Public Health Nurses' Experiences of Implementing the Registered Nurses' Association of Ontario Breastfeeding Best Practice Guideline Recommendation for a Validated Breastfeeding Assessment
Summary
My Advanced Clinical Practice Fellowship (ACPF) at York Region Public Health (YRPH) was a transformational learning experience for me. The focus of my program evaluation project was to assess public health nurses' experiences with implementing Recommendation 1.1 from the RNAO Breastfeeding - Promoting and Supporting the Initiation, Exclusivity, and Continuation of Breastfeeding in Newborns, Infants and Young Children Best Practice Guideline (BPG) (RNAO, 2018). This ACPF project focused on the Monitor Knowledge Use and Evaluate Outcomes phase of the Knowledge-to-Action Framework (RNAO, 2012). The Donabedian Framework (1988) of structure, process, and outcome was used to evaluate the quality of the implementation strategies and the nurses' experience of introducing a validated assessment tool into their clinical practice.
Our journey to BPSO designation was guided by the Knowledge-to-Action Framework. The YRPH Breastfeeding BPG Lead conducted a gap analysis which highlighted the need to implement high quality, evidence-informed standardized breastfeeding assessments in public health. The RNAO Breastfeeding BPG Recommendation 1.1 indicated the need to "assess the breastfeeding process, using validated and reliable tools, during pregnancy and at key stages of lactogenesis" (RNAO, 2018, p. 18). After reviewing the literature on validated breastfeeding assessment tools, the BPSO Team selected the Bristol Breastfeeding Assessment Tool (BBAT) because it was concise, facilitated accurate, rapid breastfeeding appraisal, was applicable to all time points in a breastfeeding journey, and aligned with the goals and objectives of the breastfeeding program at that time (Ingram et al., 2015).
The Breastfeeding BPG Lead designed the implementation strategies based on a stakeholder analysis, identification of facilitators and barriers to implementation, assessment of physical, human, time, space, and financial resources, and a literature review on implementation strategies for public health. As suggested in the RNAO Toolkit: Implementation of BPGs (2012), a variety of approaches were selected that best aligned with our available resources and supports, including local opinion leaders (BPG Champions), educational meetings (training workshops and team meetings), educational materials, reminders, and managerial leadership. The purpose of this ACPF project was to evaluate the implementation strategies and to make recommendations for future BPG implementation into clinical practice.
My overall learning goal was to increase my knowledge and skills in implementation science and program evaluation. Following the learning plan I created for my ACPF proposal, I was able to achieve my clearly identified objectives. My first objective was to complete formal and informal online educational courses and attend the RNAO Clinical Summer Institute. I learned that YRPH was well positioned to promote the uptake of evidence-based research into routine practice for the purpose of improving the quality and effectiveness of health care services (Nilsen, 2015). The process was grounded by the Knowledge-to-Action Framework and the theoretical underpinnings of Lewin's Change Theory (Leeman et al., 2017).
My second objective was to gain knowledge of the data collection tools and methodology for my project. I analysed and synthesized the relevant empirical and conceptual literature and found a dearth of information specific to research-to-practice in public health nursing (Mathieson et al., 2018). Due to the time constraints of my ACPF project, I focused on specifically evaluating the aspects of implementing a BPG recommendation to determine implementation success among nurses practicing within a public health setting. The literature review and the online learning modules provided me with the knowledge to design qualitative and quantitative methodologies based on structural, process, and outcome indicators (Donabedian, 1988). Data collection involved a triangulation of online survey questions, interviews, and focus groups of 14 public health nurses trained in implementing the validated BBAT. From the raw data, I learned to create themes using literature, online learning modules, and data analysis software.
The analysis and synthesis of the data was the most challenging part of my learning. The iterative process of thematic analysis required several steps (Braun & Clarke, 2006) and extensive support from my mentorship team. The identified themes aligned with the Conceptual Model of a Healthy Work Environments for Nurses (RNAO, 2013). Understanding the structural, professional, and cognitive/psycho/sociocultural components within individual and organizational contexts illuminated the evaluation outcomes described below. My final objective of gaining expertise in disseminating the findings will be achieved beyond this ACPF through manuscript production, YRPH BPSO website, and future conferences.
Outcomes
The client population affected by this Fellowship was the public health nurses trained in implementing the BBAT. From the total of 14 nurses, 11 completed the online survey, 9 participated in focus groups, and 4 completed interviews. The quantitative results (chart audits) showed that nurses consistently provided validated breastfeeding assessments to enhance the quality of care delivered in a clinical setting. Overall, the use of conceptual and instrumental knowledge to change practice was supported by the implementation strategies. The theme induced from structure and process outcomes was related to the extrinsic motivators created for practice change such as policy and procedure changes, accessing electronic documentation forms, attending educational sessions, and recognition of time required to make a practice change. Nurses rated ongoing support and reminders from local opinion leaders as most helpful implementation strategies. Challenges were identified with the ability to provide consistent training amidst competing priorities such as staffing reorganization and external forces for change.
