A Maternity Hospital’s Achievement of Baby-Friendly Designation: Exploration of Success Factors ()
1. Introduction
The Baby-Friendly Hospital Initiative (BFHI) was launched by the World Health Organization (WHO) and UNICEF in 1990 to promote healthy outcomes for mothers and infants by encouraging early and exclusive breastfeeding [1] [2]. This initiative was part of the Innocenti Declaration, which called for global support in protecting and promoting breastfeeding in maternity and newborn care facilities. BFHI accreditation requires hospitals to implement the Ten Steps to Successful Breastfeeding and uphold the International Code of Marketing of Breast-Milk Substitutes [3]. In doing so, the hospital commits to comprehensive mother-baby care, which includes breastfeeding resources and education, skin-to-skin interaction between mother and baby immediately after birth, and 24-hour rooming-in for both the infant and the mother.
2. Problem Statement
The problem addressed in this study is that many hospitals in the United States do not seek Baby-Friendly designation. According to Baby-Friendly USA, 9,000,000 babies were born in 600 Baby-Friendly facilities [2]. The WHO developed the Ten Steps to Successful Breastfeeding as a framework for hospitals to achieve Baby-Friendly designation [2]. However, the implementation process presented numerous challenges. A frequent barrier to adopting BFHI concepts is the perceived costs associated with its implementation.
3. Research Questions
RQ1: What are the essential practices, processes, and resources needed for successful implementation and designation as a Baby-Friendly institution?
RQ2: What do healthcare providers who are working at the Baby-Friendly hospital identify as critical for successfully becoming and maintaining a Baby-Friendly designation?
4. Significance of Study
Many maternity hospitals in the United States have been unsuccessful in gaining the BFHI designation [3]. In New Jersey, of 57 maternity hospitals, only 12 hospitals had BFHI designation or had been redesignated by 2022. Prokop et al. identified the need for facilities to increase their focus on preparing RNs to support women in breastfeeding effectively [4]. Programs such as in-depth breastfeeding education, role modeling, and mentoring may enhance RNs’ abilities and confidence in support of breastfeeding. According to Conflitti et al., many nurses lack the skills and knowledge to promote breastfeeding and educate new mothers in the early postnatal period [5].
5. Literature Review
King’s Theory of Goal Attainment was chosen to guide this study due to the expected number of interactions nurses encounter with their patients [6]-[8]. The World Health Organization encourages maternity institutions to implement the Ten Steps to Successful Breastfeeding. Ateefa Al-Noor identified in her study that skin-to-skin has many benefits for mother and baby [9]. They include reduced crying, temperature adjustment, heart rate, respiratory rate, and promotion of initial breastfeeding. According to the World Health Organization, the Baby-Friendly Hospital Initiative has led to facility-wide changes to protect, promote, and support breastfeeding in a baby-friendly environment [2]. McRae et al. stated that the practice of rooming-in by many maternity hospitals is the core foundation of BFHI [10]. This practice encourages bonding with their infants while recognizing and responding to clues for hunger and breastfeeding. According to DiCicco et al., skin-to-skin contact immediately or soon after birth is now considered standard care due to its numerous benefits, including facilitating breastfeeding initiation and thereby increasing exclusive breastfeeding rates, which should become the standard of care [11].
Additionally, they concluded that delaying the newborn bath is associated with an increase in hospital-exclusive breastfeeding rates. Lonn et al. employed semi-structured, open-ended interviews to explore participants’ experiences, aiming to obtain an overall picture of the phenomenon of interest, such as exclusive breastfeeding and the practice of rooming-in [12]. The above literature reviews demonstrate the importance of maternity organizations following the Ten Steps to Successful Breastfeeding created by the World Health Organization.
