Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program

International Journal of Environmental Research and Public Health Article Barriers Perceived by Managers and Clinical Professionals Related to the Implementation of Clinical Practice Guidelines for Breastfeeding through the Best Practice Spotlight Organization Program Antonio Jesús Ramos-Morcillo 1, David Harillo-Acevedo 2,*, David Armero-Barranco 1,*, César Leal-Costa 1,* , JoséEnrique Moral-García3and María Ruzafa-Martínez 1 1Faculty of Nursing, University of Murcia, 30100 Murcia, Spain; [email protected] (A.J.R.-M.); [email protected] (M.R.-M.) 2Maternal-Pediatric Unit, Hospital Rafael Mendez, 30813 Murcia, Spain 3Physical Activity and Sports Sciences, Faculty of Education, Pontifical University of Salamanca, 37007 Salamanca, Spain; [email protected] *Correspondence: [email protected] (D.H.-A.); [email protected] (D.A.-B.); [email protected] (C.L.-C.) Received: 3 August 2020; Accepted: 26 August 2020; Published: 27 August 2020   Abstract: International institutions facilitate the contact of health professionals to evidence-based recommendations for promoting exclusive breast feeding (BF). However, the achievement of good rates of exclusive BF is still far from the optimum. The intention of the present work is to determine the barriers identified by managers and health professionals involved in the implementation and sustainability of Clinical Practice Guidelines (CPG) for breastfeeding under the auspices of the Best Practice Spotlight Organization program. A qualitative research study was carried out. The participants were managers, healthcare assistants, nurses, midwives, pediatricians and gynecologists. Semi-structured interviews were conducted which were transcribed and analyzed using the six steps of thematic analysis. Twenty interviews were conducted, which defined four major themes: (1) Lack of resources and their adaptation; (2) Where, Who and How; (3) Dissemination and reach of the project to the professionals; and (4) The mother and her surroundings. This research identifies the barriers perceived by the health professionals involved in the implementation, with the addition of the managers as well. Novel barriers appeared such as the ambivalent role of the midwives and the fact that this CPG is about promoting health. The efforts for promoting the implementation program should be continuous, and the services should be extended to primary care. Keywords: barriers; guideline; breastfeeding; clinical practice guideline; BPSO; nursing; science implementation; midwifery 1. Introduction The interest in the application of recommendations for promoting breastfeeding (BF) in clinical contexts appeared in the 1990s [ 1 ]. Since 1991, with the Baby-Friendly Hospital Initiative (BFHI), the WHO and the UNICEF have made contributions to motivate health organizations in the world to support BF through the implementation of 10 steps for successful BF [ 2 ]. More recently, public organizations and professional associations have also developed clinical practice guidelines (CPGs) for facilitating the contact of healthcare professionals to recommendations based on current scientific knowledge for promoting BF [ 3 , 4 ]. Even then, at the worldwide level, the 50% rates of exclusive BF are far from being achieved at 6 months after the birth of the infant, an objective set out by Int. J. Environ. Res. Public Health 2020,17, 6248; doi:10.3390/ijerph17176248 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020,17, 6248 2 of 18 the WHO for 2025, and the implementation of these recommendations has been inconsistent according to countries and even regions [2]. Starting with programs such as the BFHI or the implementation of CPGs for BF at the level of health organizations implies a complex process of change, since obtaining good results depends on multiple factors and is influenced by different types of barriers [ 5 , 6 ]. Knowledge about these barriers could help in the creation and implementation of guides, the design of effective interventions, and the planning of strategies that are more adequate for facilitating their use [ 7 , 8 ]. Research on CPG implementation barriers is highly documented. A systematic meta-review which included 25 systematic reviews published until 2017 [ 9 ] and three systematic reviews published posteriorly [ 10 – 12 ] underline as the main barriers the aspects related to: political and social context, such as lack of leadership and lack of coordination by the team; health organizational system context, such lack of staffing, and economic and time resources; clinical practice guideline context, such as recommendations that are not clear, and doubts about the quality of the evidence and rigidity; health professional context, such as lack of knowledge about the CPGs, negative attitude, and clinical inertia of practice and the belief that it is not part of one’s role; and patient context, such as lack of knowledge of the patients about the guidelines, the characteristics of the system and their illness, expectations that are contrary