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A review of breastfeeding training intervention studies that evaluate staff

knowledge outcomes in NICU

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DOI: 10.1016/j.jnn.2017.10.002

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Review

A review of breastfeeding training intervention studies that evaluate

staff knowledge outcomes in NICU
Wendy Higman a, *, Louise Wallace b, Amber Dunlop c
a
Department of Health and Life Sciences, Coventry University, Coventry, CV1 5FB, UK
b
Department of Psychology and Health, Open University, UK
c
University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK

a r t i c l e i n f o a b s t r a c t

Article history: Background: The NICU environment presents many barriers for mothers to provide breast milk for their
Received 22 May 2017 infants. In order to succeed, mothers require advice and assistance from healthcare staff, however some
Received in revised form staff lack the necessary knowledge and skills to support them. This review evaluates studies of breast-
18 August 2017
feeding education interventions on staff knowledge outcomes.
Accepted 8 October 2017
Available online xxx
Methods: A systematic search of the literature was conducted. Research studies that measured NICU staff
knowledge outcomes of training were included.
Results: From 94 studies identified, four were included, each demonstrated significant positive effects on
Keywords:
Breastfeeding
staff knowledge outcomes following a breastfeeding educational intervention in NICU. There were no
Preterm RCTs, three studies used a pre and post-test design, and one used a post-test only design. One study
NICU performed a time series analysis of knowledge, staff attitudes and beliefs and two studies conducted an
Staff knowledge audit of breastfeeding rates.
Education Conclusions: This review identified a lack of good quality evidence on the effectiveness of breastfeeding
Training educational interventions for staff in NICU. Future research should address the breastfeeding education
needs of multidisciplinary healthcare staff in NICU through large, well-conducted RCTs.
© 2017 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

1. Background milk production may be inhibited if mothers are unable to interact

Supporting mothers in providing breastmilk for their infants is
an important goal for neonatal units. For premature infants, human
milk feeding reduces the risk of retinopathy of prematurity (Zhou
et al., 2015), sepsis (Chapman, 2013; Patel et al., 2014) and necro-
tizing enterocolitis (Sisk et al., 2007; Meinzen-Derr et al., 2009).
Furthermore, several major reviews exploring the role of human
milk for preterm infants have reported shorter hospitalisation,
fewer hospital readmissions for illness in the year after NICU
discharge and fewer serious infections and respiratory illnesses (Ip
et al., 2007; Renfrew et al., 2009; Schanler, 2011; Underwood,
2013).
Mothers may be dependent on milk expression for many weeks
or months until their infant is able to breastfeed effectively. Breast
* Corresponding author.
E-mail address: higmanw@gmail.com (W. Higman).
with their babies during the post-partum period, and for extended
periods of time while their infant is in NICU (Lau et al., 2007;
Zanardo et al., 2011). It is important, therefore, that mothers un-
derstand the benefits of breastfeeding and the process of milk
production, and are given effective clinical support to maximise
their chance of success. In order to do this, staff must have the skills
to guide and counsel mothers in their decision to breast feed, assist
them to safely and effectively provide breast milk for their infant
and support them in the transition to breastfeeding.
The WHO UNICEF Baby Friendly Hospital Initiative states that all
those in contact with breastfeeding mothers should receive edu-
cation and have clinical experience in breastfeeding management
(WHO/UNICEF, 2009). Health professionals play a major role in
determining the feeding outcomes of infants in neonatal units, and
it is essential that they receive evidence based education and
training (Dykes, 2006; Renfrew et al., 2009; Ward and Byrne, 2011;
Nyqvist et al., 2015). However, a systematic review of factors that
help or hinder breast milk supply in NICU found that parents had

https://doi.org/10.1016/j.jnn.2017.10.002
1355-1841/© 2017 Neonatal Nurses Association. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Higman, W., et al., A review of breastfeeding training intervention studies that evaluate staff knowledge
outcomes in NICU, Journal of Neonatal Nursing (2017), https://doi.org/10.1016/j.jnn.2017.10.002
2 W. Higman et al. / Journal of Neonatal Nursing xxx (2017) 1e8

