Family Practice Vol. 17, No. 6, 541-546
© Oxford University Press 2000
Education |
Improving residents' breastfeeding assessment skills: a problem-based workshop
a Department of Family Medicine, University of Wisconsin, 777 South Mills Street, Madison, WI 53715 and
b Physicians Plus, 1 South Park Street, Madison, WI 53705, USA.
Correspondence to JC Haughwout.
Haughwout JC, Eglash AR, Plane MB, Mundt MP and Fleming MF. Improving residents' breastfeeding assessment skills: a problem-based workshop. Family Practice 2000; 17: 541–546.
Received 23 March 2000; Accepted 17 July 2000.
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Abstract |
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Background. It is well documented that residents have limited knowledge about common breastfeeding problems.
Objectives. The purpose of this study was to assess whether a problem-based, interactive breastfeeding workshop would improve resident skill level.
Methods. Two groups of second- and third-year family medicine residents were assigned to an intervention or control group; both groups participated in pre-and post-intervention Objective Structured Clinical Examinations (OSCEs) and completed written questionnaires. The intervention consisted of a 4.5 hour interactive workshop with didactic presentations and opportunities to work with a lactation consultant and standardized patients trained to role-play selected breastfeeding problems.
Results. There were no baseline differences in knowledge or performance scores on the OSCEs between the intervention and control groups. OSCE scores after intervention were significantly better in the intervention group for the content areas assessing position and latch and the evaluation of sore nipples (P < 0.001 and P = 0.05, respectively). There was a trend towards improvement in assessment of the problem of low milk supply (P = 0.31). All residents in the intervention group correctly diagnosed the cause of both the sore nipples and low milk supply at the follow-up OSCE, with P values of <0.001 and 0.068, respectively. The intervention group felt significantly more confident in their breastfeeding problem-solving (P < 0.001).
Conclusions. An interactive, problem-based workshop to teach residents the basics of breastfeeding problem solving can be implemented in residency and improve clinical diagnostic skills and residents' comfort with breastfeeding.
Keywords. Breastfeeding, clinical competence, education, medical, patient simulation.
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Introduction |
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There is little dispute that breastfeeding is the preferred source of nutrition for infants
4–6 months; infections1–3 and allergies4–6 are prevented or attenuated by exclusive breastfeeding. The major maternal benefit is delayed fertility.7 In response to this increasing evidence of the benefits of breastfeeding, the American Academy of Pediatrics issued a statement in December of 1997 recommending that women breastfeed for at least a year, and that they attempt to breastfeed exclusively for 6 months.8 While increasing numbers of American women leave hospital planning to breastfeed, many of them do not continue to breastfeed for the recommended period of time. In 1995, only 22% of women were still breastfeeding at 6 months, when nearly 60% had left hospital planning to breastfeed.9 This decline has significant implications for maternal and child health since much of the research on the benefits of breastfeeding has found that if a woman exclusively breastfeeds for at least 4–6 months, there is a greater benefit to the infant and the mother than if she stops before that time.3
There are several hypotheses as to why so many women stop breastfeeding. Women cite back-to-work issues as important reasons for stopping breastfeeding prematurely; social pressures to wean may also play a role. Difficulties with breastfeeding may also arise and cause a woman to stop breastfeeding: sore nipples and perceptions of low milk supply are common problems.10 When physical problems combine with the above-mentioned social pressures, a new mother's resolve to nurse her infant can be greatly diminished. Because recent generations of American women have bottle-fed their infants, general knowledge about solving breastfeeding problems is poor and immediate family members and friends may not have relevant information to share from their own experiences. Thus for many women, the primary care physician is their main source of support and information about breastfeeding.
There have been many studies over the past few years looking specifically at physicians' knowledge about common breastfeeding problems, but the largest and most comprehensive was a national survey done by Freed et al.11 This study confirmed earlier reports that family practitioners, paediatricians and obstetricians/gynaecologists have all been inadequately trained to handle common breastfeeding problems.
The goal of this project was to develop and test a skill-based experiential curriculum which is short enough to be incorporated into residency education and which focuses on common clinical problems encountered by breastfeeding women.
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Methods |
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Subjects
All second- and third-year family practice residents at the University of Wisconsin, Madison, were invited to participate in the study. Twenty-four of 30 residents volunteered. Due to the multiple scheduling conflicts inherent in residency, the group of 10 resident participants who were on the in-patient hospital service at the time of the study were designated to the control arm of the study, while the 14 residents not on the in-patient rotation, one of whom was ultimately unable to participate in the study, were assigned to the intervention group.