The impact of the implementation strategies on nursing practice outcomes was demonstrated by most nurses reporting they had the knowledge, capability, and resources to apply a new tool in their practice. Survey responses related to attitudes about using a new tool were further explored in the focus groups and interviews. The theme of intrinsic motivators was induced from the outcomes experienced by the nurses. The awareness of background information and rationale for choosing the BBAT, and customizing teaching strategies to learning styles and objectives, were clearly identified among participants as enablers to value change. Experiential learning through return-demonstration and reflective practice was most often reported among participants as highly important and most helpful in the adoption of a new tool into practice. Expert nurses with highly proficient competencies and beliefs in evidence-based practice were driven by their ability to critically analyze and self-reflect on the application of a new tool and compare and contrast scores to the overall assessments of maternal-infant dyads. Nurses were confident to base interventions on the interpretation of BBAT scores and valued reflective practice with peers to determine the benefits and limitations of implementing a validated assessment tool.
At the organizational level, the theme of extrinsic motivators related to structural outcomes helped to inform decision-makers about lessons learned in the implementation process. Nurses stated they valued the time, integration of the electronic BBAT into the documentation system, and enhancements to internal policy and procedures. Many nurses mentioned the human factor evaluation for user-testing of the electronic BBAT prior to implementation was helpful. Our organization supports a culture of quality and the delivery of evidence-informed care as an entry-to-practice nursing competency (CNO, 2018). The process outcome challenges at an organizational level identified by the nurses involved the fidelity of training to the original program. That is, the ability to provide consistent and timely training to staff impacted by the practice change would improve the implementation quality (Centre for Implementation, 2019). For orientation sustainability, consideration of resources such as time, funds, people, physical space, and technology have been made to enhance the training for new staff assigned to the YRPH breastfeeding clinics. Nurses valued implementation strategies aimed at sustaining change, such as ongoing audit and feedback reports, and suggested to share results only in aggregate form.
Many nurses indicated their appreciation of the organization's support for an inter-professional approach to implementing the RNAO Breastfeeding BPG. Having an implementation team made up of colleagues with expert opinions on technology, quality improvement, and program evaluation enhanced the integrity of the implementation process and ensured adherence to the Knowledge-to-Action Framework. Another suggestion provided by the participants involved the collaboration between hospital and public health to provide consistent validated breastfeeding assessments and a continuity of quality evidence-informed care from hospital to community. The lessons learned from the implementation of the RNAO Breastfeeding BPG in a public health setting could be transferred and adapted to the hospital context. There is future potential to measure outcomes for breastfeeding clients who complete a BBAT in a local hospital post-partum unit and compare the scores to a BBAT completed in our public health breastfeeding clinics. Using scores to determine referral for ongoing breastfeeding support in the community is another consideration for organizational collaboration.
Overall experience
Keeping a journal of self-reflection was instrumental to my transformative learning during this ACPF experience. My ways of knowing as an expert nurse had transformed to a novice program evaluator seeking a deeper understanding of the key factors in the implementation of evidence-based nursing practice (Chinn & Kramer, 2018). As a learner, I expanded my consciousness to enlighten my perspective of BPG implementation (McAllister, 2015). Referring to Carper's ways of knowing (Chinn & Kramer, 2018), I valued the relationship between the empirical and ethical nature of evidence-based practice with a nurse's personal and aesthetic knowledge of a client's experience. The contribution I hope to make through this ACPF is the transformation of nursing knowledge by re-thinking the context of a BPG and its interpretation through critical thinking and self-reflection. Allowing the space to reflect among peers when translating research into nursing practice has the potential to transform nursing knowledge beyond this Fellowship.
Another important contributing factor to my learning was the support I received from my mentorship team. I am extremely grateful to my public health colleagues, the BPSO Team, and my Ryerson University mentors for their encouragement, patience, and authentic interest in the growth and development of my nursing leadership competencies. Weekly interactions with team members kept me accountable to my learning plan. The inter-professional approach to translating an evidence based recommendation into practice was integral in the success of the implementation process. As a result of this project, quality improvements for the next orientation and training of public health nurses in implementing the BBAT have already begun. Lastly, I am inspired by my mentorship team to become a mentor for future RNAO Fellows and to give back to the nursing profession. Through opportunities such as the RNAO ACPF, nursing leaders are cultivated. My reflections are symbolic of growth and advancement into a future horizon as a nursing transformational leader.