reported the provision of inconsistent information and a lack of

expert advice in breastfeeding support in five out of seven studies
(Alves et al., 2013).
Maternal breastfeeding self-efficacy has been identified as an
important variable affecting breastfeeding outcomes in mothers of
preterm infants (Swanson et al., 2012; Wheeler and Dennis, 2013).
NICU staff play an important role in ensuring the NICU environ-
ment is favorable to supporting maternal self confidence in
breastfeeding (Flacking et al., 2006; Boucher et al., 2011) and can
influence the decision to initiate and continue breastfeeding
(Nyqvist et al., 1994; Swanson and Power, 2005). For staff to facil-
itate maternal self-efficacy to breastfeed they must have confidence
in their own specialised knowledge and ability to convey correct
information to mothers. Yet poor clinician knowledge about
breastfeeding and low levels of confidence and clinical competence
has been reported in studies in the UK and USA (Renfrew, 2006;
Strong, 2013; Nyqvist et al., 2013).
Several quality improvement interventions to promote breast-
feeding in NICU have been undertaken that include education and
training of staff. However, it is often not possible to measure the
educational aspect of these studies because the training interven-
tion was part of a wider programme of change, including feeding Fig. 1. Study selection process.
policies and clinical protocols, and staff knowledge was not
measured (Lee et al., 2012; Ward et al., 2012; Giannì et al., 2014;
Dereddy et al., 2014; Bixby et al., 2016). There is a paucity of
3.2. Study characteristics
studies that evaluate the efficacy of breastfeeding training in-
terventions on health professionals in NICU. This paper provides a
Designs varied, (See Table 1). Bernaix et al. (2008) performed a
review of studies that have evaluated educational interventions for
time series analysis of knowledge, attitudes and beliefs, pre inter-
neonatal clinicians that measured the effect on clinician knowledge
vention, immediately post intervention and 2 weeks and 3 months
of breastfeeding practices in neonatal care.
post intervention. Jones et al. (2004) used a pre-post test design
and conducted a clinical audit of the baby's notes alongside the
2. Methods
intervention to provide background information regarding patient
care and feeding outcomes. Siddell et al. (2003) used a pre-post test
Structured searches were conducted on nine electronic data-
design with a control group that consisted of paediatric staff nurses
bases in February 2017 and were undertaken by the specialist
who worked on medical/surgical units. Pineda et al. (2009) used a
librarian at University Hospitals Coventry and Warwickshire, En-
post-test only design and conducted a retrospective audit of
gland. The search strategy for this review included searches
breastfeeding rates.
through medical and nursing databases including CINAHL, British
Nursing Index, ProQuest Hospital Collection, CINAHL, Cochrane,
PubMed, BNI, TRIP, BestBETs for both quantitative and qualitative 3.3. Participants
research papers on educational interventions for clinicians to
support breastfeeding in NICU published between 1994 and 2014, From the four studies there were a total of 238 participants. The
where there were measures of clinician knowledge as the primary majority were nurses (n ¼ 221), and also included doctors (n ¼ 5),
outcome. Secondary outcomes included breastfeeding rates, rehabilitation therapists (n ¼ 3), social workers (n ¼ 2), respiratory
maternal satisfaction with breastfeeding support or any quality therapist (n ¼ 1), nurse practitioner (n ¼ 1) and ‘other health
improvement measures not related to clinician knowledge out- professionals’ (n ¼ 5). Siddell et al. (2003) used control group that
comes and staff attitudes to breastfeeding support. The keyword consisted of paediatric nurses (PEDI) who did not have the inter-
search terms included: breastfeeding, milk, human or breast milk, vention. Personal and job characteristics of nurses were presented
Baby-Friendly Hospital Initiative, breast milk storage, human milk in two of the studies (Siddell et al., 2003; Bernaix et al., 2008). Two
storage, staff knowledge, student knowledge, nursing knowledge, of the studies included the multidisciplinary team in the inter-
professional knowledge, healthcare personnel knowledge, health- vention (Jones et al., 2004; Pineda et al., 2009). Three of the four
care provider knowledge, lactation, self-efficacy, staff confidence, studies were conducted in the USA; the fourth was conducted in
healthcare personnel confidence, healthcare provider knowledge, the UK (Jones et al., 2004). All were single centre studies and
healthcare provider confidence, preterm, preterm infant, neonatal, conducted in a hospital setting. Recruitment methods were similar
intensive care, neonatal intensive care vulnerable infants and NICU. across studies; clinicians working on the NICU were invited to take
Research papers that did not include clinician knowledge outcomes part in an in-house breastfeeding education programme (See
of educational interventions in NICU and papers describing non- Table 2).
peer reviewed studies, or conference abstracts, were excluded
(Fig. 1). 3.4. Interventions

3. Results The content of the educational intervention was briefly

described in all four studies and all included lactation physiology
3.1. Study selection and breast milk expression in the context of the high-risk infant.
The four studies tested different formats, duration of the educa-
tional interventions (See Table 1). In all studies, neonatal

Please cite this article in press as: Higman, W., et al., A review of breastfeeding training intervention studies that evaluate staff knowledge
outcomes in NICU, Journal of Neonatal Nursing (2017), https://doi.org/10.1016/j.jnn.2017.10.002
 W. Higman et al. / Journal of Neonatal Nursing xxx (2017) 1e8 3

Table 1
Included studies: Design, participants, setting, method and interventions.

