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Overview of Selected Evidenced-Based Practice Project
Evidence-based practice is an approach to health care that ensures the best possible outcomes for the patients. In its currently accepted form, the approach is founded on three core principles: the values and expectations of the patients, the clinical expertise of the provider, and evidence from available academic sources. The three principles are combined using critical thinking with the ultimate goal of achieving the best result. It is important to understand that due to the constant involvement of critical approach and assessment of the process, the approach also necessitates adjustments as soon as the need for change is identified in one of the three domains. For instance, if the selected intervention is evidenced to provide insufficient improvement, it would be reasonable to consider other options.
Research is thus one of the crucial elements of evidence-based practice. The main reason for this is the inherent limitations of individual judgment. Both the field expertise of the clinician and the preferences of the patient are subject to cognitive biases. They cannot serve as the ultimate determinant of decision-making in healthcare (Grove, Burns, & Gray, 2015). On the other hand, the research conducted according to the academic standards eliminates the overwhelming majority of the said limitation. It can thus be used to determine the objective value of the selected approach to the client.
The nursing issue selected for the project is the challenges experienced by mothers during the breastfeeding process. According to the consensus, the rates of initiation and continuation of breastfeeding in many high-income countries are inadequately low (Renfrew, McCormick, Wade, Quinn, & Dowswell, 2012). The negative impact of the issue is twofold. On the one hand, the mothers who do not possess enough knowledge to breastfeed successfully experience a range of problems that include physical pain, psychological discomfort, and undesirable social and cultural issues. On the other hand, and, perhaps, more importantly, the lack of breastfeeding harms public health, including the behavioral issues and challenges in education for the children that were not breastfed (Ericson et al., 2013). While breastfeeding mothers support and counseling have been considered effective in resolving the issue, it is necessary to obtain reliable data in support of these claims.
Application to Selected MSN Program Specialty Track
My MSN Program specialty track is a Family Nurse Practitioner. The responsibilities pertinent to the specialty include diagnosis and management of the common health problems, promotion of healthy living, and education of individual patients and families. The diversity of care provided in the primary setting includes breastfeeding issues and constitutes a high probability of encountering the problem in my future practice. By that point, it would be beneficial to identify the components of the intervention that could be applied to the issue and evaluate their relative efficiency to estimate the patient outcomes.
Resolving the issue of insufficient breastfeeding initiation and continuation is expected to impact the advancing practice in my specialty tracks in two major areas. First, the confirmation of the suggested approachs effectiveness would likely impact the choice of strategies available to the nurses for supporting the breastfeeding mothers. The breastfeeding support phone line is a highly specialized area and requires the allocation of resources and equipment for successful functioning. To obtain the necessary administrative support to introduce the practice, it is required to provide robust evidence of its efficiency following the principles of evidence-based practice. Second, the positive outcome of the project is expected to have numerous indirect effects. One of these is the overall improvement in the health of the patients, including the relief of issues such as breast pain and breast engorgement. By extension, the exhaustion and stress related to the problem will be decreased. Finally, a positive impact on child health can be expected, accompanied by respective improvements in behavior and academic performance. The combined effect of the said impacts will decrease the load on nursing practitioners, which is extremely important, considering the constantly growing population and an increasing proportion of aging patients. Thus, the issue is directly related to my specialty track.
Nursing Issue and Supportive Evidence Regarding the Issue
Breastfeeding is an important part of the childs development cycle, bearing multiple short- and long-term effects on their health and the health of the mothers. The areas of impact include child mortality, prevention of several gastrointestinal and respiratory diseases, childhood obesity and diabetes in children, and the increased risk of breast cancer and cardiovascular disease in adults (Forster et al., 2014). While the magnitude of the adverse impacts varies depending on several factors such as socioeconomic status, it is safe to conclude that the effects of not breastfeeding are universally negative across different population groups (Colen & Ramey, 2014). It is also important to understand that not breastfeeding bears significant considerations from the economic standpoint, primarily due to the high cost of care for the mothers and children who develop chronic conditions associated with the issue. Importantly, the lack of breastfeeding success cannot be attributed solely to the mothers individual decision as it is strongly dependent on previous experience and available knowledge on the matter. As such, it is reasonable to expect that sufficient support from women will aid them in the initiation and continuation of the practice.
