Assessing psychological readiness for learning about breastfeeding in mothers of NICU infants: a guide for postpartum nurses.
Abstract: When a mother and newborn must be separated because of the child's admission to the neonatal intensive care unit, feelings of disconnection, frustration, and fear can ensue. One way to increase involvement and decrease stress for mothers interested in breastfeeding is early initiation of breast pumping to stimulate milk production and provide essential nutrition for the infant when stable. Postpartum nurses are in an ideal position to teach new mothers about breast pumping, especially during evening and night shifts when a lactation consultant may not be available. This article provides a guide for the postpartum nurse to increase understanding of the psychological and readiness indicators for patient learning.
Subject: Infants (Premature) (Food and nutrition)
Nurses
Breast feeding
Author: Hadsell, Christine A.
Pub Date: 09/22/2010
Publication: Name: Journal of the New York State Nurses Association Publisher: New York State Nurses Association Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 New York State Nurses Association ISSN: 0028-7644
Issue: Date: Fall-Winter, 2010 Source Volume: 41 Source Issue: 2
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Accession Number: 257675202
Full Text: When a postpartum mother cannot breastfeed her child due to the infant's illness and subsequent admission to the neonatal intensive care unit (NICU), this mother may feel psychological and physical distance from her child, as well as a loss of empowerment to influence the child's growth and well-being (de Azevedo & Mendes, 2008). In the absence of a lactation consultant, this mother is dependent on her postpartum nurse to be an advocate, facilitator, and teacher of an alternative method to support infant nutrition. Lessen and Crivelli-Kovach (2007) discussed the obstacles that women may face, including "insufficient support and education as well as unsupportive hospital practices," and how improving upon these factors could ultimately increase the incidence of breastfeeding. Wigert (2006) described feelings of "disruption and exclusion" reported by new mothers when they could not be involved with their infants.

There is much research focused on the interaction between NICU nurses and new mothers related to infant nutrition (Lessen & Crivelli-Kovach, 2007; Panagl, Kohlhauser, & Pollak, 2001; Spicer, 2005; Ward, 1999). During the early postpartum period, however, the new mother may be physically unable to travel to the NICU, and/or the infant may not be physiologically stable enough for stimulation provided by parental contact, so teaching in the NICU may be contraindicated. The postpartum nurse is in an ideal position to initiate a conversation about the importance of early initiation of breast pumping, given the nurse's role as caretaker and advocate for the mother. An essential part of this conversation is the assessment of psychological readiness for learning (Lawson & Flocke, 2009; Moriconi & Stabler-Haas, 2010).

The purpose of this article is to provide a guide for the postpartum nurse to recognize indicators for patients' readiness to learn about breastfeeding. Since direct breastfeeding may not be an option in this particular population, positive indicators for learning readiness can facilitate teaching about an alternative method, breast pumping. This article is written especially for evening and night shift postpartum nurses, as they must often initiate teaching without the aid of a lactation consultant (Mantha, Davies, Moyer, & Crowe, 2008). This guide will also be helpful to new graduates, because developing awareness about readiness to learn will help to promote timely interventions. It should be noted that, although fathers are also key recipients of assessment and teaching, this article focuses on the unique relationship between the postpartum nurse and new mother.

Literature review

Postpartum nurses influence the characteristics of the education being delivered to their patients. Therefore, it is critical that these nurses know how to identify the window of opportunity for teaching. Patient readiness for learning is related to a number of factors, such as alertness, pain level, and motivation (Lawson & Flocke, 2008). The ultimate determination of this teaching time is based upon the combination of patient readiness and nurse recognition of that readiness, which do not always equate.

Factors that may affect the nurse's perception include the patient's physical and psychological state. Nurses are educated in collecting objective and subjective data during the nursing process, which include assessment, diagnosis, outcome, plan, implementation, and evaluation (Potter & Perry, 2005). During the process of data collection and analysis, however, nurses may draw inaccurate conclusions about psychological status if they assume that the patient is too distraught and emotionally incapacitated over the infant's condition to absorb any new knowledge; in other words, the nurse may assume a lack of readiness for learning when this is not the case. Drawing inaccurate conclusions may be a symptom of a larger problem--a lack of knowledge about how to psychologically assess a patient for readiness to learn (Moriconi & Stabler-Haas, 2010). A mother may be quite ready and willing to learn as a coping mechanism to gain some control over her child's health status. This control may be facilitated by the ability to provide nutrition for her infant. De Azevedo and Mendes (2008) discussed how, although premature birth is a difficult situation and lactation is a complex process, mothers embraced this situation by developing mechanisms to maintain lactation. Maternal stress levels also may be decreased by involving mothers in the basic care of their infants (Jopek, Gadzinowska-Szczucinska, & Szczapa, 2009).