6. Method and Design
The method employed in this qualitative descriptive research was designed to gather and analyze pertinent information to answer the research questions posed in this study. This method included capturing the clinical practices, processes, resources, and progression of a maternity organization. This qualitative descriptive study included interviews with registered nurses, nurse midwives, lactation consultants, and charge nurses who worked with their patients on the maternity units, as well as other healthcare professionals identified during the collection as instrumental to the initiative’s success. This method best addresses the research questions as qualitative inquiry suits the phenomenon of interest and is described by those who experienced it [13]. A distinguishing characteristic of qualitative research is its flexible data sources. Therefore, additional data collection sources emerged and were identified for this qualitative research study. Data saturation was achieved with only nine participants because the range of participants was broad enough to capture the required information from Research Questions 1 and 2. As the interviews progressed in this study, no new themes continued to emerge from the participants’ perspective. Therefore, it was determined that the sample size was sufficient to achieve data saturation. With the continuous evolution of knowledge and advancement of technology in a rapidly evolving healthcare environment, King’s theory of goal attainment is an appropriate framework for many nursing studies, which underpinned this study [6] [7]. The primary purpose of King’s theory was to guide research that generates knowledge in nursing.
7. Assumptions
It was assumed that participants strive to provide high standards of care in line with evidence-based practices. Data supporting the Ten Steps to Successful Breastfeeding is abundant in the literature, which organizations can use to implement the Ten Steps and achieve BFH status. In addition, it was assumed that the study’s participants would be able to describe the elements, processes, systems, and resources essential for successfully attaining Baby-Friendly Hospital status and openly share them.
8. Limitations
As the purpose of this study was to describe the experience of one organization’s implementation of Baby-Friendly interventions, its findings are limited to that organization and may not be generalizable. Additionally, the researcher, a former Director of Maternal and Child Health Services, observed that nurses often separated infants from their mothers immediately after birth, which may introduce unconscious bias into the study’s data collection and analysis phases. Research bias in this study would occur when the researcher intentionally influences the results to favor a specific outcome [14]. The main limitation of this study is the inability to generalize the findings to other qualitative studies. However, the findings may be applied to other organizations with similar contexts. During the interview session, questions could be asked that may steer participants toward a single perspective. To mitigate this potential bias, an instrument field test was conducted to limit bias in the questions asked of participants.
9. Setting, Population, and Sample
This study was conducted in a healthcare facility that records approximately 200 deliveries per year. The maternity unit at this organization consisted of a Labor, Delivery, Recovery, and Postpartum unit (LDRP). In addition, there is an intensive care unit for compromised newborns, an operating room for cesarean deliveries, and a recovery room for care following cesarean deliveries. This maternity hospital is part of a health system in a rural area in the eastern United States. The study included a purposeful sample of registered nurses, nurse midwives, lactation consultants, and charge nurses who were employed at the maternity hospital at the time of practice changes to implement the Baby-Friendly Hospital Initiative (BFHI). The sample was 9 participants. The purposeful sampling in this study involved selecting specific participants who would provide the most valuable information for the study [13]. For this study, participants had to have practiced for at least one year on the maternity unit and be able to discuss the practice changes necessary for pursuing and maintaining a BFH designation.
10. Materials and Instruments
After receiving approval for the study from the hospital’s Institutional Review Board, the Director of Nursing, along with maternity unit leaders and educators, sent a scripted email invitation to registered nurses, nurse midwives, charge nurses, lactation consultants, and obstetric physicians who provided care to patients on the maternity unit. This email invitation served as an introduction to the study. If the participant agreed to participate in the survey, a scheduled time and date were arranged, and a consent form was sent to the participant. The participant was told to read, sign, and return the consent form to the principal investigator. The consent form informed participants that data collection would consist of one-on-one, semi-structured interviews conducted via a recorded video conference, and that these interviews would last between 60 and 90 minutes. The consent form also included a reminder of the risks and benefits of participating in the study. An interview guide was used, which included semi-structured and probing questions.
Additionally, the updated Ten Steps to Successful Breastfeeding were used as a resource to inform the creation of interview questions. Before the interview began, the participant completed a demographic questionnaire. Participants were informed that the audio recording would be transcribed, and they would have the opportunity to review the transcript for accuracy before the data analysis phase of the study. The participants validated the content and accuracy of the transcripts before they were analyzed for emergent themes.