The issue is relatively common in the selected practice setting. According to the CDCs data, only twelve states have met the objectives set for breastfeeding as a part of the Healthy People 2020 initiative (CDC, 2016). The most significant discrepancy is observed in the infants of six months or younger, where the current rate is just below fifty-two percent as opposed to the sixty percent set as a target (CDC, 2016). The difference is reduced with each subsequent age group, but several areas are still behind schedule in meeting the goals. It is also important to remember that the stated proportion is an aggregated result and that different states demonstrate varying results. It is also notable that the rates for breastfeeding after six months are universally lower, which suggests that mothers discontinue the practice despite the successful initiation. Therefore, it is possible to characterize the issue as relatively frequent in the practice area in question.
According to Renfrew et al. (2012), education is a crucial factor in determining breastfeeding success. Specifically, the greatest percentage of breastfeeding mothers received better health education and support compared to those that received no support at all (Renfrew et al., 2012). The accessibility to educational resources and counseling provided by healthcare organizations was considered another important determinant of success, with a positive correlation between the communitys resources and the rates of breastfeeding continuation (Renfrew et al., 2012).
Admittedly, support is a broad category that commonly includes delivery by a qualified nursing practitioner, the involvement of community organizations, one-on-one consultations, and dedicated educational events. Therefore, it would be reasonable to limit the scope of the project to proactive telephone support. One of the reasons behind this particular choice is the negative correlation between socioeconomic status and breastfeeding success, where disadvantaged women tend to terminate the practice earlier (Renfrew et al., 2012). Telephone-based consultations do not pose challenges in terms of financial accessibility. Their delivery can be adjusted to the time restrictions that commonly prevent mothers from engaging in other activities (e.g., community meetings). Therefore, it is reasonable to expect higher population involvement in response to the selected intervention.
The two main stakeholders involved are breastfeeding mothers and nursing practitioners. The former are impacted directly by experiencing a range of physical, psychological, and social issues identified above and indirectly by experiencing the health and behavioral disorders associated with discontinuation in the long run. The latter receive greater workload as a direct result of the issue and are required to provide extended care to mitigate the associated problems such as chronic conditions. Other stakeholders include healthcare organizations that face administrative issues resulting mostly from the long-term outcomes of the problem and the additional expenses and families of the impacted individuals who are strained financially and emotionally by the negative health outcomes. Finally, educational organizations are impacted by the long-term outcomes of the issue, such as the declined academic performance and disrupted behavior (Ericson et al., 2013).
The projects successful implementation is expected to clarify the effectiveness of the proposed support method and determine its applicability to nursing practice. As a result, it is reasonable to expect the increase in the number of breastfeeding mothers and, by extension, the decrease of the adverse public health effects. Also, the decrease in expenses associated with additional care, improved patient outcomes, and the minimization of excessive workload among nurses can be expected.
Evidence-Based Practice Question
In accordance with the information presented in the previous section, the following components of the PICO are proposed.
For the postpartum mother, would post-discharge breastfeeding support phone calls become an appropriate and appraised intervention that increases the breastfeeding success if compared with womens attitude to the traditional model presupposes no post-discharge support phone call?
Where the population is postpartum mothers, the proposed intervention is breastfeeding support phone calls. A comparison is a group receiving no post-discharge support phone calls; the outcome is the improved attitude preconditioned by the breastfeeding success.
Research Literature Support
The findings of the article by Borra, Iacovou, and Sevilla (2015) showed a very weak correlation between the distressed states of women suffering from postpartum depression and their breastfeeding patterns and activities. The main aim of this research was to investigate the correlation between postpartum depression and breastfeeding. Thus, the authors used the qualitative approach and surveys to conduct the study and prove the existence of the suggested correlation. The authors were limited by the number of participants; however, they collected credible data that contributed to the high relevance of results. Regardless of the large size of a sample, the findings did not show any significant connections.
The article by Carlsen et al. (2013) is aimed at investigating breastfeeding behaviors in a sample of obese mothers. Thus, they used the qualitative method to analyze the issue and provide reliable information about it. Therefore, the interview was used as the main data collection method. The authors fund that the length of breastfeeding did not affect the growth of infants but was in correlation with their initial size. Additionally, the researchers noted that the group that received support using telephone calls continued to breastfeed for longer periods than the control group that was given no such support. The comparatively small number of respondents was among the leading barriers that limited investigators; however, the believable character of findings is one of the central advantages of the study.
Figueiredo, Canário, and Field (2014) conducted another research with the main purpose of studying the impact of breastfeeding on the prevalence of postpartum depression. Their nature of the research question preconditioned the choice of the qualitative approach and the statistical analysis of the relevant data. The findings of this research indicated a correlation between the length of breastfeeding period and the rates of depression in mothers. In particular, it was detected that the women who continued breastfeeding for longer than three months postpartum also experienced a significant decrease in the magnitude of depression. The papers main advantage is the use of critical statistics and its implementation to determine the actual correlation. However, the investigators were limited in data that could be obtained from credible sources.