to the doctor’s, and lack of family support. The barriers highlighted in these systematic reviews are generally linked with the implementation of CPGs directed at interventions for the treatment of frequent pathologies and chronic diseases [ 10 – 12 ]. The studies on the implementation of CPGs of health promotion such as BF are less common, and have been mainly studied in environments of primary care and on aspects related to the prevention of chronic health problems and the implementation of practices related to lifestyle changes [13]. To date, studies related to the implementation of CPGs for BF have not been found. We only found a small number of studies that specifically studied the implementation of BFHI [ 14 ]. The barriers mentioned have some similarities with those specified in the literature about the implementation of CPGs mentioned in the previous paragraph, although with some their own specificities: involvement of the governments in the support of the BFHI, practices of the industry and legislation industry, lack of policies of BF support, contact routines with the mother and the newborn, the dependency of the hospital on infant formula companies, resistance in the promoting of BF due to the respect of the beliefs of the mothers, abuse of pacifiers, milk bottles, and scarce support from the families. The BFHI shares certain similarities with the implementation of the CPG for BF; their objective is the support and promotion of BF in maternity and newborn services through the implementation and recommendations based on scientific and updated evidence, and they also use models that guide the process of implementation and evaluate specific result indicators. However, the implementation processes of the CPGs have specific particularities; they are generally part of the implementation programs that have a greater reach within the institution, use implementation processes that are specifically oriented to the implementation of evidence and the guides contain a greater number of recommendations. These differences justify the specific study of the barriers experienced by the managers and health professionals involved in the implementation. On the other hand, despite the current knowledge about the existence of barriers related with the implementation of the CPG, it is unknown until what point the barriers suggested are common to those linked to the implementation of a CPG on breastfeeding. Thus, the objective of the present study was to determine the barriers identified by the managers and health professionals involved in the implementation and sustainability of a CPG for Breastfeeding in a medium-sized hospital in Spain under the auspices of the Best Practice Spotlight Organization program. Int. J. Environ. Res. Public Health 2020,17, 6248 3 of 18 2. Materials and Methods 2.1. Study Design A qualitative approach was used, and an inductive thematic analysis [ 15 ] was performed to discover the experiences and expectations of the participants. 2.2. Settings and Participants The study was conducted within the National Health System (Spain) in a 300-bed hospital. This center is not an accredited baby-friendly hospital. The Care Quality Department of the hospital prioritized the promotion of breastfeeding because the exclusive breastfeeding rate at discharge was only around 40%. In Spain, the rate of breastfeeding at 3 months is 72.4%. This hospital adhered to the Best Practice Spotlight Organization (BPSO ® ) Madrid, Spain, coordinated by the Nursing and Healthcare Research Unit of the Carlos III Health Institute (Investen-isciii), in collaboration with the Registered Nurses Association of Ontario (RNAO) [ 16 ]. Between 2012 and 2015, and following the BPSO ® program, five CPGs were implemented, one of them related to BF. The BPSO program includes multicomponent interventions for the implementation of the CPG. Among the different interventions, we find the training of the professional health workers, changes in the policies of the organization about breastfeeding, greater accessibility of the users, the creation of an exclusive breastfeeding room, etc. The implementation of the BF guide followed the conceptual framework adapted by the RNAO, the Knowledge to Action Framework (KTA), which is composed of six phases: (1) identification of the problem and (2) adaptations to the local context; (3) assessment of the facilitators and barriers; (4) adaptation and implementation of these interventions; (5) monitoring and evaluation of the results; and (6) sustainability. In 2015, the hospital was accredited as a BPSO ® hospital, and the sustainability phase began, which has been maintained until the present day. The participants in the study were managers involved in the BPSO ® implementation program and health professionals from the maternity and pediatric units at the hospital where the CPG for BF was implemented, included health assistants, nurses, midwives, pediatricians, and gynecologists. A maximum variation sampling method [ 17 ] was used to obtain highly rich heterogeneous information with respect to gender, age, professional profile and role (manager or clinician). All the participants had been working in the health services where the CPG was implemented during the period of implementation and sustainability (2012–2017). The total number of professionals who worked in all the services was 82. 