11. Credibility and Transferability
Credibility is one of the most critical factors of trustworthiness. Hinds et al. noted that some scientists consider qualitative research methods less rigorous than quantitative methods [15]. Consequently, they view the findings and conclusions of qualitative research with scientific skepticism. The researcher field-tested the interview questions with qualified content experts with similar educational backgrounds. The content experts had experience and expertise in mother-baby skin-to-skin contact and the initiation of breastfeeding following birth. Qualitative analysis needs only a small purposeful sample; therefore, it is impossible to demonstrate whether the findings and conclusions apply to other situations and populations. However, institutional leaders may use the evidence-based findings to promote and enhance their policies regarding early mother-baby skin-to-skin care and the initiation of breastfeeding in similar hospitals in the Eastern United States. Although the findings of this study are not generalizable, they could be helpful to other maternity hospitals by serving as a structure for self-assessment or as an example of this study in different settings. Maternity hospitals that have not gained Baby-Friendly status are also encouraged to implement the Ten Steps to Successful Breastfeeding and uphold the International Code of Marketing of Breastmilk Substitutes [3].
12. Dependability and Confirmability
To address dependability in this qualitative study, the researcher provided a detailed report of the process within the study. Lincoln and Guba noted that the primary method for establishing confirmability is the confirmability audit [16]. The researcher used member checking throughout the interview and after transcribing the audio recording. The auditor’s assessment was used to establish the confirmability of the results.
13. Data Collection and Analysis Procedure
The purpose of this qualitative descriptive study was to describe the process, resources, and progression of one organization in the eastern United States achieving and maintaining the Baby-Friendly designation. Before the start of each interview, the investigator reassured participants that their participation was voluntary and confidential, and they could choose to end the interview questioning at any time. The participants were informed that following the interview, their audio-recorded responses would be transcribed, and they would have the opportunity to review the transcripts for accuracy before the data analysis phase of the study. King developed three interacting systems in her goal attainment theory [7]. Each system was given different concepts. Concepts related to interpersonal systems include interaction, communication, transaction, role, and stress. In this study, interviews were used to gather nursing information from nine participants. Themes were developed to assist in the interpretation of the participants’ answers.
14. Demographics
To participate in this study, one must be a registered nurse, Nurse midwife, lactation consultant, charge nurse, or other healthcare professional in the above list who the maternity hospital employed at the time of practice changes to implement the BFHI. The sample included nine participants. Before the interview, the researcher reviewed the consent form again, asked demographic questions, and completed the questionnaire to gather information about the sample.
15. Data Collection and Analysis
This research was conducted using a thematic data analysis guided by the six steps proposed by Braun and Clarke [17]. The data analysis procedure outlines how the information obtained from data collection is organized and presented (see Table 1). In this study, the analysis was an ongoing process that co-occurred with data collection. Miles et al. stated that this type of data collection and analysis process encourages the researcher to go back and forth between reflecting on nurse transcripts and generating ideas for collecting new or better data [18]. According to Bhatia et al., data analysis helps to accomplish three goals related to the study objective before starting the information collection [19]. Data were generated through virtual, semi-structured, and in-depth interviews. After the interviews, the researcher listened to the audio recordings of the interviews several times to gain a deeper understanding of the participants’ responses. Next, the researcher transcribed the audio information, classifying and organizing it to identify different themes and relationships. A qualitative analytics software was used to assist in data analysis.
Table 1. The six steps of the inductive, thematic analysis.
Step |
Description of steps |
1 |
Data familiarization |
2 |
Initial coding |
3 |
Searching for themes |
4 |
Reviewing the themes |
5 |
Naming the themes |
6 |
Presenting the findings |
Note: Adapted from Braun and Clarke [17].
16. Results
Many hospitals in the United States do not seek Baby-Friendly designation. Therefore, a qualitative, descriptive study was employed to explore the processes, resources, and progression of one organization in the eastern United States in achieving and maintaining a Baby-Friendly designation for a maternity hospital within a large healthcare system. The researcher presented the findings neutrally and objectively, using a straightforward text narrative that includes the research questions, data collection methods, demographics, data analysis, results, and a chapter summary. The researcher collected data from nine participants. This sample size was appropriate for conducting in-depth semi-structured interviews to answer the research questions.
