This two-group parallel randomized controlled trial examined an educational program specialized in breastfeeding support for LPIs. Previous programs seeking to educate nurses and midwives on LPI care have conducted single-group assessments .
The BSLPI intervention resulted in significantly higher scores on the three parameters immediately after and one month after the intervention compared to immediately before it. SS and K-S test scores were significantly higher in the BSLPI group immediately after and one month after the intervention than in the NTS group.
According to a previous report, the SBS scale score may have increased because watching the video allowed participants to revise their knowledge or techniques . In another report, using the acquired knowledge and skills in a counseling setting with the mother allowed healthcare workers to increase their self-efficacy related to breastfeeding support .
There are two possible reasons why the intervention in this study increased the SBS scale scores. First, the gaps between required breastfeeding support for LPIs and actual breastfeeding support offered in individual facilities may have been clarified, together with information sharing between participants and a focus on behaviors aimed at solving the problems. After providing information on interventions deemed effective in breastfeeding support for LPIs, such as starting breastfeeding early, pumping, and continuous skin-to-skin contact or kangaroo mother care , the implementation status at the participants’ facilities, and opinions on challenges related to their implementation were discussed within groups. This was done based on a previous finding that there are fewer resources and less support for mothers of LPIs to breastfeed successfully than mothers of term infants . Some of the individual participants might have understood effective interventions in breastfeeding support for LPIs, but their organizations as a whole were not implementing them. Participants could draw out the problems they faced in their facilities, investigate for solutions, and discover aspects that could benefit from improvement in their facilities through the BSLPI intervention.
Second, the simulation learning method was adopted, which could have given participants the confidence to apply the knowledge or skills they acquired. Divided into small groups, participants took turns playing the role of the breastfeeding supporter and the mother. The simulation scenario was set to be similar to actual breastfeeding support situations, consisting of a baby-mother pair, with the following details: three days postpartum, LPI body weight loss of 7.8%, sleepy infant, exhausted mother, and mother only producing a small amount of breastmilk. This scenario was intended to determine if participants could use appropriate knowledge on breastfeeding support for LPIs who were losing weight and aimed to consolidate that knowledge. At the end of the simulation, participants engaged in “reflection” and “discussion” for a debriefing session to promote autonomous thinking and future behavioral changes. In the debriefing session, they experienced other participants validating that they could individually simulate the scenario. Bandura named four sources of information that influence awareness of self-efficacy . In this intervention, participants may have increased their SBS scale scores by applying two sources of knowledge: enactive mastery experience, which consists of the awareness of achievement, and verbal persuasion, which others convinced them that they can achieve their goals.
Although the differences between the programs were not significant, the NTS group also saw an increase in mean scores immediately after and one month after the intervention compared to those before the intervention. It is possible that the control condition also contained elements that increased self-efficacy related to breastfeeding support; therefore, it warrants revisions so that the effects of the BSLPI intervention can be tested against a control that has no effects on the participants assigned to it.
Previous educational programs on breastfeeding for healthcare professionals involved interventions for improving communication. However, few studies assessed the effects of the interventions [32–35]. This study assessed the verbal and non-verbal skills used for maintaining good relationships with mothers and revealed that an intervention could be helpful in this regard, which is explained by two possible reasons. First, the intervention simulated a realistic, commonly encountered clinical situation. The case used in the training was of an exhausted mother of an LPI reluctant to breastfeed. Previous studies have reported that cases used in training should simulate specific scenes that frequently occur in clinical settings to increase the frequency of participants’ application of their communication skills [36, 37]. This study supported these results.
Second, reflecting on their tendencies after training allowed participants to apply their social skills in clinical settings. Participants scored significantly higher one month after the intervention than immediately after it, and their frequency of using social skills had increased. During training, participants experienced both the mother and the breastfeeding supporter’s roles. This experience may have helped participants improve their communication skills by increased use of the social skills necessary for maintaining good human relationships . This might also increase SS scale scores and could be useful for clinical education for nurses and midwives.
Until now, studies assessing the effectiveness of educational interventions in medical facilities that provide breastfeeding support have reported that such interventions allow medical staff to improve their knowledge [34, 38]. However, we were unable to identify any studies where the interventions were specific to breastfeeding support for LPIs and assessed the benefits of such a program. Therefore, we created a test of the knowledge and skills necessary for breastfeeding support based on guidelines developed by experts [20, 39]. The K-S test scores were significantly higher in the BSLPI group than in the NTS group. The higher scores are attributed to the fact that the content of expert guidelines was summarized and explained, making it easier for participants to comprehend. Breastfeeding support for LPIs is believed to require strategic planning and execution . Therefore, we created a simple chart depicting the types of care needed at various stages, based on references such as the Ten Steps to Successful Breastfeeding , The Academy of Breastfeeding Medicine Clinical Protocol#10 , and the Neo-BFHI Core document . Participants used this chart in the group work and took it home after the program, which allowed them to carry forward the acquired knowledge and skills to their workplaces.
The program we developed included clarification of issues at each facility and facilitated sharing among participants; it also helped in the acquisition of knowledge to deal with the relevant issues, made use of exercises to integrate knowledge and skills, and implemented pretend play among the participants. This program is expected to be used to improve the skills of nurses and midwives involved in breastfeeding support for LPIs.
Regarding clinical application, in order to strategically implement breastfeeding support for LPIs as an organization, we hope that nurses and midwives involved in providing breastfeeding support will create a document that summarizes who will provide which intervention and at what stage, as this will foster clarity on the functions to be performed and how they are to be performed. Furthermore, we believe that the quality of breastfeeding support for LPIs can be improved throughout the organization by actually using, evaluating, and revising the created document.
First, the sample size was relatively small. Second, there is a need to examine methods to make the study more interactive for participants. Third, it is necessary to consider which method of delivering the educational program is most effective: face-to-face, online, or a mixed method. Finally, while the quality of the educational program was ensured because the facilitator was a researcher, to disseminate it widely, it is necessary to train facilitators who can ensure its reproducibility.