Author, year and Design Participants Setting Knowledge Assessment and Format of Educational
country other measures Intervention

Siddell et al. (2003), Pre-test/post-test with
USA intervention group and a
control group who had no
educational intervention
Jones et al. Pre-test/post-test.
(2004), UK Pre/post intervention audit
of
Infant cohorts (not
matched) between Sept
2001 and Feb 2002
Bernaix et al. (2008), Quasi-experimental, time
USA series pre-test/post-test
Pineda et al. (2009), Knowledge post-test
USA intervention. Pre/post
intervention matching
cohort infants with control
group.
Retrospective audit of
breastfeeding outcomes.
Conducted between April
2004 and April 2005.
Total pre and post test
n ¼ 51 Nurses
30 NICU
21 Paediatric
N ¼ 34 staff
8 NICU trained midwives, 8
NICU trained paediatric
nurses, 2 paediatric house
officers and 1 paediatric
registrar
pre-intervention cohort
babies n ¼ 90
post-intervention cohort
babies n ¼ 76
64 NICU nurses pre test, 31
post test due to attrition
2 sets of mothers
n ¼ 19 (pre intervention)
and n ¼ 13 (post-
intervention)
89 HCPs (63% of all HCPs
working in the NICU) 75
nurses, 3 rehab. therapists,
1 nurse practitioner, 2
neonatologists, 2 social
workers, 1 respiratory
therapist, 5 other health
professionals
81 infants pre-intervention
54 infant-mother dyads
post-intervention group.
Freestanding children's
hospital in Northeaster
United States. Level III NICU
(26 beds) and 3 paediatric
medical/surgical units (66
staffed beds)
NICU North Staffordshire
UK Maternity hospital
Midwestern USA 42 bed
NICU in tertiary care
children's hospital
40 admissions a month
120 nurses
NICU USA.
Knowledge and attitude An 8 h breastfeeding
Questionnaire: education program
2 weeks pre and 2 weeks specifically designed
post intervention. for NICU nurses,
practical teaching
sessions and panel
discussion with 4
mothers who had
breastfed on NICU
Knowledge test pre and Training programme in
post intervention 5 modules/10 h
Audit of notes pre and post delivered by a neonatal
intervention 1 year apart to breastfeeding co-
measure breastfeeding ordinator - allocated
outcomes. away from clinical area.
The programme
included practical
assessments and
tutorials.
Nurses' knowledge, 4 h educational
attitudes and beliefs intervention using
measured: 2 weeks pre lecture and discussion
(T1), immediately post (T2), format taught by
2 weeks post (T3) and 3 neonatal nurse
months post intervention practitioner/lactation
(T4). consultant.
Mothers' perceived support
measured pre and 3 months
post intervention.
Staff Knowledge test: post- One hour educational
intervention over 6-week presentation or self
period. study educational
Breastfeeding outcomes module.
measured.

breastfeeding coordinators or lactation specialists delivered the during their infant's stay and that the information was consistent
intervention, with three (Siddell et al., 2003; Bernaix et al., 2008; with staff training materials. However, the inclusion of this addi-
Pineda et al., 2009) using a lecture and discussion format and one tional intervention confounds the independent effect of clinician
(Jones et al., 2004) using a tutorial format. One study had the education on feeding outcomes. Bernaix et al. (2008) incorporated
alternative option of a self-study module (Pineda et al., 2009). motivational encouragement techniques in the intervention in
Course duration ranged from 1 h (Pineda et al., 2009) to 10 h (Jones addition to the specific breastfeeding content, however this is not
et al., 2004), the latter course divided into 5 sessions. Two studies further described. No studies reported an educational theory or
included practical elements using dolls, breast models and nipple programme logic behind the development of the interventions.
shields (Jones et al., 2004; Siddell et al., 2003), and one included a
panel discussion with four mothers who had attempted to breast-
4. Measurement of primary outcome
feed their infants on NICU, and provided written resource mate-
rials, though this was not described (Siddell et al., 2003). Jones et al.
4.1. Knowledge
(2004) developed an educational intervention that used research-
based evidence regarding preterm mammary physiology, breast
Each study employed previously unreported methods to assess
milk expression and the establishment of preterm oral skills. In this
knowledge, without prior validation. Bernaix et al. (2008) reported
study, they provided an optional CD-ROM about human lactation
using the Nurse Lactation Survey (NLS), a 24-item questionnaire
and videos on positioning and breastfeeding the preterm infant
with forced-choice responses (true/false/unsure), but with low in-
were available if additional guidance was required.
ternal and test-retest reliability. Pineda et al. (2009) used a 20-
Pineda et al. (2009) evaluated the effectiveness of a three-part
question multiple choice post-test and created a pass mark of 80
educational intervention instituted over a 6-week period that
per cent to signify adequate breastfeeding knowledge, but do not
included staff training, a complementary educational pamphlet for
report validity and reliability testing. Siddell et al. (2003) created a
mothers, and the addition of a breastfeeding pathway to the baby's
7-item knowledge test (KNOW) from the content of the educational
care plan. The educational pamphlet was developed to ensure that
intervention, reporting modest but acceptable levels of internal
all mothers received standard information about breastfeeding
reliability. Jones et al. (2004) designed eighteen short, hypothetical