Regarding location, the semi-structured interviews were conducted online via a web-based video conference platform, lasting 60 - 90 minutes. The interviews consisted of both semi-structured and open-ended questions. The audio recording feature of the online meetings platform was used after obtaining permission from the participants. Notes were taken as a backup. Although the plan was to interview 11 to 20 healthcare providers, ultimately, only nine participants fully participated in the data collection. Although the sample size was smaller than initially planned, it was sufficient to reach data saturation. Four themes emerged that addressed research questions. Research Question # 1 addressed “Leadership Support” and “Policy and Protocols.” Research Question 2 addressed “Changing the culture” and “Enough staff and Education” (see Table 2 and Table 3).
Table 2. Research question and themes alignment.
Research Question |
Emergent Theme |
RQ1. What are the essential practices, processes, and resources needed for successful implementation and designation as a Baby-Friendly Institution? |
Theme 1: Leadership support |
Theme 2: Policy and protocols |
Theme 1: Leadership Support
This theme suggests that the healthcare professionals identified leadership support as needed for the hospital’s successful implementation and designation as a Baby-Friendly institution. All nine nurses mentioned this theme 65 times. Participant 1 talked about a leader, “who is assertive and will continue to follow up on anything that the nurses need to maintain the tools that they need to continue Baby Friendly.”
Participant 2 stated, “I think just in terms of succeeding with Baby-Friendly as an organization, I do think a lot of that did come from management’s persistence also, and just being encouraging and trying to get everyone on board with it. I just think that it helped that the leadership was enthusiastic and encouraging.”
Participant 3 mentioned, “Supportive leadership that truly believes in baby friendly as well. The manager is just amazing and supportive of her team. She answers questions. She jumps in and helps when needs be.”
Theme 2: Policy and Protocols
This theme shows that the healthcare professionals that a policy of babies not going to the nursery anymore but staying in the rooms with their mothers, supporting skin-to-skin contact, nurses being in the room hands-on with the mother more often, as well as having protocols in place of not giving the patients formula and pacifiers unnecessarily was needed for the hospital’s successful implementation and designation as a Baby-Friendly institution. All nine participants mentioned this theme 145 times.
Participant 1 talked about the policy of, “encouraging moms to have their babies room-in with them.” She added, and that’s one of the biggest changes, practices changes because as opposed to the babies being out in the nursery for a large part of the night with a nursery nurse, now they are in the rooms with mom.” Participant 4 reported “One thing that was good is that the moms started to keep their babies at the bedside. So, we did not take their babies from them unless there was a medical reason to do that.” According to Participant 5, the practices are like they are friendly. Wants you to be doing skin-to-skin immediately after delivery. They want you to minimize mom and baby not being together. So, minimize the time apart from each other, if possible. Participant 3 talked about the protocol of not giving formula, mentioning, “The biggest thing is not offering formula to the patient unless it is medically needed. That is the big practice change.” Participant 4 spoke about the protocol of not giving pacifiers and formula: “Well, no pacifiers, getting rid of bottles, not supplementing with formula that wasn’t medically indicated...the other thing that was good about the change is that we were not giving formula unnecessarily.”
Speaking of protocols, Participant 1 mentioned: “So, protocols, there is documentation that we must make sure that we do know for Baby Friendly, making sure that we document babies when they come out of the rooms whether it may be neonatal testing or mom’s choice to have the baby out of the rooms so she can get some sleep, and documenting also when they go back into the rooms. Again, our protocol is not to have the baby out longer than an hour. But when the mom must rest, then sometimes an hour is not enough. And we must make sure that we document mothers’ choice as opposed to the reason.”
Table 3. Research question and themes alignment.
Research Question |
Emergent Theme |
RQ2. What do health care providers who are working at the Baby-Friendly hospital identify
as critical for successfully becoming and
maintaining a Baby-Friendly designation? |
Theme 3: Changing the culture |
Theme 4: Enough staff and education |
Research Question 1
For this study, RQ1 was as follows: What are the essential practices, processes, and resources needed for successful implementation and designation as a Baby-Friendly institution? Two themes emerged from the analysis of the data collected during the interviews. These are (a) Theme 1: Leadership support, and (b) Theme 2: Policy and protocols. Table 4 shows the number of participants who mentioned the theme.
Table 4. Research Question 1 Themes.