Timeline
The study took place in the fall of 1998. Both the intervention and control groups completed baseline written examinations and Objective Structured Clinical Examinations (OSCEs) over a 2 week period. Approximately 30 days later, the intervention group attended the 4.5 hour workshop. After another 30 days, both groups again completed the written examination and OSCE. The pre- and post-workshop OSCEs and written examinations were scheduled over a 4 day period, 2 hours on each day over lunch, to accommodate the residents' and standardized patients' schedules. The workshop was given once in a 4.5 hour time block during a regularly scheduled resident conference morning. The curriculum was repeated for the control group in the spring of 1999.
Approval for this study was granted by the Human Subjects Committee of the University of Wisconsin in Madison, Wisconsin. All resident participants were volunteers, signed an informed consent form, were provided lunch after the OSCE and were paid $35 for their time. Each resident received a detailed explanation of his or her OSCE and written examination scores and suggestions for improvement at the completion of the study.
Curriculum
Residents, the lactation professionals and mothers with nursing experience were surveyed before the development of the OSCEs and workshop to ascertain their beliefs regarding the most critical components of breastfeeding education; the goals and objectives for this workshop were formulated based on this multidisciplinary input. The three core content areas identified as the most important were the evaluation of position and latching on, and the evaluation and treatment of both low milk supply and sore nipples. A 4.5 hour, interactive, problem-based workshop resulted from this input.
Family practice physicians taught this highly interactive workshop with the assistance of lactation consultants and standardized patients who were nursing mothers with their infants. This interdisciplinary approach was chosen to promote the physician's role as educator and supporter of breastfeeding mothers and to model the importance of working with knowledgeable medical colleagues and community support groups.
Relevant physiological information was dovetailed into the problem-based workshop format. Short didactic portions with time for resident questions were followed by an opportunity for each resident to do standardized patient interviews. Thus immediately after hearing a formal presentation on a content area, the residents were expected to use their knowledge by interviewing, doing physical examinations and generating differential diagnoses and treatment plans with standardized patients trained to role-play the three clinical scenarios. These standardized patient sessions were facilitated by the lactation consultants. The curriculum included a sheet summarizing important educational points sent to the workshop group about 2 weeks after the workshop.
Evaluation
OSCEs are used for objectively evaluating learner performance in clinical situations. They comprise an observed role play centred on a clinical problem; the learner takes a history and does a physical examination appropriate to the situation while a trained observer scores the learner using an objective checklist developed for each specific problem. Standardized patients are trained to role-play the clinical scenario consistently for each learner; the trained observer is silent except for answering methodological questions and, as in the post-intervention testing, providing constructive feedback. Each resident in the study completed both pre- and post-intervention OSCEs. Trivial changes were made to the post-intervention OSCE to give the appearance of new clinical problems.
Statistical analysis
Pre- and post-intervention knowledge test and OSCE scores, as well as demographic information and information on the residents' background and level of comfort with breastfeeding, were entered into a computer database. t-Tests were performed to detect significant differences between the intervention and control groups on continuous variables before intervention. Binary variables were assessed for pre-intervention differences using Fischer's exact test. The improvements in pre- versus post-intervention OSCE and knowledge test scores were evaluated for significance using the two-sample t-test. Regression analysis was performed on the improvement in total OSCE scores in order to adjust for possible differences in the make-up of the intervention and control groups.
A linear regression analysis model was developed to determine the effect of attending the workshop on the overall OSCE scores of the intervention group. The dependent variable was an OSCE score from each resident's pre- and post-intervention tests. Variables included in the model were intervention and control group status, an indicator as to whether the OSCE score was from a pre- or post-intervention test, an interaction term between experimental and control group status and the pre-/post-interaction test indicator; and potential independent predictors of test results such as year of residency, age, gender, previous OSCE experience, previous personal or work experience with breastfeeding, and breastfeeding education. The interaction term between group status and test results before and after intervention is the gauge of the impact of the workshop, since it specifically indicates the effect of the experimental group's workshop experience on the scores, after adjusting for underlying group differences and general pre-/post-intervention trends.
