked in a cabinet.
Compensation: The participants will not receive any compensation.
Questions/ Contact Information: In case you have any questions regarding the research study, kindly feel free to approach our information desk or the nurse in charge at the prenatal or obstetric clinic. Alternatively, you can reach the hospital on the official landline and email address.
Disclaimer: participation to this study is purely voluntary and participants can withdraw from the study at any time.
Consent Statement
I have read and understood the information provided to participants on the information sheet concerning the research study and I understand the contents of the informed consent sheet. (Kindly tick this box) ☐

Appendix F: Timeline for the Project

Appendix G: Resource List
No
Resource
Description
1.
Human Resources
Human resources include nurses at the prenatal clinic and obstetric clinic who will be tasked with the responsibility of implementing the education intervention
2.
Fiscal resources
Finances to cover the training program for the nursing professionals who will lead the change project

Money to cover the printing costs of materials that will be needed to educate the pregnant women, to produce the questionnaires
3.
Educational materials
PowerPoint presentations and brochures needed to educate pregnant women on breastfeeding initiation.

Appendix H: Questionnaire
Introduction
The survey will ask you about your experience of the breastfeeding education program you have attended at the prenatal or obstetric clinic. We are interested to hear your views so we can improve the way we do things and to understand whether our training has been effective in informing you about breastfeeding benefits, as well as, your willingness to initiate and extend the breastfeeding duration to the recommended period.
Did you attend and receive information or advice on breastfeeding when attending the prenatal clinic or obstetric clinic?
☐ No
☐ Yes
If you answered yes, was that information or advice about
☐ Breastfeeding benefits
☐ A demonstration of how to breastfeed
☐ Handling difficulties during breastfeeding
☐ Formula feeding
☐ Available services to help with breastfeeding others (please specify)______________
____________________________________________________________________
How was the information or advice provided to you
☐ Printed form/brochure
☐ Information session at the waiting room using PowerPoint presentation
☐ Individual appointment
Using the following scale, how helpful or unhelpful was the information provided to you?
☐ Very important
☐ Somewhat important
☐ Neither important nor unimportant
☐ Not very important
☐ Not important at all
After attending the breastfeeding class how likely are you to initiate breastfeeding and practice exclusive breastfeeding for at least six months?
☐ Very likely
☐ Somewhat likely
☐ Neither likely nor unlikely
☐ Not likely
☐ Not likely at all
If you answered not very important or not important at all in question 4, why was it that the information provided did not help you to make decision about infant feeding?
☐ Already decided to breastfeed
☐ Already decided to formula feed
☐ Already decided to combine breastfeeding and formula feeding
☐ Information was not clear
☐ Advice was not clear or conflicting
☐ Others (please specify)________________________________________________

Appendix I: Breastfeeding self-initiation Scale
The attending nurse will fill the breast-feeding self-initiation scale based on infant chart card to assess the ability of the mother to initiate breastfeeding after childbirth.
No.
Description
Please tick yes or no

The mother was able to initiate breastfeeding immediately after childbirth
☐ Yes
☐ No

The mother was unable to initiate breastfeeding immediately after childbirth and was assisted by the nurse or midwife?
☐ Yes
☐ No

The mother did not want to initiate breastfeeding and only initiated after nurse requested her to initiate
☐ Yes
☐ No

The mother refused to initiate breastfeeding even after intervention from the nurse
☐ Yes
☐ No

Appendix J: Data Collection Tools

Data Collection Method
Description

Questionnaires
Quantitative questionnaires/surveys will be used to quantify the benefits of breastfeeding education among pregnant women attending prenatal and/ or obstetric clinic. The survey template is provided at Appendix H. surveys will be conducted in a printed paper format handed to every pregnant woman who attends the prenatal or obstetric clinic and attends the training. The paper-based survey was preferred because the target population is in a defined place, which makes it easy to hand over the survey.

Infant Charts and scale
The infant charts contain accurate data recorded during childbirth. The charts were preferred because they are readily available at the hospital and they contain correct information.

Appendix K: Budget Plan
No.
Description
Cost

Compensation for personnel offering training to 20 nurses on breastfeeding education from the prenatal and obstetric clinic
$ 2,500

Developing and printing training materials including brochures
$ 800

Designing and printing questionnaires
$ 1,200

PowerPoint presentation development
$ 300

Database access
$ 1,600

Consumable supplies for the nurses attending the training
$ 2,000

Motivation fee for the nurses attending the training and delivering the educational program
$ 6,000

Total
$14,400.00