2.3. Data Collection Semi-structured interviews were performed to obtain information, which were audio recorded and transcribed for their posterior analysis. The interviews took place between May and August 2017, and were given by the research team members (A.J.R.-M., M.R.-M., C.L.-C. and D.H.-A.), who had training and experience on interviewing. The participants who complied with the inclusion criteria were invited to participate, and a place, day, and time were agreed upon for the interviews. All the health professionals who were asked to participate accepted. A script (Table S1) with questions about the difficulties and barriers found in the implantation of the CPG was used, which asked for information from the most general to the more specific matters. A pilot study before the script was conducted as well [18]. The saturation criteria was applied to establish the number of informants needed [19]. 2.4. Data Analysis The sequence of 6 steps proposed for thematic analysis was used [ 20 ]: (1) Familiarizing yourself with your data; (2) Generating initial codes; (3) Searching for themes; (4) Reviewing themes; (5) Defining and naming themes; (6) Producing the report. All the authors participated in the thematic analysis and the interpretations of the results. The interviews were audio recorded, transcribed and imported to the qualitative research software MAXQDA version 12 (VERBI Software, 2015, Berlin, Int. J. Environ. Res. Public Health 2020,17, 6248 4 of 18 Germany) for analysis. The coding, themes and subthemes were agreed upon by the research team for their verification. When faced with discrepancies between researchers, these were resolved by consensus. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) [18]. 2.5. Ethical Considerations This research was approved by the research committee from the Health Area III from the Region of Murcia (ID: 002/2015). All the participants received an informational document about the purpose and process of research and participated voluntarily. They were allowed to ask and reflect before the interview, and their informed consent was obtained. Additionally, to ensure the confidentiality of the participants, the interviews were anonymized through the use of codes. 3. Results A total of 20 health professionals participated, aged between 28 to 62 years old. The interviews lasted between 23 and 71 min. The characteristics of the participants are shown in Table 1. Table 1. Characteristics of the participants and duration of the interviews. Participants * Gender Professional Profile Age Years of Professional Practice Duration of Interviews (Minutes) 20 2 Men 18 Women Hospital Administration: 3 Midwife: 5 Pediatric nurse: 3 Pediatrician: 1 Maternity Nurse: 3 Gynecologist: 1 Pediatric healthcare assistant: 1 Maternity healthcare assistant: 1 Delivery room healthcare assistant: 1 28–62 4–40 23–71 * To guarantee anonymity, the characteristics of each participant are not identified individually. Four major themes were identified: (1) Lack of resources and their adaptation; (2) Where, Who and How; (3) Dissemination and reach of the project to the professionals; (4) The mother and her surroundings. A detailed description of the themes and subthemes is found in Table 2. Table 2. Themes and subthemes. Themes Subthemes Lack of resources and their adaptation Physical resources Economic resources Human resources Lack of time Adaptation of the resources Where, Who and How Work context, attitudes, motivation and preferences We have always done it like this. Always the same thing: breastfeeding. Age Inter-professional perceptions Int. J. Environ. Res. Public Health 2020,17, 6248 5 of 18 Table 2. Cont. Themes Subthemes Dissemination and reach of the project to the professionals Dissemination Reach The mother and her surroundings Lack of preparation before the birth Close family and prior decisions Transversality: BF and it socialization, and immigration 3.1. Lack of Resources and Their Adaptation One of the main barriers identified by all the health professional categories and profiles involved in the implementation of the CPGs were lack of resources. Thus, we find barriers related to the lack of resources in three levels: physical, economic and human. 