Theme |
n of participants contributing to this theme (N = 9) |
n of references to this theme in the data |
Theme 1: Leadership support |
9 |
65 |
Theme 2: Policy and protocols |
9 |
145 |
Research Question 2
RQ2 was as follows: What do health care providers who are working at the Baby-Friendly hospital identify as critical for successfully becoming and maintaining a Baby-Friendly designation? Two themes emerged from the data in response to this question. These are (a) Theme 3: Changing the culture, and (b) Theme 4: Enough staff and education. Table 5 shows the number of participants who mentioned each of the RQ2 themes.
Table 5. Research Question 2 Themes.
Theme |
n of participants contributing
to this theme (N = 9) |
n of references to this theme in the data |
Theme 3: Changing the culture |
7 |
17 |
Theme 4: Enough staff and education |
7 |
28 |
Theme 3: Changing the Culture
The healthcare providers working at the BFH identified changing the culture of the organization and gaining buy-in from staff members as critical for a hospital to achieve and maintain a Baby-Friendly designation. Seven participants mentioned this theme 17 times. Participant 3 talked about “the culture changes of the staff, especially older nurses who came from a different culture.” She added, “Coming from an older maternity unit where I used to work, and where babies spent the night in the nursery and were returned to their mothers in the morning... I also had that culture. So, having to transition nursing from that way of thinking, which is not what is best for the baby and for breastfeeding. The challenges are re-educating all the staff in changing the cultural mentality and informing them that this is not the best thing to do for mom and baby.”
Participant 5 stated, “Sometimes the culture of a hospital or a unit or a floor can affect the success of something like that.” According to participant 6, “I think the next one thing is having staff buy-in, so changing the culture of not just giving a bottle. You know, a formula, and that you know, it takes a lot of effort from the nurses.”
Participant 9 stated, “I think it’s just a lot of education and the culture, and it’s very difficult to change the nursing culture.” Participant 9 also indicated, “That ongoing process of how we can change the culture so that baby-friendly comes easily...Okay, we must change everything so that we can be baby-friendly. That it must be very ongoing and a work in progress. So, leadership must be committed to making, you know, continuous changes.”
Theme 4: Enough Staff and Education
The healthcare providers also identified having an adequate number of staff, including lactation consultants, as well as providing nurse and patient education, as critical success factors for achieving and maintaining a Baby-Friendly designation. Seven participants mentioned this theme 28 times. Participant 2 mentioned.
Participant 2 mentioned, “So, I guess maybe one of the things they would need to do, now that I am thinking about it, is really increase lactation support, have more lactation consultants, and have them there on all shifts, because you can’t put it all on nurses...if they want to be Baby-Friendly, they have to really invest in having lactation consultants available, and not just one for 20 patients on a floor. You have got to have enough, and you must have them on all the shifts, not just nine to five.”
Participant 5 spoke of staffing ratios. She stated, “A big help to being baby-friendly and breastfeeding is staffing ratios. You really must have a breastfeeding program. It can be difficult. It takes work for the mom and baby. Sometimes the baby has a tongue-tied or there are other issues, and you know, the mom is struggling...So, for a hospital to be baby-friendly, they really need to have the staff and or lactation consultants on every shift.”
Participant 7 also talked about “staffing the way we work.” She added, “Breastfeeding takes a lot of time, and sometimes we don’t have enough staff to devote to the time that it needs to be in one room when you have other people to care for. So, staffing is an issue. You can be in a room breastfeeding with a mom for up to an hour per feeding. We can have a patient in labor and two couplets, and a mom struggling with breastfeeding, you are kind of torn.”
Furthermore, speaking about providing patients and nurses with education and encouragement, Participant 1 stated, “So I would say for other facilities who want to follow the same model of practice for Baby-Friendly, that educating your staff is definitely key and also educating your patients as well.”
17. Discussion
In this qualitative study, data were collected to address the problem that many hospitals in the United States do not seek Baby-Friendly designation. Ten steps to Successful Breastfeeding were developed by the World Health Organization in 1981 as a guide for maternity hospitals to gain designation. With the assistance of a thematic analysis, four themes emerged from this study: Leadership Support, Policy and Protocols, Changing the Culture, and Sufficient Staff and Education. Challenges were noted during the implementation process [20]. Frequent barriers to embracing the BFHI concepts included insufficient staff and education, as noted during the interview process, and the study’s findings indicated partial implementation of the BFHI steps. The reasons for partial implementation were inadequate capacity in terms of staffing and training on BMFI. A staff shortage resulted in insufficient time for staff to show mothers how to manage breastfeeding. In a study by Amadhila and van Rensburg, which involved nurse managers from several hospitals, it was stated that healthcare staff should undergo 20 hours of training, including three hours of supervised clinical training in breastfeeding management [20]. Inadequate space in smaller hospitals made it difficult for mothers and their infants to practice.