Recruitment of standardized patients and lactation consultants
The standardized patients were all recruited from a local lay organization dedicated to breastfeeding support. Each ‘patient’ underwent a 1.5 hour training session with the physician investigator and was given extensive written materials which introduced her to her role as a standardized patient with a specific problem to portray. This training also described potential resident reactions to the presentation of a problem. The standardized patients' infants were present during the OSCEs as well.
Local hospitals provided names of members of the International Board of Certified Lactation Consultants (IBCLCs), who were also registered nurses. Three of these were recruited by the investigator and helped develop the OSCEs and workshop. The lactation consultants were present for each OSCE and scored residents as they completed each scenario. The same lactation consultants were used for pre- and post-intervention OSCEs in an attempt to keep the inter-rater variability as low as possible, and each consultant scored the same scenario each time using an objective yes/no checklist to score each resident's performance, leaving little room for subjective interpretation. The OSCE was set up as a series of stations and each resident had 15 minutes to complete the task at each station. Just before beginning each station, the residents were given a sheet of paper detailing the chief complaint and patient's age. Growth curves were provided where appropriate.
The three scenarios were as follows:
Scenario 1: getting a woman started in breastfeeding.. The patient was a first-time mother, having given birth a few days earlier, who had multiple questions about position and latching on. The residents were expected to give her basic breastfeeding information and specifically show her how to assess position and latching.
Scenario 2: evaluation and treatment of sore nipples.. This woman, who had given birth 4 months previously, presented with sore nipples. Residents were expected to take a full history and do a limited physical examination to discover that she had a yeast infection of the breast and the infant had a yeast diaper rash.
Scenario 3: evaluation and treatment of low milk supply.. This woman, 3 months' post-partum, was worried because her infant seemed to want to nurse all the time. The residents were expected to take a full history and do a limited physical examination to discover that the woman had been started on an oestrogen-containing oral contraceptive and had a resultant decrease in her milk supply.
Written test
Information on the age, gender, residency year and breastfeeding experience, including spousal, personal and professional, and previous OSCE experience, was gathered at the pre-workshop OSCE. The pre- and post-workshop questions about breastfeeding were in three categories: knowledge, attitudes and experience. Many were taken from a national survey of residents and practicing physicians done by Freed et al. and were used with those authors' permission. The knowledge questions covered known benefits, medical contraindications and proper treatment in brief clinical vignettes. Residents' attitudes were assessed by questions such as, "Do you feel it is the role of family physicians to promote breastfeeding to expectant mothers?" on a five-point Likert scale.
Residents were also asked to rate their skills in handling common breastfeeding problems on a five-point Likert scale with questions such as, "How comfortable are you in helping a woman who has problems breastfeeding in the first few hours of life?" Residents' experience was assessed by asking questions such as, "How many times have you taught a new mother breastfeeding techniques (i.e. latch-on, position)?"
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Results |
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TopAbstractIntroductionMethodsResultsReferences |
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Subjects
Of the 30 eligible residents, 24 (80%) participated. A disproportionate number (5/6) of the non-participants were male. One resident in the intervention group was unable to complete the workshop or post-intervention OSCE. The baseline characteristics of the residents who participated are presented in Table 1
. Intervention and control groups did not differ with respect to age, gender, previous OSCE experience, previous work experience with breastfeeding, previous breastfeeding education or personal experience with breastfeeding. They did differ somewhat by year in residency, with the intervention group having more third-year residents than the control group (P = 0.10). Although there were more third-year residents in the intervention group, both groups reported similar previous experience working with nursing mothers. Baseline OSCE and written knowledge test scores, as reported in Table 2, did not differ significantly between the intervention and control groups.
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Resident performance/outcomes
Residents completing the workshop showed significant improvement in the skills-based OSCE examinations relative to the control group of residents (Table 2
). The area of most improvement was the evaluation of position and latch-on (P < 0.001); this is important since poor positioning and latch-on are recognized as the most important cause of sore nipples. OSCE scores for the evaluation and treatment of sore nipples were significantly improved for residents completing the workshop (P = 0.05). This problem is considered one of the most common causes of premature breastfeeding termination. There was some improvement in the intervention group's OSCE scores for the evaluation and treatment of low milk supply, but this difference was not statistically significant (P = 0.31). The overall OSCE scores of the residents in the intervention group improved significantly (P < 0.002), with a 35% average increase compared with an average 10% improvement in the control group. This overall improvement remained statistically significant when controlling for year in residency (Table 4), which had been the only significant difference in baseline characteristics.
