Lactation Assessment Tools: A Qualitative Analysis of Registered Nurses’ Perceptions of Tool Limitations and Suggested Improvements

Abstract

Background Several lactation assessment tools are available for in-hospital assessment of breastfeeding dyads, and their components vary widely. To date, no research has evaluated the perceptions of registered nurses (RNs) regarding the limitations and future improvements of these tools. Research Aim The aim was to describe RNs' perceptions of the limitations of currently used lactation assessment tools and how these tools could be enhanced. Methods Focus groups ( n = 7) were conducted with RNs ( N = 28) whose current responsibilities included in-hospital breastfeeding assessment. Recruitment occurred from April through July 2015 at regional and international lactation conferences. Focus groups were audiotaped and transcribed verbatim. Two lactation researchers analyzed the transcripts to identify emerging themes and subthemes. Results RNs identified three key limitations of the tools included being too subjective and time-consuming, difficulty in assessing audible swallows, and missing the big picture (e.g., overemphasizing numbers, being a snapshot in time). Suggested improvements focused on maternal characteristics (evolving breasts and nipples, holding it together, "got milk?," risk factors, embracing the role), infant characteristics (day of life, latch/suck/swallow, baby's "driving the bus," risk factors for supplemental feeding), their interaction (two to tango, positioning, better qualitative descriptors), and tool organization (formatting and multiple versions). Conclusions RNs suggested novel components for consideration when developing future lactation assessment scales, including removing audible swallowing, adding mother/infant interactions, infant output, and expressible colostrum, and developing criteria specific to infant age. Future research should translate these suggestions into evidence-based indicators and evaluate the resulting proposed tools for reliability and validity.

Commentary on Measurement in Lactation and Breastfeeding

“…Development of an improved tool that takes into account the end users' views was seen as a first step in the challenging process of developing a new assessment tool. Chapman and Kuhnly (2018) conducted seven focus groups to gather qualitative data from 28 registered nurses who currently conducted in-hospital breastfeeding assessments as part of their nursing and/or lactation responsibilities. Content analysis of the verbatim transcripts yielded key limitations of the assessment tools, including the subjective indicators and time-consuming nature of the tools, difficulty in assessing audible swallowing, and missing the big picture (i.e., overemphasis on assigning numbers and the assessment being a snapshot in time).…”

“…Process variables and outcome variables are also salient in healthcare and breastfeeding research and/or clinical practice. For example, the clinical lactation assessment tools focused on by Chapman and Kuhnly (2018) are process tools that have quantitative aspects (points for each indicator). AlKusayer, Midodzi, Newhook, Gill, et al (2018), in developing cutoff scores for the Iowa Infant Feeding Attitudes Scale (IIFAS) among Canadian women, were interested in predicting the outcome of feeding method at 1 month postpartum (qualitative categories of exclusive breastfeeding, exclusive formula feeding, mixed breastfeeding, and formula feeding).…”

“…Chapman and Kuhnly (2018) sought to examine registered nurses’ views on the limitations of lactation assessment tools and how tools could be improved. The need for this research was based on the wide variety of currently used lactation assessment tools, the long-standing concerns about the psychometric properties (reliability and validity) of current tools, and the lack of research about registered nurses’ views on the tools and how tools could be improved.…”

“…Lactation assessments are used to document “important” indicators/activities during the feeding with the goal of assessing progress in the developing feeding relationship and infant intake (Koehn & Dowling, 2016). Chapman and Kuhnly’s (2018) efforts to gather information from practicing nurses and International Board Certified Lactation Consultants (IBCLCs) via focus groups demonstrate a beginning step in gathering information on the salient indicators needed for assessment of the breastfeeding dyad during this critical period after birth. Although lactation assessment measures are not based on a specific theory that would inform what should be measured in the assessment, information about salient components of assessment from caregivers is appropriate because they are the intended users of the assessment tool.…”

“…This commentary focuses on the measurement of breastfeeding-related concepts in research and clinical lactation practice. In this issue of JHL , three reports provide three very different examples of measurement-related processes and issues, but all ultimately relate to providing evidence-based clinical care of breastfeeding dyads (AlKusayer, Midodzi, Newhook, Gill, et al, 2018; Chapman & Kuhnly, 2018; Yang, Schmied, Burns, Brodribb, & Salamonson, 2018). In this commentary, I will give background to the role of measurement in building evidence and knowledge.…”