18. Conclusions
The purpose of this qualitative, descriptive study was to explore the processes, resources, and progression of one organization in the eastern United States in achieving and maintaining a Baby-Friendly designation for a maternity hospital within an extensive healthcare system in the eastern United States. Data were collected using semi-structured interviews and analyzed through thematic analysis. The study’s findings led to the development of themes and sub-themes for the research questions. RQ1 was “What are the essential practices, processes, and resources needed for successful implementation and designation as a Baby-Friendly institution?” The findings revealed that, according to healthcare professionals, the essential practices, processes, and resources include adequate personnel who are open-minded, support the change, and work in a team. Babies not being taken to the nursery anymore but allowed to stay in the rooms with their mothers with skin to skin; educating patients and staff about breastfeeding and offering the needed competencies; and leadership support. Other practice changes include not giving the children formula and pacifiers unnecessarily; nurses being in the room, working hands-on with the mother, and assisting her to get some rest; and having protocols in place and documentation. RQ2 was “What do healthcare providers who were working at the Baby-Friendly hospital identify as critical for successfully becoming and maintaining a Baby-Friendly designation?” The answer is that nurses recognize the following as necessary: changing the culture and obtaining buy-in from staff, as well as assessing departmental needs to determine what is required to achieve the Baby-Friendly designation.
The actionable recommendations of success factors for other maternity hospitals to achieve baby-friendly designation include four themes: 1. Leadership support includes managers who are enthusiastic and who believe in promoting the implementation of Baby-Friendly designation. Theme 2 includes the revision and creation of policies and protocols. Theme 3 addressed changing the culture, such as adopting the concept of rooming-in, where infants could be in the room with their mothers 24 hours a day. Them 4. To be successful as a Baby-Friendly hospital, nurses must be educated on the care of mothers and infants on inclusive breastfeeding. This type of care requires the assistance of extra lactation consultants.
Appendix A: Email Invitation to Participate in Research
Dear XXX,
I am contacting you to invite you to participate in a research study titled: “Becoming a Baby-Friendly Hospital: A Descriptive Study.” The purpose of this research study is to describe the process, resources, and progression of one organization in the eastern United States at achieving and maintaining “Baby-Friendly” designation. Participation is voluntary. If you agree to participate, we will set up a mutually agreed-upon time for an interview by the Zoom system. The interview may last for approximately 60 to 90 minutes and only, if necessary, a follow-up phone call will be initiated to clarify some content of the original interview. A transcript of the interview will be sent to you to review and ensure accuracy. Information you provide during the interview session will be audio-recorded to ensure all the information you provide is reported accurately. Protecting your privacy is of utmost importance to me. Therefore, no one else will have access to your contact information, and it will be kept separate from your interview responses. A unique code will be used on the transcriptions for the study. If you agree to participate, you will be asked to sign an informed consent form. This form will provide details about the study. Please do not hesitate to reach out to me if you have questions. I can be reached at XXXXX or email me XXXXXXX If you have any questions about your rights as a research participant, please contact the University of Phoenix Institutional Review Board: [email protected].
Thank you,
Doctoral Student with the University of Phoenix
Appendix B: Flyer
Doctoral Student with the University of Phoenix
Registered Nurses (FT, PT, Per Diem), Nurse Midwives, Lactation Consultants, Charge Nurses, OB Physicians, OB residents. I am a doctoral student at the University of Phoenix conducting a study entitled: Becoming a Baby-Friendly Hospital: A Descriptive Study. The purpose of this research is to describe the process, resources, and progression of a Maternity Hospital for achieving and maintaining a Baby-Friendly designation, and to identify and document roles, experiences, and perceptions of maternity unit employees during the planning and transition stages.
Let us do this Together!