Mothers who wish to breastfeed, but cannot, may have the ability to pump and store breast milk. Stimulation of lactation via breastfeeding or pumping leads to milk production (Lessen & & Crivelli-Kovach, 2007). Breast milk can be pumped, bottled, and refrigerated for the infant in the NICU unit (Slutzah, Codipilly, Potak, Clark, & Schanler, 2009) or can be frozen for up to 30 days (Silvestre et al., 2009). Infants can then be fed orally or via various gastric routes when they are physically able. The mother can bond with the child directly and indirectly by the provision of life-sustaining nutrition, taking an active stance in the life of the child. This is vitally important to the psychological well-being of the mother and the subsequent mother-child relationship (Panagl, Kohlhauser, & Pollak, 2005).

Ward (1999) discussed the importance of a team approach between staff and NICU mothers, stressing the need to teach and involve mothers in basic infant care such as bottle-feeding. Given their main responsibility of infant care, NICU nurses may not have the time to teach mothers about basic care with the goal of incorporating them into the care team.

Assessment of readiness

The notion of nurse availability and time constraints may have implications for the postpartum nurse as well. One could hypothesize that the time element involved in teaching breast pumping, combined with a perceived lack of patient readiness and the nurse's discomfort and/or lack of knowledge related to psychological assessment of the mother, diminishes the chances that teaching and learning will occur. A thorough nursing assessment of women with infants in the NICU must include basic readiness questions such as, "Are you ready to learn about breast pumping at this time?" and "Do you have any previous experience with breast pumping?" If the patient is ready and her physiologic state permits, this is an effective time to teach. Prompt initiation of teaching and breast pumping will accelerate the active phase of parenting and its psychological benefits (Spicer, 2001). Since most newborns arrive spontaneously and unscheduled, the lactation consultant at the birthing facility may not always be available. Nonetheless, it is important that the initiation of breast pumping occurs at the appropriate time for the mother and infant, which may fall on the evening and night nurses.

Previous research focused on teaching and learning related to fostering healthy behaviors in patients with various medical issues, and has included the concept of readiness to learn as an important variable when determining a teaching plan (Grahn & Johnson, 1990; O'Shea, 2001; Tiivel, 1997; Whyte, Watson, & McIntosh, 2006). Nurses need to be aware of how readiness-to-learn indicators fit within the psychological assessment. Positive psychological behaviors, such as an appropriate affect, awareness of one's environment, or taking an interest in the newborn, indicate a positive psychological state (Weiss & Lokken, 2009). This state generally tends to be conducive to further conversation, which should include questions about readiness to learn.

Timely initiation of breast pumping can be supported by an integrated assessment and an appropriate teaching plan. Table 1 was developed as a guide, which integrates readiness-to-learn questions within an overarching framework of psychological assessment concepts. The readiness questions were based on Whyte and colleagues' (2006) article about education related to smoking cessation, where they identified four key elements of health education: the teachable moment, readiness to learn, information, and oral communication skills. Within the readiness category, they recommended asking questions related to experience, beliefs, and the identification of barriers to learning. The ideal patient responses would reflect psychological stability in addition to motivation to learn. Postpartum nurses will need to use critical thinking skills to analyze and form judgments about the information obtained through use of the table.

Ideally, the table will be used within the first 1 to 2 hours after the new mother is stabilized. The table could be easily included within the general unit orientation. The nurse can use the table as a guide to initiate a conversation about infant nutrition. In combination with assessment of the patient and her family, the patient responses will help the nurse to gain an overall understanding of the patient's readiness to learn and develop a comprehensive teaching plan.

Each row of the table represents a section of the psychological assessment, along with the general readiness category to which that section applies. Next is the appropriate readiness question, related to breastfeeding/ breast pumping. Last is the objective for asking that question. The table will help the nurse to visualize how these questions fit within the larger psychological assessment framework. Psychological assessment categories are purposefully broad, as this table is not meant to replace a comprehensive mental status exam. Questions may be asked in any order. The readiness questions are loosely tied to the psychological assessment concept. For example, previous experience can be associated with awareness of the need for learning about breastfeeding and the identification of patient concerns can be associated with the patient's mood. Information obtained from patient responses could, however, provide additional information about other parts of the psychological assessment.

Exemplars

Following are two fictional exemplars, whi ch i llustrate th e applicati on of the psychological readiness guidelines to varying degrees, with different maternal and newborn outcomes. The exemplars are not meant to be prescriptive. The nurse may elect to ask the questions verbatim, use a portion of the questions, or reword them to fit the particular patient scenario. Keep the following questions in mind as a framework during the reading: Are the mother's physiologic barriers controlled to an adequate level, including low pain rating and stable vital signs? Has she or her significant other asked questions about infant nutrition? Have they initiated contact with the NICU? Does she have an interest in initiating pumping with the ultimate goal of breastfeeding? Is this a realistic time to teach, given the nurse's work assignment?