Please cite this article in press as: Higman, W., et al., A review of breastfeeding training intervention studies that evaluate staff knowledge
outcomes in NICU, Journal of Neonatal Nursing (2017), https://doi.org/10.1016/j.jnn.2017.10.002
4 W. Higman et al. / Journal of Neonatal Nursing xxx (2017) 1e8

Table 2
Included studies: Outcomes, measurement, results, inclusion/exclusion and limitations.

Author, year and Outcomes Measurement Results Inclusion/Exclusion Limitations

country

Siddell et al. (2003), 1. Relationship between
USA nurses' demographic
variables, knowledge and
attitudes pre intervention
2. Nurses' knowledge and
attitudes about
breastfeeding post
intervention
Jones et al. 1. Clinician knowledge 1. Knowledge test
(2004), UK difference pre and post 2. Clinical audit
intervention
2.
a. Fed expressed breast milk
b. Documented problem
solving plans in notes
c. KMC offered
d. Incidence of baby being
put to the breast
e. Breast feeding on
discharge
Bernaix et al. 1. Relationships between
(2008), USA demographic variables,
knowledge and attitudes
2. Lactation knowledge,
attitudes, and beliefs pre
and post intervention
3. Intention to provide
lactation support to
mothers post intervention
4. Mothers' perceptions of
support pre and post
implementation of
intervention
Pineda et al. (2009), 1. Breast milk feeding
USA initiation pre and post
intervention
2. Breastfeeding at the
breast pre and post
intervention
3. Breast milk feeding at
discharge pre and post
intervention
4. Clinician knowledge post
intervention
Personal and job A significant increase
characteristics were (F ¼ 21.43, p < 0.001,
measured by 5 items, df ¼ 1,49) in NICU nurses'
knowledge 7 items, Pro- knowledge post
breastfeeding 4 items, intervention. Higher
baby-focused care 5 items, education attained was a
nurse-focused care 3 items. significant predictor of
greater knowledge scores
(r ¼ 0.06, adjusted
r ¼ 0.05,p < 0.05)
1. Overall improvement
p < 0.001
2.
a. pre 86% post 97%
p ¼ 0.012*
b. pre 2% post 86%
p < 0.0001*
c. pre 65% post 85%
p ¼ 0.006*
d. pre 75% post 94%
p ¼ 0.002*
e. pre 67% post 79&
p ¼ 0.10*
* full statistical tests not
presented in paper
1. 13 item personal and job 1. Intentions to provide
characteristics lactation support were
questionnaire positively correlated with
2. 24 item Nurse Lactation nurses' with age (r 5 0.51, p
Survey (NLS) 0.01), years of experience
3. 64 item Nursing Support on NICU (r 5 0.54, p 0.01),
for Breastfeeding lactation beliefs (r 5 0.40, p
Questionnaire modified for 0.01) and subjective
NICU (NSBQ) normative beliefs (r 5 0.32,
4. 46 item Mothers' p 0.05). Beliefs about
Perceived Support lactation improved with
Questionnaire (MSPQ) and knowledge
12 item demographic 2. Knowledge scores T1 to
questionnaire (Bernaix, T2 (t (42) ¼ -10.53,
2000) p < 0.001), T1 to T3 (t
(22) ¼ -5.88, p < 0.001), and
T2 to T4 (t (27) ¼ 7.5,
p < 0.001), T1 to T4 (t
(31) ¼ 6.8, p ¼ 0.103).
3. Move from moderately
positive to very positive
4. Post intervention sample
perceived statistically
greater support (t ¼ 2.48,
p ¼ 0.02)
1-3 Retrospective chart 1. 74.1%e85.2% - not
review: significant (RR 1.14, 95% CI
4. 20-question post-test 0.74e1.76)
2. 25.9%e44.4% p < 0.03
3. 35.8%e40.7% - not
significant
4. 100% scored >80% ¼ pass
Registered Nurses (RNs)
working at the children's
hospital. The intervention
group (NICU) consisted of
RNs, regular staff, and per
diem nurses, who work in
the hospital's NICU. The
comparison control group
(PEDI) consisted of
paediatric staff RNs who
work on the medical/
surgical units.
Only babies who were
breastfed were included in
the study
None stated
Very low birth weight
(VLBW) infants hospitalized
in the NICU for more than
seven days and born
weighing <1500 g.
Unpublished and
invalidated self-report
measures. Internal
consistency of knowledge
measurement reported as
low. Non-equivalent
control group (NICU versus
PEDI), small sample size
and attrition.
Intervention conducted at
single site with single set of
instructors. Control group
not from a NICU setting.
Unpublished and
invalidated self-report
measures Audit included
infants that had only briefly
been in the unit. Staff had
little opportunity to have
influence. Audit questions
not applicable to bottle fed
babies thus limiting data
that could demonstrate an
improvement in those who
had not expressed a wish to
breastfeed.
Small convenience sample
limits generalisability, also
related to this is that nurses
predominantly represented
one ethnic background
(White) and one setting.
Self-selection bias of
volunteer participants.
Necessary infant feeding
sample size post
intervention was not
obtained.
No pre intervention
knowledge test.
Unpublished and
unvalidated self-report
measure. Self-selection bias
of volunteer participants.