In other related research, Hatamleh (2012) aims to analyze breastfeeding patterns among low-income mothers. Using the clinical data and statistics in quantitative research, the author finds that a prenatal breastfeeding intervention is effective for increasing the length of the breastfeeding period.
Papathanasiou, Sklavou, and Kourkouta (2013) suggest another investigation with the primary purpose to examine the womens reaction to postpartum changes. The qualitative design of the study promotes the improved comprehension of the issue and contributes to the high relevance of data. The main advantage of the paper is the authors attempt to offer the framework suitable for the research because it allows studying and understanding participants behaviors from a psychological perspective.
Mitchell (2013) revolves around the change theory developed by Lewin. The main purpose of the research is to determine the theorys practical utility and opportunities for its application. The author conducts an in-depth investigation of the issue and concludes that the theory is suitable for the practical aspects of the research implementation as it breaks down the process into three major steps unfreezing, moving, and refreezing. However, the paper has particular limits from the lack of statistical evidence to prove the main hypothesis.
The article by Pope and Mazmanian (2016) has the main purpose of exploring the relationship between postpartum depression and the duration, dose, intention, and initiation of breastfeeding. The researchers adhere to the statistical analysis of credible data. They overviewed multiple articles using diverse methodologies and recommended that a set of standardized measuring protocols is created for the collection of transferrable and reusable data and that the variables used to measure and define breastfeeding are operationalizedthe paper benefits from the use of relevant information which could be considered its central advantage.
Jain, Tyagi, Kaur, Puliyel, and Sreenivas (2014) attempted to detect connections between the birther of girls, postnatal depression, and exclusive breastfeeding. For this reason, they used the qualitative approach design. The data was collected through a specific scale: the prevalence and levels of depression in women were measured using the Edinburgh Postnatal Depression Scale (EDPS). The authors found that women with higher depression scores were less likely to breastfeed within the first 48 hours postpartum. Additionally, male infants were exclusively breastfed within 48 hours of life in a significantly greater number of cases than female ones. The use of a particular tool to measure the most important showings is the main advantage of the paper as it helps obtain the relevant data and process it. The authors were limited by the number of participants in their research.
Abuchaim, Caldeira, Lucca, Varela, and Silva (2016) attempted to find relevance between maternal self-efficacy for breastfeeding and postpartum depression. In this regard, they conducted a qualitative study. Abuchaim et al. (2016) used a specific interview to collect the data and use it to prove the correlation between postpartum depression and breastfeeding. The researchers found that a high score on depression among the participating mothers was strongly associated with a reduced breastfeeding self-efficacy score. At the same time, the findings also showed that medium and high self-efficacy scores in breastfeeding women led to reduced depression scores by over 27 and over 38 percent, respectively. The advantageous character of the chosen data collection method contributes to the increased importance of findings, which are the main articles strength.
Brown, Rance, and Bennett (2016) researched the role of pain and psychical discomfort in the correlation between postnatal depression and breastfeeding. The researchers attempted to find whether physical difficulties in breastfeeding linked to the prevalence of postnatal depression come before or after the diagnosis. They used the quantitative design to investigate the hypothetic interdependence between these factors. In the course of the research, the authors reviewed the relevant literature to collect data. The authors found a significant correlation between the increase in depression scores and the discontinuation of breastfeeding due to the pain that it followed. It is important to note that many of the overviewed works used EDPS to measure the scores of postnatal depression in women, and thus managed to collect standardized sets data that can be used for further research in the field. This fact should be considered the paper strength as many other investigators could use it. However, the authors were limited in the number of works and patients used in their research.
Ahn and Corwin (2015) researched the issue of correlation between breastfeeding patterns and postnatal depression with the main aim to determine the impact these factors have on each other. The nature of the research preconditioned the choice of the qualitative research method, along with the interview to collect data needed for the investigation and provide final results. The authors found the visible correlation based on a self-report; however, it was noticed that the group of women who primarily breastfed had a lower level of salivary cortisol in the morning than the group of women who primarily bottle-fed their infants. The appropriate sampling could be considered the main advantage of the paper as it preconditions the high relevance of data. At the same time, the further increase in the number of participants is useless regarding the obtained results.
The central purpose of Sharma and Sharmas (2012) article was to provide a theoretical exploration of postpartum depression, its causes, and outcomes. For this reason, they used a mixed approach, which included both qualitative and quantitative methods. Sharma and Sharma (2012) investigated numerous cases along with patients reports to provide the conclusion. The authors noted that postpartum depression is difficult to diagnose and treat. It is critical to focus on its signs and attempt to prevent its aggravation and development because it is associated with some comorbid risk factors. Thus, the lack of self-reported data could be considered the main limit that impacted the research. Simultaneously, the combined approach contributes to improved outcomes and could be considered the main papers strength.