Scenario

The client is a new mother who delivered her premature infant at 10 p.m., resulting in a NICU admission. It is now midnight and the mother is physiologically stable. She was observed over the first postpartum hour to be crying but actively seeking information from the NICU team about the status of her infant. Family was present and supportive. The patient indicated an interest in breastfeeding during the admission assessment.

"Nurse A" response

The nurse assesses pain, performs a fundal check, and monitors input and output. The client is oriented to the room and to available supports, including the lactation consultant. The nurse, having noticed the earlier period of crying, decides to allow the family time to process the infant's condition by entering the room infrequently. The nurse continues to perform postpartum checks every 4 hours. The patient is wondering when she may begin to breastfeed. She asks the nurse who states, "The lactation consultant makes her rounds in the morning. I'm sure she'll stop in to see you. Until then, just try and relax." The lactation consultant visits the patient at 10 a.m., approximately 12 hours after delivery. She and the patient discuss breast pumping, and the lactation consultant asks the nurse to bring in a pump when the nurse has a chance. Since the postpartum unit census is full, the nurse's first opportunity to bring in the pump is at 2 p.m., 16 hours after delivery. The nurse observes the patient crying on two more occasions between 10 a.m. and 2 p.m., so the nurse feels like the delay of pumping was for the best--that the patient needed this time for herself. The client begins pumping at 3 p.m. and is able to express a few drops of colostrum. Over the next 24 hours, she is able to express 1 ounce of breast milk. The infant receives a bottle containing the breast milk at 4 p.m. on postpartum day 2, 42 hours after delivery. Prior to this, the infant had to be supplemented with formula.

"Nurse B" response

The nurse assesses pain, performs a fundal check, and monitors input and output. The client is oriented to the room and to available supports, including the lactation consultant. The nurse is a bit reluctant to ask the patient questions about readiness to learn about breast pumping at this time, given the period of crying, but decides to ask the five questions from the guide. The patient's demeanor seems to brighten and she states, "I want to start breastfeeding as soon as possible, and, if I can't do that, I want to at least do something." The patient also responds that she has no previous breastfeeding experience and is very interested in learning about breastfeeding and breast pumping as soon as possible. The patient expresses no particular concerns about infant nutrition and doesn't state any barriers to learning at this time. It is a busy night on the postpartum unit, but the nurse manages to bring in a pump and teach the patient about pumping for about 15 minutes, after which the patient is able to successfully demonstrate the skill. The patient initially expresses a few drops of colostrum at 2 a.m., 4 hours after delivery. Over the next 24 hours, she meets with the lactation consultant and continues to pump. There are no further episodes of crying observed. She is able to express 1 ounce of breast milk, which is fed to the infant 28 hours after delivery.

Discussion

A marked difference in the time between delivery, initiation of pumping, and initiation of feeding with breast milk is seen in the two responses. Amidst reluctance to "interfere" with the adjustment process of the mother, Nurse A actually does her patient a disservice. The nurse assumes the patient would be burdened by additional assessment, teaching, and pumping. This assumption prevents further conversation about breastfeeding and breast pumping, as evidenced by the nurse not using the guiding questions.

Nurse B may very well have the same assumptions, but provides a more thorough assessment and data collection, which includes the use of guiding questions. Nurse B notes an improved affect, decreased periods of crying, decreased need for formula supplementation, and active participation by the mother. Nurse B also uses time management more effectively. Incorporating an additional 15 to 30 minutes at the beginning of the patient's stay for "proactive" support may minimize the need to provide "reactive" support to the patient later in the stay, as a result of the patient's unmet emotional needs.

In summary, if the majority of the psychological readiness analysis is positive, the postpartum nurse should initiate teaching about breast pumping. If observations are negative, the nurse can plan a teaching session at a later time, perhaps later in the shift. The important point to remember is that a planned teaching time must be formulated so that the nurse and patient can initiate the critical first steps to infant nutrition.

Conclusion

The postpartum nurse is integral to the well-being of the new mother and infant. The nurse is part of the care team and thus needs to facilitate the nursing care plan from time of delivery to discharge. During this facilitation, it is important to remember to avoid assumptions about readiness to learn and to communicate with the new mother early in the postpartum stay. This article supports the need to examine psychological assessment and readiness for breastfeeding in the postpartum environment. Further research should include empirical studies to evaluate the relationship between psychological readiness, breast pumping, and nursing intervention.

REFERENCES

de Azevedo, M., & Mendes, E. M. (2008). Maintenance of lactation: a challenge for hospitalized premature infants and mothers. Revista Gaucha de Enfermagem, 29, 68-75.