3.1.1. Physical Resources Part of the period of implementation of the CPG coincided with an important architectural remodeling period of the pediatric unit and delivery room (always within the period of implementation and with a duration of 11 months). The professionals have an ambivalent discourse about this period. The midwives and nurses indicated that the renovations were an obstacle, but at the same time recognized that in the end, the implementation of the guide was favored due to the improvement of the spaces with respect to those that existed previously. What happens is that in the provisional delivery room, well, we didn’t have space. E10. The hospital is doing things. In pediatrics, a parent room was created during the renovation so that they could stay, so I don’t see physical barriers. E7. Maybe the reforms have created them [limitations]. A lot of work has been done in the new structure. The division of the delivery room and maternity ward, having the resources dispersed too, could have slowed us down, so that we could not address the objectives well. E11. The different categories and profiles manifested that the institution was not prepared at the level of the infrastructures to be able to provide high-quality care before the renovations. We did not count with many structures or many resources for doing it, we adapted to the structures, the resources, to what we had. E1. On the one hand [barriers] that: the architectural barriers. E2. Not having space, . . . E3. Because if there had been a lactation room here in maternity, that would have helped a lot. An adapted room, where a woman could be with her child, that would help a lot. E4. 3.1.2. Economic Resources A group of barriers identified by the interviewees was related with the lack of economic resources. It was also observed how these economic resources were identified as necessary during the implementation or maintenance period of the CPG and not only as a one-time intervention. Well, I don’t know if I should venture in saying economic, but due to the period we were going through, without assistance. E13. I think that we were missing human, physical, and economic resources so that the guide becomes more important, or it’s going to stagnate. E4. Int. J. Environ. Res. Public Health 2020,17, 6248 6 of 18 Nevertheless, the managers believed that the personal interest was necessary, and that the implementation of a CPG implied savings for the organization. No clinician thought the same. I don’t think money is needed, what is needed is personal interest. E12. Really, the BF guide has even meant savings. Or it means savings for the organization. E1. 3.1.3. Human Resources The clinicians and managers, in all the professional profiles, manifested the lack of human resources. They indicated the existence of distancing between the efforts demanded from them and being able to do them, due to the lack of human resources. What happens? That there is also a human resources part. There is a lack of personnel. We are always lacking people. There is a lack of professionals. E6. More personnel is needed, let’s leave it at that, I’m not going to specify categories. E16. The professionals indicated that there was a relationship between failure in breastfeeding and the insufficient number of professionals. They identified that the support of breastfeeding had specific events that could not be delayed, linked to each mother and newborn, and that their availability for tending to them was not always there due to the lack of personnel, especially when there was a smaller number of professionals (at night, weekends). . . . if we had more people for the weekend, perhaps. Because everything happens on the weekend, although you want to go a room, you can’t . . . , then this person is left hanging, without help, many who do not breastfeed well, the baby does not latch well, problems start to occur, and this makes difficult the follow-up later on. E4. If you’re saturated with work, you cannot tend to the patient as you would like to. You are lacking human resources. E13. [lack of] personnel, maybe it’s true, you start and make sure that the baby latches, but if you have four to five mothers, you are who you are, not more. You can’t spend more time with one and not tend to the others. Another situation that implies a barrier is hiring during vacation periods, with substitute professionals and their characteristics. Then summer comes, with the hiring, not too many substitutions. Then the demotivation starts. E6. It is hard to motivate people who have not chosen to end up working in an area such as this, who are here not by choice but because he or she studied nursing. And the contracts are like that, they have ended up here . . . , then, motivating them is the hardest . . . I think they should be motivated in some way, making them understand that it is important because . . . that it’s one of their functions, just as in other floors they have other functions, here it is breastfeeding. E9. The lack of personnel is partly recognized by the managers, although at the same time they indicated that more personnel was available, and an investment had been made for this. Part of the managers, just as the clinicians, also recognized that if the professionals were asked to perform some interventions, then more resources were needed. If more personnel is solicited and they have not given it to you, it’s because they didn’t want to, I think, not because they could not. E1. Yes, they have added midwives in the morning for the maternity ward [ . . . ]. That has been done. E1. But humans yes, hands are needed. And also, when the professionals