vignettes to test knowledge. To improve validity of the question- 5. Measurement of secondary outcomes
naire, feedback was sought from experienced specialists in relation
to accuracy, relevance, construction flaws, bias and level of read- 5.1. Nurse attitudes
ability. There is no description of the method of assessment to
ascertain the possible levels of correct scores that might be ach- To measure nurses' intentions and beliefs about providing
ieved by chance. lactation support to new mothers during the immediate

Please cite this article in press as: Higman, W., et al., A review of breastfeeding training intervention studies that evaluate staff knowledge
outcomes in NICU, Journal of Neonatal Nursing (2017), https://doi.org/10.1016/j.jnn.2017.10.002
 W. Higman et al. / Journal of Neonatal Nursing xxx (2017) 1e8
postpartum period, Bernaix et al. (2008) used the Nursing Support
for Breastfeeding Questionnaire (NSBQ). The NSBQ is modified from
an earlier study to suit the NICU environment (Bernaix, 2000). It is a
64 item questionnaire that uses the Theory of Reasoned Action
(TRA) (Ajzen and Fishbein, 1980) constructs in order to measure
nurses' intentions, attitudes, and beliefs about providing lactation
support to new mothers in NICU. The authors report Cronbach's
coefficients above 0.72 for all except one of the five subscales used
in the questionnaire. Content validity for the modified tool was
established based on the review of literature and consensus be-
tween a certified lactation consultant and two nurse researchers.
Siddell et al. (2003) measured nurses' attitudes towards breast-
feeding using (1) pro-breastfeeding attitudes (Pro-BF), (2) attitudes
representing baby-focused care (BFC), and (3) attitudes repre-
senting nurse-focused care (NFC). ‘Baby-focused’ items refer to
actions directed toward the exclusive needs of baby, whilst ‘nurse-
focused’ items refer to arranging breastfeeding support at the
convenience of the nurse's work schedule, rather than the needs of
the mother-infant dyad. Items for the Pro-BF, BFC, and NFC attitude
measures were derived from a review of literature related to
nursing attitudes (Bernaix, 2000; Martens, 2000).
5.2. Maternal perceptions of lactation support
One study used maternal perceptions of support as an outcome.
Bernaix et al. (2008) used the Mothers' Perceived Support Ques-
tionnaire (MPSQ). This is a 46-item tool measured on a 5 point
Likert scale and modified from an earlier study (Bernaix, 2000).
Items were sub-divided into three groups to differentiate different
types of lactation support: informational support (16 items), tech-
nical support (15 items), and emotional support (15 items). Internal
consistency of the original version of the instrument using Cron-
bach's Alpha was reported to be high (0.97 overall, and between
0.91 and 0.95 for each of its three subscales), with similar levels
reported for the version used in this study.
5.3. Breastfeeding outcomes
Jones et al. (2004) audited medical and nursing records of dis-
charged babies pre and post training intervention (1 year). Pre and
post audit groups were divided into those intending to breastfeed
and those intending to bottle-feed. Siddell et al. (2003) provide
figures for breastfeeding rates at discharge pre and post
intervention.
6. Results: primary outcome
6.1. Clinician knowledge
Siddell et al. (2003) report a statistically significant increase in
knowledge scores in NICU nurses post intervention (F ¼ 21.43,
p < 0.001, df ¼ 1,49). Jones et al. (2004) report a statistically sig-
nificant improvement in median scores from 32.5 pre-test to 44.6
post-test from a possible total of 85 (p < 0.001) but do not report
the statistical test used, however the range was wide, 9 to 39 pre-
test and 34 to 60.5 post-test. In the study by Pineda et al. (2009),
a score of 80% was considered to suggest adequate knowledge
acquisition about breastfeeding in NICU and scores were dicho-
tomised to pass or fail. All participants who took part in the
educational initiative achieved a pass. Bernaix et al. (2008) report a
statistically significant improvement in lactation knowledge scores
at each post intervention time point when compared with the pre-
intervention measurement: Time 1 (pre-intervention) to Time 2
(immediate post-intervention) (t (42) ¼ -10.53, p < 0.001), Time 1
to Time 3 (2 weeks post-intervention) (t (22) ¼ -5.88, p < 0.001),
Please cite this article in press as: Higman, W., et al., A review of breastfeeding training intervention studies that evaluate staff knowledge
outcomes in NICU, Journal of Neonatal Nursing (2017), https://doi.org/10.1016/j.jnn.2017.10.002
5
and Time 2 to Time 4 (3 months post-intervention) (t (27) ¼ 7.5,