Baby-Friendly Hospital
All the above professionals who have been in their role for a minimum of one year are being asked to share their roles, experiences and feelings during the planning and transition stage to becoming and maintaining a Baby-Friendly institution. Participation entails a virtual interview on Zoom, which is expected to last approximately 60 - 90 minutes. Participation will be kept confidential, and the names of participants will be protected by using codes or pseudonyms. Data will be analyzed as aggregate or group data to assist in developing future strategies to gain and maintain the Baby-Friendly Hospital designation. If you have any questions or are interested in participating in the study, please contact me at XXXXXX or email me at: XXXXXXX.
Appendix C: Participants’ Research Consent Form
Study Title: “Becoming a Baby-Friendly Hospital: A Descriptive Study”
Introduction: You are being asked to participate in a research study, you will also be asked to explore how the decision was made to become a Baby-Friendly Hospital. The purpose of this research is: to examine and describe how the criteria for the nursing protocol were followed using the Ten Steps to Successful Breastfeeding as dictated by the World Health Organization. This information may assist other Non-Baby-Friendly hospitals in developing strategies and improvements to gain Baby-Friendly status and improve breastfeeding rates. Procedures: If you choose to participate, you will be asked to complete a demographic questionnaire and participate in a telephone interview about your knowledge, skills, and experiences as a mother-baby nurse. The interview is expected to take approximately 60 to 90 minutes in duration. The interview will be tape-recorded and only pseudonyms will be used to protect your identity. You will also be asked to validate the transcript’s content within approximately one week of the interview completion. The tape recordings will be destroyed after the validation of transcriptions.
Risks: No risks are anticipated due to your participation in this study. You may experience temporary stress and anxiety while reflecting on your role as a mother-baby nurse. There may also be a risk of breach of confidentiality, but measures are in place to protect your identity.
Benefits: This study may be of no direct benefit to you. You may benefit by discussing your knowledge and experiences during your role. The study may help future hospitals to gain BFHI status.
Costs and Compensation: There are no costs for you for participating in this study, nor will you be compensated.
Right to Withdraw: Participation in this study is entirely voluntary. The choice is completely up to you. You may refuse to participate without any consequences. You may discontinue the study or stop participating at any time without consequences. You may also leave at any time during the interview or request that the tape is turned off. If you withdraw from the study, all information you have provided will be destroyed.
Confidentiality: Your responses to the questions and information will be kept anonymous as only pseudonyms will be used. The data will be analyzed as an aggregate or group data. Names or other identifying information will not be used in the reporting of any information. The audiotape will be destroyed when you validate the transcription from the audiotape. Only the transcript and the informed consent will be kept for three years and then destroyed. Your transcripts may be reviewed by my research mentors at the University of Phoenix.
Other Pertinent Information: Should you have any questions or concerns about the study, you may contact via email at XXXXXXXX.
Participant Agreement: I have read the information in this consent form and agree to participate in this study. I have had the chance to ask any questions I have about this study, and they have been answered for me. I am entitled to a copy of this form after it has been read and signed.
Print name of Participant ______________________________________
Signature of Participant Date and Time ___________________________
Signature of Researcher Date and time ____________________________
Appendix D: Demographic Survey
The following questions will be used to provide background information for the research.
Questions:
1) Age
18 - 30 yrs.__________
31 - 40 yrs. _______
41 - 50 yrs. ________
51 - 68 years _______
2) Gender:
Male_____
Female_____
3) Number of years’ experience outside of this organization:
Less than 3 years______
More than 3 years______
4) Length of time in the present position at this current organization:
Less than 1 year_____
1 – 2 yrs. _____
2 + yrs. _____
5) Educational Degree (check all that apply)
Diploma______
Associate degree Nurse (ADN)______
Bachelor of Science in Nursing (BSN)______
Master of Science in Nursing (MSN)/focus______
Other bachelor’s degree (State)______
Other master’s degree (State)______
Other Degree (State)______
Appendix E: Interview Guide
A qualitative descriptive study design will be used to answer the following research question:
1) What were the necessary processes, resources, and key clinical practice changes needed to achieve “Baby-Friendly” designation at one organization in the eastern United States?
2) What guidelines and recommendations do healthcare providers who have been part of the process of attaining BFH status believe are critical for the success of another organization in doing so?