ask, if they want us to do this, then they have to give us the other [ . . . ]. And you know that the professionals were right and this tires you out. Giving an answer to the demands and you know that they are right. E1. Int. J. Environ. Res. Public Health 2020,17, 6248 7 of 18 3.1.4. Lack of Time The clinicians identified that the problem was the lack of time for performing interventions, and they linked it to lack of personnel. The managers think the opposite. I think the lack of personnel, but it’s the lack of time because there is no personnel. E15. You need time. Time to sit with the mother, [ . . . ]. The discharge we can do while on duty depends if there’s only one of us. If there’s only one, it could be that you can leave or not. We are lacking personnel. E3. Time was available. It has been facilitated, there have not been problems of time or equipment. E11. 3.1.5. Adaptation of the Resources On many occasions the resources were available, but their adaptation to the needs demanded by the implementation of the guide was necessary. Thus, we should distinguish the profiles of clinician and manager. The clinicians do not refer to this in a general manner; however, the managers attest that the process of data collection allowing posterior analysis has been complicated. This was pointed out as the starting problems of different degrees of implementation of the computer programs, different computer programs at different attendance levels, and bureaucratic problems faced to be able to obtain data that are adapted to the evaluation needs of the CPG. Well, it is a lot of work getting data from the computer program, especially because the services have their own clinical history . . . and we have had to ask the central services for authorization and help with getting these data out, as it was not possible through a normal exploration of data. E12. The extraction of data has been difficult. Getting used to recording the information to be able to get it and evaluate these data. This has not only been hard, but it is still hard. Our computer system does not allow for a smooth extraction of data. Obtaining the data has been the hardest. E1. 3.2. Where, Who and How This theme includes different subthemes that are intimately related and linked to the place where the implementation takes place and the characteristic of those who do them, as well as the relationships between them. This is how the barriers are described that are related to context, the characteristics of the professionals themselves and their relationships. 3.2.1. Work Context, Attitudes, Motivation and Preferences There are peculiarities of the work context that entail certain barriers. The interviewees point out that there is no system of formal recognition for the quality of the work performed. Since it doesn’t matter who does more or who does less, it you do more, you receive the same recognition. E7. Other barriers were the attitudes, motivation and preferences of the professionals. Also our attitudes, this past years, I didn’t care much about breastfeeding. E17. Yes, in the end it becomes something that you like, in the end it is a personal taste. E9. I need motivation, otherwise this becomes very monotonous. E4. Well, it depends on one’s interest, because there are people who don’t care about the subject of breastfeeding, or they don’t care about offering high quality care or anything else. I’m telling you like it is (laughs). E16. Int. J. Environ. Res. Public Health 2020,17, 6248 8 of 18 3.2.2. We Have Always Done It This Way Clinicians as well as managers have the opinion that there are people who do not update their knowledge and keep on performing their tasks as they did years ago. The history of this hospital is that is that for many years, the advantages of artificial milk were defended. They identified that it was difficult to achieve professionals changing their routines, and that some of these routines were perpetuated to younger professionals. There are people who say that the evidence, what’s that? We’ve always been doing this . . . nothing bad has ever happened, no child has died. E1. That from one day to another they tell you that what you’ve done it’s not right and that now that’s the best thing, when our mothers gave it to us, because they didn’t have money, we were breastfed. Of course, it’s hard . . . E10. We are still following erroneous health routines which makes so that the results do not change. Let’s see, some are young, but they are stuck with the old routines. There are a lot of young people who acquire the old routine from a colleague. And this is how it works, I don’t know, they question things. E20. Well, if someone comes with ideas, that are not new, and that’s what it is [evidence], and they tell them “and now you come . . . after I’ve been here for 20 years and seen all I’ve seen . . . ”. I think there are people who have been with the subject of bottles for 30 years, and now it’s not easy for them. E6. 