Grahn, G., & Johnson, J. (1990). Learning to cope and living with cancer: Learning-needs assessment in cancer patient education. Scandinavian Journal of Caring Science, 4(4), 173-181.

Jopek, A., Gadzinowska-Szczucinska, J., & Szczapa T. (2009). Evaluation of stress responses in parents of newborns hospitalized in the intensive care unit. Ginekologia Polska, 80(5), 367- 373.

Lawson, P. J., & Flocke, S. A. (2008). Teachable moments for health behavior change: A concept analysis. Patient Education and Counseling, 76(1), 25-30.

Lessen, R., & Crivelli-Kovach, A. (2007). Prediction of initiation and duration of breastfeeding for neonates admitted to the neonatal intensive care unit. The Journal of Perinatal & Neonatal Nursing, 21(3), 256-266.

Mantha, S., Davies, B., Moyer, A., & Crowe, K. (2008). Providing responsive nursing care to new mothers with high and low confidence. The American Journal of Maternal/ Child Nursing, 33(5), 307-314.

Moriconi, C., & Stabler-Haas, S. (2010). Making connections: Integration of psychiatric and medical-surgical nursing and relationship-based care. Creative Nursing, /6(i), 13-17.

O'Shea, H. S. (2001). Teaching the adult ostomy patient. Journal of Wound Ostomy Continence Nursing, 28(1), 47-54.

Panagl, A., Kohluauser, C., & Pollak, A. (2005). Integrated psychological parental assistance in the neonatal intensive care unit: Concepts and first experiences. Zeitschrift fur Geburtshilfe und Neonatologie, 209(1), 14-21.

Potter, P. A., & Perry, A. G. (2005). Fundamentals of Nursing. St. Louis: Mosby.

Silvestre, D. D., Miranda, M., Muriach, M., Almansa, I., Jareno, E., & Romero, F. J. (2010). Frozen breast milk at -20 [degrees]C and -80 [degrees]C: A longitudinal study of glutathione peroxidase activity and malondialdehyde concentration. Journal of Human Lactation, 26(1), 35-41.

Slutzah, M. M., Codipilly, C. N., Potak, D., Clark, R. M., & Schanler, R. J. (2010). Refrigerator storage of expressed human milk in the neonatal intensive care unit. The Journal of Pediatrics, 26(3), 233-234.

Spicer, K. K. (2001). What every nurse needs to know about breast pumping: Instructing and supporting mothers of premature infants in the NICU. Neonatal Network, 20(4), 35-41.

Tiivel, J. (1997). Increasing the effectiveness of your teaching program for the elderly: Assessing the client's readiness to learn. Perspectives, 21(3), 7-10.

Ward, K. G. (1999). A TEAM approach to NICU care. RN, 62(2), 47-49

Weiss, M. E., & Lokken, L. (2009). Predictors and outcomes of postpartum mothers' perceptions of readiness for discharge after birth. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 38(4), 406-417.

Whyte, R. E., Watson, H. E., & McIntosh, J. (2006). Nurses' opportunistic interventions with patients in relation to smoking. Journal of Advanced Nursing, 55(5), 568-577.

Wigert, H., Johansson, R., Berg, M., & Hellstrom, A. L. (2006). Mothers' experiences of having their newborn child in a neonatal intensive care unit. Scandinavian Journal of Caring Science, 20(1), 35-41.

Christine A. Hadsell, MA, MS, RN

Christine A. Hadsell is an adjunct instructor at Maria College in Albany, NY, and a doctoral nursing student at the University of Kansas in Lawrence, KS.
Table 1. A guide for assessing psychological readiness for learning
about breastfeeding/pumping

Psychological
Assessment      Readiness Category       Readiness Question

Awareness       Prior knowledge,         Do you have any previous
                personal experience      experience with breastfeeding
                                         or pumping?

Mood            Barriers to learning     Do you have any concerns
                                         about breastfeeding or
                                         pumping?

Affect          Knowledge, experience,   Is this a good time for you
                barriers                 to learn about breastfeeding
                                         or pumping?

Behavior        Knowledge, experience,   Is there anything that would
                barriers                 prevent you from learning at
                                         this time?

Thought         Knowledge, experience    What do you hope to learn
Content                                  during this teaching session?

Psychological
Assessment      Objective

Awareness       Nurse taps into previous
                experience.

Mood            Nurse clarifies information.

Affect          Nurse identifies current
                patient needs.

Behavior        Nurse identifies barriers to
                learning.

Thought         Nurse tailors teaching plan to
Content         patient.

Note: Readiness sections adapted from Whyte, Watson,
and Mcintosh (2006).
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