p < 0.001), however the pre-intervention to 3 months post-
intervention measurement failed to reached significance (t
(31) ¼ 6.8, p ¼ 0.103). Also, analyses do not appear to have taken
account of different levels of missing data at each period.
7. Results: secondary outcomes
7.1. Nurse attitudes
Siddell et al. (2003) undertook repeated measures ANOVAs and
reported a statistically significant interaction for baby-focused care
(BFC) (F ¼ 10.38, p < 0.005, df ¼ 1,49). An ANCOVA, adjusting for
pretest nurse-focused care (NFC) scores also showed a significant
different between groups NFC (F ¼ 11.32, p < 0.005, df ¼ 1, 48). The
group by time interaction was not significant for the repeated
measures ANOVA for the Pro-Breastfeeding (Pro BF) score though
visual inspection showed the NICU group to have the highest post-
test mean score. Siddell et al. (2003) demonstrate that the training
intervention enhanced attitudes about breastfeeding however, they
found a negative relationship between the length of time nurses
had worked on NICU and pro-BF and BFC attitudes. This demon-
strates the importance of not making assumptions about the atti-
tudes of those staff considered to be more senior and more
experienced and highlights the need for continued professional
development once staff are established in the workplace.
Bernaix et al. (2008) report that age (r ¼ 5.51, p < 0.01), years of
experience on NICU (r ¼ 5.54, p < 0.01), lactation beliefs (r ¼ 5.40,
p < 0.01) and subjective normative beliefs (r ¼ 5.32, p < 0.05)
positively correlated with intention to provide lactation support to
mothers', although knowledge did not. However, knowledge
(r ¼ 5.32, p < 0.05), along with nurses' subjective normative beliefs
(r ¼ 5.39, p < 0.01) correlated with nurses' beliefs about lactation.
Importantly, the study showed that despite nurses having positive
attitudes towards providing lactation support, they felt negative
about their ability to impact on the lactation outcomes for mothers,
and did not feel supported by their peers and managers. Paired t
tests were used to measure the difference in nurses’ attitudes to-
wards providing lactation support for mothers pre and three
months following the intervention. The research found a significant
increase in all three sub scales; subjective normative beliefs (t
(30) ¼ -3.23, p < 0.01), attitudes (t (31) ¼ -10.17 p < 0.001), and
lactation beliefs (t (31) ¼ -4.75 p < 0.001). As noted above, this
study had a 50% drop out rate from pre to post intervention, so the
data is based on a possibly biased sub-sample of those participants
willing to remain in the study, and who may have had more
favorable attitudes to the intervention than those who dropped out.
7.2. Maternal perceptions of lactation support
Bernaix et al. (2008) report that the first cohort of mothers' pre-
intervention scores for the Mothers’ Perceived Support Question-
naire (MPSQ) ranged from 122 to 159 (possible score range was
46e230), with a mean of 143 and standard deviation of 9.7. When
the measurement was conducted with a second cohort of mothers
at three months post-intervention, MPSQ scores ranged from 100 to
204, with a mean of 162 and standard deviation of 31.8. The dif-
ference in MPSQ mean scores showed a statistically significant
improvement (t ¼ 2.48, p ¼ 0.02). This result demonstrates a wider
range of scores in the second cohort of mothers, suggesting some
mothers felt much better supported than others. This may reflect
the fact that only half the staff in the unit underwent the training,
thereby providing inconsistent levels of care. Also, the cohorts of
mothers differed, so variations may have been due to factors not
controlled for in this study.
6 W. Higman et al. / Journal of Neonatal Nursing xxx (2017) 1e8
7.3. Breastfeeding outcomes
Pineda et al. (2009) measured pre and post intervention feeding
outcomes from matched cohort controls of babies. Breastfeeding
rates increased significantly from an average of one time for every
17 days of admission to one time for every 7 days of admission
(Mann-Whitney U p < 0.01), though this difference is unlikely to be
clinically significant. The odds ratio of ‘ever breastfed in hospital’
was also calculated to be 2.3 (95% CI 1.1e4.8), indicating that
women in the post-intervention groups were more than twice as
likely to breastfeed their infants while in the hospital than those in
the pre-intervention group. However, they found no change in the
proportion of breast milk ever provided in hospital (before: 60/81,
after: 46/54; RR 1.15, 95% CI 0.97e1.36) or at discharge (before: 29/
81, after: 22/54; RR 1.14, 95% CI 0.74e1.76). Jones et al. (2004) report
an improvement following the intervention with an increase in the