Gulamani, Premji, Kanji, and Azam (2013) explored the phenomenon of postpartum depression and the factors that can contribute to its prevalence to better understand the condition and identify the influences that need to be voided or minimized. They use a mixed approach to increase the credibility of findings. The authors agree with Sharma and Sharma (2012) and stated that regardless of the devastating effects of the condition, it is difficult to detect. Regarding the similarity of the research issues, the authors face the same limits Sharma and Sharma have experienced. Additionally, the paper benefits from its correlation with other research studies as it underlines the articles relevance.
Kao, Johnson, Todorova, and Zlotnick (2015) researched the influence of a group intervention to prevent postpartum depression. The choice of the research question promoted the use of the qualitative design to investigate the suggested phenomenon. Therefore, the authors distributed the survey among women who had the needed experiences. The researchers found that the women who undertook the intervention demonstrated a long commitment to breastfeeding even though the breastfeeding initiation rates were similar in both intervention and control groups. The comparatively small sample size could be considered the main limitation of the given study. The authors were able to collect data only among women with a particular intervention experience.
Montgomery-Downs, Stremler, and Insana (2013) linked new mothers decision to breastfeed as a significant factor that impacts their sleeping patterns and can contribute to sleep deprivation, which, in turn, may lead to the aggravation or development of postnatal depression. Thus, the research aimed to determine the correlation between breastfeeding and sleep patterns. The authors used a mixed approach to investigate all possible factors. In that way, it can be concluded that the relationship between breastfeeding (including its dose, length, initiation, and intention) and postnatal depression is very complex and can be interconnected with a variety of additional factors. However, the vague results are the main drawback of the suggested study as they demand further discussion and investigation.
Researching the association between exclusive breastfeeding and postpartum depression, Silva et al. (2017) found that postpartum depression resulted in the decreased practice of exclusive breastfeeding and concluded that due to this condition and its dangers, early postnatal support need to be included in care programs. They used mixed methods with the focus on the statistical data along with patients self-reports. The paper could be used to further investigate the issue because of the improved credibility of its findings.
Interestingly, the authors of the overviewed articles found a mutual connection between breastfeeding rates and the prevalence of postnatal depression. Practically, the lack of breastfeeding may lead to the aggravation of postnatal depression and, at the same time, postnatal depression may cause a decrease in the intention to breastfeed. As a result, the decision to continue breastfeeding is likely to produce a significant positive impact on new mothers. Thus it should be supported by the providers of early postnatal care.
Research Approach
The proposed research will be focused on the initiation and stimulation of breastfeeding in new mothers who have been discharged from hospitals. The intervention intended to stimulate breastfeeding intention in women will be delivered in the form of telephone communication between the providers of postnatal care and the new mothers for the provision of support to the latter so they could continue breastfeeding. The intervention is expected to last for six weeks.
The proposed research approach will be qualitative. It will aim to collect qualitative data from the participating new mothers regarding their attitudes to breastfeeding and the levels of self-efficacy of their breastfeeding practices. The phenomenological design will be selected for this study. This type of research design focuses on collecting subjective data from the participants to analyze the nature and development of the researched phenomenon or connection. In the case of the present research, the issue in focus covers the attitude to the suggested intervention among new mothers who are receiving support from the providers of postnatal care using telephone communication. The subjective experiences recorded with the help of phenomenological design will allow understanding the participants perceptions of the intervention and understand its effects.
The rationale for the selected design is based on the need to study the effects of the selected form of intervention and the participants attitudes to it. It is hypothesized that the intervention will improve womens mood by increasing the breastfeeding intention among the participants and lead to a more successful rate of breastfeeding in the intervention group compared to the control group. The main advantage of the selected design is its focus on the collection of subjective data. It provides a precise description of the participants attitudes towards the intervention and its effects. At the same time, the subjective data will also serve as one of the main disadvantages of the selected design because there exists the potential for the participants to provide biased, incomplete, or altered information which would not reflect the trust, and thus would undermine the reliability and validity of the research findings.
