Dr. Joanna Kosmala-Anderson Prof. Louise M. Wallace National Breastfeeding Training Needs Survey

1. Dr. Joanna Kosmala-Anderson Prof. Louise M. Wallace National Breastfeeding Training Needs Survey Training needs of health service, Sure Start and voluntary sector workers who support breastfeeding mothers. Survey conducted in England. Coventry University Health Services Research Centre Email: joanna@poznan.home.pl PRZEGLĄD TERAPEUTYCZNY NR 1/2006 H S R C

2. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 KEY QUESTIONS • How do practitioners assess their competence in the different areas of breastfeeding support? • How do practitioners rate the importance of the various areas of breastfeeding support? • What are practitioners’ overall experiences of supporting breastfeeding? • What is practitioners’ knowledge of policies and guidance on breastfeeding? • What professional training have they undertaken/will undertake and how do they rate its helpfulness? • How do practitioners rate various approaches to learning?

3. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 METHODOLOGY

4. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 CHARACTERISTICS OF THE SAMPLENon medical healthcare practitioners(N=575) • Midwives (37%), Health Visitors (33%), Voluntary sector (13%) • Within nursing/midwifery, 90% were qualified; 54% were supervisors of midwives • 29% were in a teaching, audit or research role • Almost 90% of participants worked for NHS (balanced across primary care and acute) • Varied experience (55% qualified >10 years ) • Varied in contact with BF women: • 62% spend over 50% time counselling and supporting breastfeeding women BF women • 42% spend over 50%time giving direct care

5. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 AREAS OF COMPETENCE IN BREASTFEEDING SUPPORT SKILLS MANAGING COMMON CLINICAL PROBLEMS IN EARLY BREASTFEEDING(ex. thrush infection, mastitis, engorgement) • 75% of respondents find it quite or very important • Over a half of respondents are competent or experts in this area • Less than 10% of respondents are not competent in this area HELPING MOTHERS WITH OLDER INFANTS (ex. weaning to liquids/solids) • 70-80% of respondents find it quite or very important • Over a half of respondents are competent or experts in this area • Less than 10% of respondents are not competent in this area There are very strong positive associations between self rated competence and ratings of importance of the area for updating

6. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 TRAINING NEEDS IN BREASTFEEDING SUPPORT SKILLS SKILLS IN ANTENATAL CARE AND COMMUNICATION (ex. formal aspects of antenatal education) • 70 – 80% of participantsfind it quite or very important • at least 1 in 4 regarding themselves as not competent, unrelated to whether this is part of their current role PRACTICE SKILLS REGARDING BREASTFEEDING SUPPORT (ex. assisting in demand feeding) • 60 – 70% of participantsfind it quite or very important • 1 in 5 participants do not expect to be competent • nearly all can see some relevance to being updated about these skills in the next 2 years. SOCIO – CULTURAL ASPECTS OF BREASTFEEDING SUPPORT (ex. working with teenage mothers) • 80% of respondents find it quite or very important • 10% believe of they are not competent in regard to these skills while less than a half describe themselves as competent or experts

7. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 KNOWLEDGE OF POLICIES AND GUIDANCE ON BREASTFEEDING – correct answers • What is the current national rate of initiation of breastfeeding in England • Can you identify the Government target for breastfeeding? • What is the youngest age at which current Government guidance suggest solid foods are introduced? • For how long does W.H.O. suggest mothers should exclusively breastfeed their babies ?

8. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 1 Unhelpful facilities Staff do not adhere to guidelines for BF Mothers are given conflicting advice Staff’s level is to low to provide mothers support Unsupportive culture It’s difficult to recommend BF to mothers with other problems Lack of guidance on breastfeeding Problems with keeping up to date Guidelines on BF are difficult to follow ORGANIZATIONAL BARRIERS FOR BREASTFEEDING SUPPORT • All respondents experience organizational barriers, and almost 60% of participants experienced at least two organization barriers. • More organizational barriers are related to lower competence level in regard to “provision of information and support” and “socio – cultural aspects”

9. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 RECOMMENDATIONS FOR NON MEDICAL HEALTHCARE PRACTITIONERS • A systematic approach is required in all healthcare sectors to establishing the training needs to staff. This should include auditing staff experience of BF training, and evaluation of training completed. • Staff sampled welcome training in all 26 skill areas, and those already competent are most likely to want more update. This suggests both that training is reaching “the converted”, but also that staff recognize the need for continual up dating. This may be only awareness raising of areas where practical application is not feasible within the current job role • Staff are surprisingly inaccurate in their knowledge of local, national and WHO policy, and this should be addressed by training and updating on sources of guidance at a local level with reference to these key policies. • Action at executive level in healthcare and voluntary sector bodies is required to address the organizational barriers to breastfeeding practice. BFI standards will be a relevant tool in addressing these issues.

10. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 CHARACTERISTICS OF THE SAMPLEPaediatricians (N = 120) • Most respondents currently work as general paediatricians (67,5%), 35,8% work as subspeciality paediatricians • Over a half of paediatricians work for Hospital services other than Primary Care services • Most of the respondents have been a qualified medical practitioner for less than 5 years (over 68,4%). • Most of the respondents (60%) spend at least part of their working time working directly with women, their babies and infants.

11. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 CHARACTERISTICS OF THE SAMPLEMedical doctors (N = 57) • Most of the participants (86%) work as General Practitioner, i.e. in primary and community care • Almost 80% of GPs were qualified for more than 10 years • 88% of the general medical sample spend some time in their working week directly with mothers and infants. However, this more likely to be about 25% of the time (58% of respondents)

12. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 AREAS OF COMPETENCE IN BREASTFEEDING SUPPORT SKILLS - Paediatricians MANAGEMENT OF SOME FREQUENT CLINICAL PROBLEMS (ex. advising about pain management) • 30-45% of respondents find it quite or very important • 50-60% of respondents are competent or experts in this area • Less than 10% of respondents are not competent in this area HELPING MOTHERS WITH OLDER INFANTS (ex. weaning to liquids/solids) • About 50% of respondents find it quite or very important • 40-60% of respondents are competent or experts in this area • Only about 6% of respondents are not competent in this area

13. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 AREAS OF COMPETENCE IN BREASTFEEDING SUPPORT SKILLS – Medical doctors PHYSIOLOGY AND MEDICAL CONTRA-INDICATIONS TO BREASTFEEDING • About 80% of respondents are competent or experts in those areas • Less than 4% of respondents are not competent MANAGEMENT OF SOME FREQUENT CLINICAL PROBLEMS (ex. advising about pain management, trauma to nipples) • 65-80% of respondents are competent or experts in those areas • Less than 5% of respondents are not competent

14. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 TRAINING NEEDS IN BREASTFEEDING SUPPORT SKILLS - Paediatricians SOCIO-CULTURAL ASPECTS OF BREASTFEEDING (ex. understanding cultural differences in infant feeding) • 30% of respondents find it quite or very important • 30% of respondents are not competent in this area PROVIDING CARE AT THE INITIATION OF BREASTFEEDING (ex. advising about engorgement, breast refusal) • About45% of respondents find it quite or very important • 10 - 27% of respondents are not competent in this area MEDICAL ASPECTS OF BREASTFEEDING (ex. knowledge of medical contra-indications to BF) • About50% of respondents find it quite or very important • 10 – 30% of respondents are not competent in this area

15. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 TRAINING NEEDS IN BREASTFEEDING SUPPORT SKILLS – Medical doctors MEDICAL ASPECTS OF BREASTFEEDING (ex. detecting abnormal growth rates, prescribing to breastfeeding mothers) • Less than 40% of respondents find it quite or very important • 11 – 32% of respondents are not competent in this area (This is of concern as doctors’ decisions about apparently small babies/ poor feeders can result in women stopping breastfeeding or moving to mixed formula feeding.) PROVIDING CARE AT INITIATION OF BREASTFEEDING (ex. advising about breast refusal, engorgement) • Less than 30% of respondents find it quite or very important • 10-70% of respondents are not competent in this area Only a minority are likely to see these topics as of great importance for update in the next 2 years. Most of the areas of breastfeeding support listed in the questionnaire were rated as very important by not more than a third of doctors.

16. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 80,00% 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 1 Mothers have other problems Difficult guidelines Mothers go home too early Mothers are given conflicting advice Unhelpful facilities Lack of guidelines Staff's different approach Too low staffing levels Staff do not adhere ORGANIZATIONAL BARRIERS FOR BREASTFEEDING SUPPORT - Paediatricians • Paediatricians report presence of more organizational barriers to breastfeeding support in their workplace than other doctors

17. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 70,00% 60,00% 50,00% 40,00% 30,00% 20,00% 10,00% 0,00% 1 Staff don not adhere Staff's different approaches Lack of guidelines Mothers go home too early Mothers are given conflicting advice Difficult guidelines Too low staffing level Mothers have other problems Unhelpful facilities ORGANIZATIONAL BARRIERS FOR BREASTFEEDING SUPPORT – Medical doctors • Medical doctors other than paediatricians are most likely to experience problems related to guidelines

18. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 KNOWLEDGE OF POLICIES AND GUIDANCE ON BREASTFEEDING – correct answers • Paediatricians have higher level of knowledge of policies and guidance on breastfeeding than other doctors • The greater knowledge of policies and guidance on breastfeeding is positively correlated with higher level of competence in skill areas • Both samples of doctors are less aware of policies and guidance than midwives, health visitors and other non medical supporters/ counselors

19. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 RECOMMENDATIONS FOR PAEDIATRICIANS • A systematic approach is required in all healthcare sectors to establishing the training needs to staff. This should include auditing staff experience of infant nutrition and BF training, and evaluation of training completed. • Senior paediatric staff are surprisingly inaccurate in their knowledge of local, national and WHO policy, and this should be addressed by training and updating on sources of guidance at a local level with reference to these key policies. • Action at executive level in trusts is required to address the organizational barriers to breastfeeding practice. BFI standards will be a relevant tool in addressing these issues.

20. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 RECOMMENDATIONS FOR DOCTORS • A systematic approach is required in all healthcare sectors to establishing the training needs to staff. This should include auditing staff experience of infant nutrition and BF training, and evaluation of training completed. This is a responsibility that resides within the GP practice, but PCTs health services that contract general practice services have a duty to ensure independent practitioners are undertaking appropriate training, and a mechanism exists within the appraisal and contracting processes for raising these issues. • General Medical practitioners and paediatricians are surprisingly inaccurate in their knowledge of local, national and WHO policy, and this should be addressed by training and updating on sources of guidance at a local level with reference to these key policies. Access to guidelines was a particular problem for this group, and this should addressed via the PCT. • Action at executive level in trusts is required to address the organizational barriers to breastfeeding practice. BFI standards will be a relevant tool in addressing these issues. Individual practices can apply for BFIaccreditation, although there would be more gain if approached alongside other community and hospital services in their locality.

21. Dr Joanna Kosmala-Anderson Prof. Louise M. Wallace Kompetencje oraz zgłaszane zapotrzebowanie na trening doskonalenia umiejętności zawodowych w grupie pracowników służby zdrowia oraz wolontariuszy opiekujących się matkami karmiącymi piersią (streszczenie). Ogólnokrajowe badania przeprowadzone w Anglii. Coventry University, Coventry, UK Health Services Research Centre Email: joanna@poznan.home.pl PRZEGLĄD TERAPEUTYCZNY NR 1/2006 H S R C

22. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 PROBLEMY BADAWCZE • Jak osoby badane oceniają swoją wiedzę dotyczącą karmienia piersią oraz swoje kompetencje w zakresie umiejętności wykorzystywanych w opiece nad matkami karmiącymi piersią? • Jak osoby badane oceniają ważność poszczególnych umiejętności wykorzystywanych w opiece nad matkami karmiącymi piersią? • Jak osoby badane oceniają swoje doświadczenia w miejscu pracy związane z opieką nad matkami karmiącymi piersią? • Jaki jest poziom wiedzy osób badanych na temat wskazań organizacji zajmujących się problematyką zdrowotną, dotyczących różnych aspektów karmienia piersią? • Jakie formy treningu doskonalenia umiejętności zawodowych były / będą podejmowane przez osoby badane, i jak oceniana jest ich przydatność? • Jak osoby badane oceniają różne formy treningu zawodowego?

23. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 METODOLOGIA BADAŃ

24. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 WNIOSKI DLA PIELĘGNIAREK, POŁOŻNYCH I WOLONTARIUSZY: • Konieczne jest stworzenie jednolitej, usystematyzowanej metody oceny zapotrzebowania na trening doskonalący umiejętności zawodowe. Jej tworzenie powinno uwzględniać doświadczenia pracowników związane ze specyfiką ich miejsca pracy, oraz dokonaną przez nich oceną przydatności poszczególnych form treningu. • Osoby badane zgłaszają potrzebę doskonalenia wszystkich wyróżnionych w badaniu umiejętności wykorzystywanych w opiece nad matkami karmiącymi piersią. Zapotrzebowanie na trening jest pozytywnie skorelowane z bieżącym poziomem kompetencji, co może świadczyć o tym, że pracownicy odczuwają stałą potrzebę dokształcania się.Wiele osób ma także świadomość, że ich obecne umiejętności są niewystarczające do spełnienia wymagań związanych z opieką nad matkami karmiącymi piersią. • Poziom wiedzy osób badanych na temat lokalnej i krajowej polityki oraz wskazań WHO dotyczących karmienia piersią jest zaskakująco niski. Zdecydowanie potrzebne są formy treningu zawodowego uwzględniające te kwestie. • Konieczne jest podjęcie działań w celu zminimalizowania organizacyjnych barier dla karmienia piersią. Standardy zaproponowane przez UNICEF Baby Friendly Initiative (www.babyfriendly.org.uk) wyznaczają także standardy dla placówek przyjaznych niemowlętom i matkom karmiącym piersią.

25. PRZEGLĄD TERAPEUTYCZNY NR 1/2006 WNIOSKI DLA LEKARZY • Konieczne jest stworzenie jednolitej, usystematyzowanej metody oceny zapotrzebowania na trening doskonalący umiejętności zawodowe. Placówki zatrudniające lekarzy powinny być zobowiązane do ewaluowania umiejętności swoich pracowników (wg ujednoliconych standardów) oraz zapewnienia im dostępu do odpowiedniej formy treningu. • Poziom wiedzy lekarzy na temat lokalnej i krajowej polityki oraz wskazań WHO dotyczących karmienia piersią jest zaskakująco niski. Zdecydowanie potrzebne są formy treningu zawodowego uwzględniające owe kwestie. W grupie lekarzy problemem jest ograniczony dostęp do odpowiednich źródeł; dostęp do odpowiednich dokumentów powinien zostać zapewniony przez placówki. • Konieczne jest podjęcie działań w celu zminimalizowania organizacyjnych barier dla karmienia piersią. Każda praktyka lekarska może ubiegać się o akredytację UNICEF Baby Friendly (www.babyfriendly.org.uk), jednak bardziej pożądane byłoby, gdyby ubiegały się o nią wszystkie duże placówki kontraktujące lekarzy rodzinnych.