Interview Questions:
1) Were you involved in the decision-making process for becoming a Baby-Friendly hospital?
Probe: Do you remember who was working on this initiative? Why do you think it was successful?
2) What were key practice changes necessary to pursue BFH status?
Probe: Who do you think was instrumental in the success of the initiative? What do you think was the hospital’s motivation to become BF? What was good about these practice changes? What was not so good?
3) What competencies did you need to develop a successful Baby-Friendly program?
Probe: How were the staff educated about the practice changes? What was that “mood” of the organization?
4) What challenges or barriers were involved in transitioning from a traditional maternity hospital to a Baby-Friendly hospital?
5) What kind of protocols does your hospital have in place to ensure continued the success of the Baby-Friendly program?
Probe: Policies? Guidelines?
6) What type of leadership is needed to make the Baby-Friendly program so successful?
Probe: How did the multidisciplinary teams work together to assure success?
7) What type of staff was needed to make the Baby-Friendly program so successful?
8) What recommendations do you have for other organizations pursuing BF designation?
Probe: Were there things that you wish had been done differently? What was the biggest lesson learned? What made you happiest about this initiative?
Video Conference Consent
Date and Time of Video Conference Consent: _______________________
Participant Code Number: _______________________
Hello, I am a student from the University of Phoenix conducting research titled “Becoming a Baby-Friendly Hospital: A Descriptive Study” about the barriers and facilitators to Baby-Friendly designation experienced by the staff of Inspira Medical Center Elmer.
I want to ask you if you are interested in participating in this research study. Your participation is completely voluntary. This means that you do not have to participate in this study unless you want to. Your decision whether to participate in this study will not affect your relationship with your organization or leaders. If you do not agree to verbally consent to participating in this study, there will have no impact on you.
Would you be willing to hear more information about this study?
(If yes, continue with below. If no, thank them for their time and end the call.)
I appreciate your time.
Thank you for agreeing to continue. Let me tell you more about this study and what will be required of you. The purpose of this research study is to look at specific factors that have either helped support Baby-Friendly designation or that has made it more challenging. You may find some questions difficult or sensitive in nature and do not wish to answer, just tell me and we will go on to the next question.
I will ask you to be a part of this recorded zoom interview and to later review a transcript of your responses which will be sent to you by email. Your participation will take approximately 60 - 90 minutes for the phone call and approximately 30 - 60 minutes to review the transcript when it is sent to you for review.
If you agree to participate, you will be asked to answer a series of open-ended questions about the Baby-Friendly journey at Inspira Medical Center Elmer. I estimate that approximately 11 - 20 Inspira Medical Center Elmer maternity staff will enroll in this study. There are minimal risks associated with participating in this study as your identity will be kept confidential. Although this study may not benefit you personally, we hope that our results will add to knowledge about best practices to support breast-feeding.
Would you like me to continue describing the study? (If yes, continue with below. If no, thank them for their time and end the call.) You will not be compensated and there are no expenses associated with participating. I am committed to protecting your privacy and maintaining confidentiality. I will not identify you by name or any other information that would make it possible for anyone to identify you in any presentation or written reports about this study. When this call is completed, I will group all the answers together with the other participants in one report. There will be no way to identify individual participants. All information that I receive from you by phone will be strictly confidential and will be kept under lock and key.
If it is okay with you, I might want to use direct quotes from you, but these would only be cited as “from a person”. To do this research, I need to temporarily collect some health information that identifies you. I may temporarily collect your name and email address. I will only collect information that is needed for the research.
Once I gather the required information, I will delete any identifying information related to you, such as your name and email address. For you to be in this research, I will need your permission to collect this information. Only research personnel authorized for this study will have access to your information.
If you change your mind later and do not want us to use your information and responses in this study, please send a letter to the Principal Investigator at XXXXX. At that time, I will remove any information we have collected about you regarding this study. You can call the Principal Investigator at XXXXXX with any questions about this study. If you have any questions regarding your rights as a research subject, please contact the University of Phoenix, Institutional Review Board (IRB).
Do you have any questions currently? Would you like to participate in this research? If “no”, thank them for their time and end the call. If “yes”, begin asking questions/conduct an interview.
___ Participant Agreed to Participate
___ Participant Did NOT Agree to Participate