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When looking solely at whether residents determined the correct diagnosis and treatment for the clinical scenarios (Table 4
), residents in the experimental group responded with 100% accuracy in the post-workshop OSCE for the sore nipples scenario as compared with 70% correct diagnosis by the control group (P = 0.068). The entire experimental group also correctly diagnosed the low milk supply problem, significantly more often than the 20% correct diagnosis rate of the control group (P < 0.001). There was little change in attitudes on the written questionnaire in the ‘before’ and ‘after’ results for the intervention or control groups; the baseline attitudes were quite positive to begin with (8.4 and 7.9/10 respectively). The experimental group showed greater improvement in their general knowledge scores on the written exam (9.1 versus 2.8), although the difference was not statistically significant (P = 0.25). The lack of significance may have been due to the relatively small number of knowledge-based questions (17), to the practical focus of the workshop itself or to the small sample size.
As seen in Table 4, residents' self-assessment of comfort in handling common breastfeeding issues improved significantly (P < 0.001) for the intervention group, although this group was more comfortable with the breastfeeding issues before intervention, possibly because this group contained a greater proportion of third-year residents. The residents stated that they enjoyed the workshop and that they would like this method of teaching to be extended to other topics. They felt that their learning was active and that they acquired skills which would serve them well when managing breastfeeding problems in the future.
Conclusions
The positive attitude of these residents towards breastfeeding is similar to that reported in other, larger studies.11 The current study confirms previous research findings of widespread lack of resident knowledge and experience regarding breastfeeding problems.11 It goes a step further in that it evaluates not only lack of ‘book knowledge’ as assessed by written questionnaire, but also skill level as assessed by OSCE. Given the many studies done to document physicians' lack of knowledge ability to help women with common breastfeeding problems, this study attempted to measure the actual skill level of residents in assessing common breastfeeding problems and then whether there was an improvement in skill level after a relatively short intervention.
There were significant improvements in residents' ability to evaluate and diagnose three of the most important and common breastfeeding problems presented in primary care practice, namely position/latch-on, sore nipples and low milk supply. There was a correct diagnosis of the cause of both presenting problems by all residents who participated in the workshop, while only 70% and 20% of the control group were able to correctly diagnose the causes of the respective problems. Overall, the scores improved significantly and are a better proxy for clinical skill than written tests. The benefit of this OSCE method of resident education is that one can measure performance compared with a set of clinical competencies using an objective checklist.
The workshop and OSCE evaluation process were enthusiastically received by all members of this pilot effort. In addition to the measurable difference in residents' skill level after intervention, the residents felt much more confident about their skills following the workshop. They met and learned from professional community healthcare providers and patients who have experience with the breastfeeding scenarios addressed in the workshop and OSCEs. The lactation experts and standardized patients were appreciative of the chance to share their knowledge with residents who can provide key support to nursing mothers and their infants.
This pilot study is limited by its small size and the fact that residents were assigned to intervention and control groups based on their rotation schedule. While it can be argued that the presence of residents in each group could be random, randomization of residents would be an added strength. This pilot is not an exact proxy for a workshop given as part of a residency programme where there is no OSCE scheduled to evaluate learning.
Recommendations
We recommend this workshop model, partnering with lactation consultants, nursing mothers and their infants, as the only model we have found in the residency education literature which gives residents an educational experience with several nursing mothers and their possible presenting problems. It gives residents an understanding of the role of the lactation consultant and the potential benefits of a partnership with lactation consultants in their support of nursing mothers. The benefits expressed by the residents in terms of their increased comfort in talking with nursing mothers is one which should not be overlooked, and the correct diagnosis performed by all intervention group residents is certainly notable.
This pilot study should be replicated with a larger sample of residents or across several residency programmes to test the efficacy of the intervention further. We recommend the use of OSCEs as an evaluation tool for this form of resident education. A larger study could look at improved outcomes for nursing mothers and their infants.
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Acknowledgments |
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The authors would like to thank the lactation consultants who helped design and teach the workshop and who spent hours evaluating residents during the OSCEs: Jan E Miller, RN, IBCLC; Susan A Payne, RN, IBCLC; and Angela G Bakken, RN, IBCLC. We are also grateful to the patients for their time, energy and commitment to breastfeeding education. This project was funded by the University of Wisconsin Department of Family Medicine Small Grant Program and the Department of Health and Human Services National Research Service Award No. T32PE10010-07.
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