Sampling
The target population of the proposed study includes new mothers who have been discharged from hospitals. Probability sampling giving for all members of the target population an equal opportunity to be selected as participants will be used for the study. The sample will be selected from the population of the recently discharged new mothers from one or two hospitals in a specific geographic area. The women will be approached by their care providers and informed about the research and the intervention. Informed consent will be received from each of the participants prior to their inclusion in the sample; also, all of them will be assured that they are guaranteed to have full confidentiality and anonymity for their protection and safety. The first disadvantage of the selected sampling procedure will be likely to limit the sample to a small size making it under-representative. The second disadvantage is that some women may express the desire to be included in the intervention group or disregard the suggested intervention. The advantages include, first, the small sample which will make the collection of data faster and reduce costs of the study; and, second, the opportunity for researchers to focus on each participants subjective experience more thoroughly and collect more accurate data.
Methodology and Data Analysis
Describing the research methodology and data analysis processes are paramount for any type of research, as the chosen framework would determine the strength and weaknesses of the particular study. A flawed or incorrect framework could hinder the research efforts and distort the results, eventually leading to a wrong conclusion. This part of the research presents a complete framework for a phenomenological qualitative research design, which was deemed appropriate for exploring the phenomenon of self-perception of new mothers towards their skill in postpartum breastfeeding.
Type of Data
As it was mentioned in the previous sections of this research, the design of this study is qualitative, and its purpose is to collect and analyze subjective qualitative data from the participating young new mothers in regards to their attitude changes towards breastfeeding of the children, as well as the self-perceived levels of efficiency regarding their breastfeeding practices. This data will be collected via open-ended interviews and questionnaires so that the perceptions and phenomenology of the event could be thoroughly studied (Ritchie, Lewis, Nicholls, & Ormston, 2014).
Data Collection Process
The data collection process will involve interviewing new mothers on the subject of breastfeeding. It will consist of the distribution of questionnaires and phone interviews, as well as the processing and analysis of the data. The data will be collected two times the first set of interviews will take place prior to the proposed intervention in order to measure the current perceptions on the practice of breastfeeding from each individual that had agreed to participate in the research. The participants would be split into two groups: those who have experienced intervention and those who have not. The first data collection process would assist in assigning women to their respective groups. Optimally, both groups would have an approximately equal number of participants with similar views and experiences of breastfeeding. The second data collection process would help to measure the effectiveness of breastfeeding instructions received via telephone versus the results presented by women who use traditional approaches. Thus, the research design identifies two data collection points at the beginning and at the end of the research. While it is possible to add a third point of comparison somewhere in between, it will likely be unnecessary (Ritchie et al., 2014).
The estimated length of time for data collection would be one week prior and one week after the proposed intervention, which would continue for a six-week period. There is no point in continuing the intervention for a period longer than six weeks, as, by that time, it is expected for the majority of mothers to grasp the basics of breastfeeding. Prolonging the procedure would give the test group time to learn these basics on their own, without the support of qualified nurses, thus minimizing the changes in knowledge and attitudes towards breastfeeding between the two groups. One week is an acceptable amount of time to distribute the questionnaires and conduct interviews, as well as receive a response from the participants without putting unnecessary timely constraints both on them and on the researchers (Ritchie et al., 2014).
Data Saturation
As the research design for this study is qualitative and phenomenological, an important part of data collection is determining how many samples would constitute data saturation. Unlike with quantitative research methods, there is no clear number of how much is required, and the amount of processed data is usually determined by the convenience and data collection capabilities of the researchers. However, there are popular estimations for questionnaire types of research on the general attitude towards relatively narrow medical topics. According to Mason (2010), the mean sample size for similar types of studies is 31. As it is within our capabilities to increase that number to 40 samples, we will take that number to ensure data saturation. In order to represent all societal stratum in the scope of this research, an effort would be made to include the members of different economic and racial backgrounds into both participant groups.
Data Quality Enhancement Methods
In order to enhance the quality of data in a qualitative study, the most common and widespread method utilized by the researchers is the triangulation method. This method involves the diversification of the sources and methods used in data collection in order to provide a more detailed and potentially more accurate picture of the studied phenomenon. In the course of this research, there are ample opportunities for data triangulation. All three methods of data triangulation would be implemented in the following order (Silverman, 2015):
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Source triangulation. The data for this research will be collected from patients with different social and racial backgrounds.
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Method triangulation. While some participants will be asked questions in an interview, others will be required to complete questionnaires containing both open-ended and close-ended questions.
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Analyst triangulation. More than one person will participate in analyzing the data. Several groups of analysts will do so independently of one another and then compare the results.
Data Analysis
The data collected in the course of this research will be processed and analyzed two times the first part of the analysis would happen after the initial results from the first batch of interviews are received. The second analysis would come after the second batch of interviews is completed. The second analysis will also take the results of the first one into account in order to produce results. Phenomenological data analysis occurs in several stages (Miles, Huberman, & Saldana, 2013):
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