number of infants receiving expressed breastmilk (before: 75/90,
after: 72/76; RR 1.15, 95% CI 1.03e1.29) and being put to the breast
(before: 57/90, after: 65/76; RR 1.35, 95% CI 1.13e1.62), however,
rates of breastfeeding at discharge did not differ significantly
(before: 49/90, after: 54/76; RR 1.31, 95% CI 1.03e1.65). Although
Siddell et al. (2003) did not formally audit breastfeeding outputs on
the NICU, they reported an improvement in the number of babies
who initiated breast milk feeding (65%e69%) and who were
breastfeeding at discharge (49%e59%) during the year following the
intervention compared to data from 1999. The authors suggest that
this may have been related to the nurses' improved knowledge.
7.4. Summary of main results
All four studies in this review showed an improvement in
clinician knowledge following a training intervention. Post inter-
vention knowledge was repeatedly measured by Bernaix et al.
(2008) but showed no statistically significant improvement over
pre/post test scores at the longest time period point of 3 months,
although high drop out rates make these comparisons difficult to
interpret. Secondary outcomes of nurse attitudes in the studies by
Siddell et al. (2003) and Bernaix et al. (2008) showed that the
educational interventions had a positive effect on nurses’ attitudes
and beliefs about breastfeeding as well as intentions to assist new
mothers. Bernaix et al. (2008) showed that mothers perceived
greater lactation support in the post intervention cohort compared
to mothers in the pre-intervention cohort. Breastfeeding outcomes
showed improvements in rates (Pineda et al., 2009), initiation
(Jones et al., 2004) and breastfeeding at discharge (Siddell et al.,
2003).
7.5. Study quality
Single site locations and a lack of clinical information on the
infants and of job related data for staff cohorts limit the general-
isability of these studies. It is not clear how representative partic-
ipants were of all staff in the unit in each study. In the description of
their limitations Bernaix et al. (2008) acknowledge that a self-
selected group of nurses undertook the training and they may be
unrepresentative of the workforce as they were more motivated to
take part. Study designs reliant on pre-post test only in one group
are weak. One study used a quasi-experimental design to compare
the intervention group with an unmatched control group (Siddell
et al., 2003), which means any differences may have arisen due to
differences in the samples and settings, i.e. for reasons unrelated to
exposure or not to the intervention. Bernaix et al. (2008) measured
maternal satisfaction with lactation support and found mothers
perceived greater support, in the sample assessed, following the
educational intervention. However, in this study only a small
Please cite this article in press as: Higman, W., et al., A review of breastfeeding training intervention studies that evaluate staff knowledge
outcomes in NICU, Journal of Neonatal Nursing (2017), https://doi.org/10.1016/j.jnn.2017.10.002
number of mothers were recruited, and these were not represen-
tative of a diverse population, but had characteristics of mothers
that would be likely to breastfeed (educated, previously breast fed)
and had indicated that they wished to breastfeed prior to delivery.
7.6. The content of educational interventions
In each of the studies, the training material is based on current
evidence-based practice, however none of the studies refer to
educational theory models used in the design of the intervention.
Whilst Bernaix et al. (2008) incorporated motivational encourage-
ment to empower nurses to support mothers into the training
intervention they do not describe how this was provided nor what
it entailed. Jones et al. (2004) described the provision of a CD-ROM
about human lactation as an option to the training programme,
however they do not report on its use. A limitation of all the studies
is that none report participant experience of using the learning
intervention.
7.7. Measurement issues
None of the studies report a power calculation to estimate the
required sample size to detect differences in the primary outcome
variable. Three studies had small sample sizes (Siddell et al., 2003;
Jones et al., 2004; Bernaix et al., 2008). In all studies the mea-
surement tool used to assess knowledge was not previously pub-
lished, and there were either no statistical measures of validity and
reliability, or one study where the reported reliability of a measure
was low (Bernaix et al., 2008). There were no measures of practice
so it is not possible to link knowledge outcomes with changes in
practice.
All of the studies used either in-house lactation specialists or