3.2.3. Always the Same: Breastfeeding That breastfeeding plays such an important role is always pointed out by the managers as well as the clinicians as a barrier. They think that it is very repetitive, and that it has always had an important place in the training sessions. They are bored with the subject because they think of it as pounding information [on their heads]. They want to stress breastfeeding again, as if there was nothing else. E1. Sometimes we say, come on . . . more breastfeeding courses, we already know everything! Sometimes we complain, I’ve had it up to here with BF already!!! E4. 3.2.4. Age Among the personal characteristics, age has a very important role. The older professionals have a more relaxed attitude about BF. At the same time, their broad clinical experience is shaped by periods in which artificial breastfeeding “was beneficial”, and now they are living through a work period when natural breastfeeding is beneficial. Therefore, we are observing a closeness between scientific evidence and the young. They indicate that being older means less closeness with scientific evidence and vice versa. In this service, I think age has been an obstacle . . . Even when you have more experience and they can provide better advice because they have more life and professional experience . . . However, with the younger ones, they assume that when things come with evidence, they are good, you have to do them. E1. Well, many times I didn’t care as much, because as I was saying, I’m older. E10. [older professional] Let’s just say that I’m not very motivated, because it’s the end . . . you know? E10. The interest about formula and its benefits had been promoted for many years. E11. Int. J. Environ. Res. Public Health 2020,17, 6248 9 of 18 3.2.5. Inter-Professional Perceptions The clinicians perceive the responsibility of breastfeeding differently. Most think that the protagonism of BF comes from the midwife. The managers have a two-sided view. On the one hand, they have the same opinion as the clinicians, and at the same time they think that the nurses have gained importance, as compared to the doctors, in terms of the implementation of the BF CPG. It is a multi-disciplinary guide. What happens with the nurses is that we didn’t have any importance in them. Or in this BF process, the importance was held by other professionals, gynecologists, and pediatricians. Everyone recognized a role in this process, including the patients. But the nurses, no [ . . . ]. And the guide has given us a place. It tells us that we play a role and also an important role, they have to believe it and they have to assume it. E1. Yes, they are not equal. I feel that the midwives and nurses, for example, are not equal. E1. There are differences between services and between professional profiles. E20. Between the specialized nurses, midwives and us in pediatrics with the doctors, [differences] will always be there. Yes, of course, when there are midwives, the nurse calls the midwife from that floor so that she goes to the woman if she has a problem. But if the woman did not have any problem, you don’t have to wait for the midwife (she could be examining a woman or setting up a monitoring machine), you have to go. E2. That this is not only about the midwife, and the nurse. E8. It is very striking and unanimous how they highlight, both clinicians and managers, the lack of involvement of pediatricians, affirming the lack of involvement of pediatrics as a discipline itself. However, the clinicians did not evaluate this to be innocuous. Rather, they identified that in some occasions, the actions of the pediatricians wasted all the work that had been done previously to promote BF when they made recommendations that did not take into account BF. The professionals indicated that the recommendations given by the pediatricians were very much taken into account by the mothers. Of course, it is just that sometimes, if they are not involved, if you have some pediatricians and some gynecologists who are not involved with breastfeeding, it is a giant obstacle, because one word, one recommendation from them and all the work you have done before falls apart. E9. No matter if nursing and nursing assistants know something, if a pediatrician comes and gives completely opposite advice, what are you going to do? Are you going to discuss it in front of the woman? No. And who is the woman going to listen to? To the pediatrician, of course . . . E6. They, on the subject of breastfeeding . . . , the pediatricians do not become involved too much. E19. In general, the doctor profiles related with the promotion of BF, and to whom the CPG was directed, where not involved enough. This was even identified by the doctors themselves. Perhaps we the pediatricians are invited to the breastfeeding courses, but we ignore them and many times we don’t read the posters. They are for everyone, but we exclude ourselves. E13. The doctors, not at all. The doctors in this project are not involved. I don’t know what else you want. They have not wanted to become involved, they have thought of it as something for nursing exclusively. 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