educators to deliver the training, though Pineda et al. (2009) also
offered a self-study alternative. Siddell et al. (2003) note that using
a single set of instructors limits the degree to which the knowledge
improvement could be attributed to curriculum rather to the in-
structor's expertise. However, this was not discussed in the other
studies, although it may have an impact on learning outcomes.
Jones et al. (2004) acknowledge that repeating the same pre and
post-test questions can introduce practice effects, which would
confound the results of the post-test. However, in the other studies
it was not made clear whether staff were shown the correct an-
swers following testing. Jones et al. (2004) report 60.5 as the
highest reported test score out of a possible 85 which may suggest
that the learning intervention did not provide adequate informa-
tion to answer the questions. Pineda et al. (2009) report 100% of
clinicians scored a pass mark of >80% following the intervention.
However, no pre intervention knowledge measurement was taken
and this score could result from having too easy a test (ceiling ef-
fect). Only one study tested knowledge outcomes more than twice
(Bernaix et al., 2008). This study demonstrated that learning was
sustained over a three month period but failed to demonstrate
significant improvement at this time point when compared to pre
intervention scores. This may be an artifact of the 50% drop out rate,
but it may support the authors' recommendation of regular
educational updates and practice to ensure information is retained.
Jones et al. (2004) report breastfeeding outcomes only from
mothers intending to breastfeed, consequently the audit did not
capture the effect of training on breastfeeding initiation rates, and
did not include data collection on those who did not intend to
breastfeed. The authors acknowledge that improvements seen in
auditing the post intervention group may be partly because of
better record keeping by staff, as this was noted to have improved
during the study period. Pineda et al. (2009) measured breast-
feeding rates, but not breast milk feeding and therefore do not
 W. Higman et al. / Journal of Neonatal Nursing xxx (2017) 1e8
capture potential improvements in the provision of breast milk
through breast milk expression. They recruited a clinically chal-
lenging cohort of babies who weighed less than 1.5 kg at birth and
who were likely to be preterm, although the gestation is not
described. Their findings show no significant improvement in
breastfeeding at discharge following the intervention. The disparity
in sample sizes between groups is recognised as a limitation by the
authors and was because of lower numbers of admissions in the
time allowed for data collection.
7.8. Further research
Future studies should evaluate the retention of knowledge by
clinicians over longer periods, the effects on their practice, the
formats suited to different types of learners and the constraints of
working in NICUs. As the NICU team is a multidisciplinary work-
force it is also important to ensure that all those involved in sup-
porting mothers are given access to the same training in order to
avoid providing inconsistent or incorrect advice. Education design
research recommends that studies should involve multiple itera-
tions that are user tested in order to refine and improve training
materials (Reeves et al., 2005). Therefore user involvement should
be central to the development of educational interventions. Bernaix
et al. (2008) included staff behavioural skills training and tested
motivation to apply the knowledge from the intervention. The in-
clusion of brief behaviour change skills training such as motiva-
tional interviewing techniques, which have been found effective in
many other contexts (Lundahl et al., 2010; Miller and Rollnick,
2013), is promising component worthy of future study.
8. Conclusions
This review has shown the paucity of studies of breastfeeding
education for NICU clinicians that test knowledge outcomes. The
four studies show positive effects on these and some other out-
comes, but study designs are poor, measures lack reliability and
validity, and description of educational interventions, their delivery
and the engagement by learners is largely unreported. To ensure
consistent evidence based care for all mothers and infants in NICU
it is important to train all members of the NICU multidisciplinary
team. Randomised controlled studies that test staff knowledge
acquisition pre-post training are needed, along with process eval-
uations that describe the development and implementation of the
educational intervention.
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