Abstract Nurse-driven practice changes and breastfeeding exclusive rate in a post-partum unit.

by
Francisca Njoku, FNP, RN
MS, Lehman College, 2013
BS, University of Belize, 2006

Project Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
August, 2016
Abstract
Insert abstract here; it should be no more than one page. Abstract text must be double- spaced with no paragraph breaks. Describe the practice problem and why it is important to address. Identify the purpose of the project. State any theoretical foundations and/or conceptual frameworks,(if applicable. Summarize the key question(s) or goal(s). Concisely describe overall project design, approach, and any data collection/analysis procedures. Concisely identify major findings/ conclusions/recommendations (final project paper only). Summarize potential implications for positive social change. Here are some form and style tips: (a) Limit the abstract to one typed page; (b) maintain the scholarly language used throughout the project study; (c) keep the abstract concise, accurate, and readable; (d) use correct English; (e) ensure each sentence adds value to the reader’s understanding of the research; (f) use the full name of any acronym, and include the acronym in parentheses if you use the acronym again in the abstract; (g) do not include references or citations in the abstract; and (h) per APA style, unless at the start of a sentence, use numerals in the abstract, not written-out numbers. For more guidance on writing this paragraph, consult the Abstract Primer (available on the Center for Research Quality website).

Nurse-driven practice changes and breastfeeding exclusive rate in a post-partum unit.

by
Francisca Njoku, FNP, RN
MS, Lehman College, 2013
BS, University of Belize, 2006
Project Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Nursing Practice
Walden University
August, 2016

Dedication
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Table of Contents
List of Tables ii
List of Figures iii
Section 1: Nature of the Project 1
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Section 2: Review of Literature and Theoretical and Conceptual Framework 4
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Section 3: Methodology 5
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Section 4: Findings, Discussion, and Implications 6
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Section 5: Scholarly Product 9
References 10
Appendix A: Title of Appendix 12
Curriculum Vitae 13

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Section 1: Overview of the Evidence
Introduction
Breastfeeding has physical, emotional and economic benefits, and is considered very essential, indispensable and without substitute (Nathoo, Tasnim Ostry, & Aleck, 2009). The American Academy of Pediatrics and other health organizations recognized the advantages of breastfeeding and recommended that newborns be exclusively breastfed for the first six months of life (American Academy of Pediatrics, 2012). In spite of recommendations regarding breastfeeding, the campaign for breastfeeding has yielded little or no result at North Central Bronx Hospital (NCBH). A low breastfeeding rate is thought to be due to lack of involvement by registered nurses especially those of postpartum unit (Health and Hospital Corporation, 2014). When maternity nurses are educated about the benefits of breastfeeding, they will in turn educate, motivate and support mothers during the breastfeeding process. This paper proposes a DNP project directed at improving the breastfeeding rate at NCBH. It will also provide an overview of the project, a review of the scholarly evidence, and outlines how the project will be operationalized.
Problem statement
Despite the vast array of knowledge regarding breastfeeding and numerous governmental and nongovernmental organizations’ initiatives on breastfeeding, success in breastfeeding has remained abysmal in the organization. All efforts to raise the current 15% exclusive breastfeeding rate to 25% have not been successful. The main factors contributing to the failure to increase the breastfeeding rate include the lack of hospital practices that promote breastfeeding, and a lack of enthusiasm and compassion exhibited by the nurses (Seabolt, 2012). Another factor is the Community norm and belief that influences Breastfeeding.
Baloh, Uthical and Moon (2008), have posited that both the structure and the culture of an organization could be a challenge to evidence-based practice changes as is difficulty associated with managing stuffs in people’s head. NCBH as an institution has over the years accumulated practices and ways of delivery of healthcare that does not help or enhance breastfeeding. As mentioned elsewhere in this project, the practices of separating babies from their mother mothers, the use of healthy-baby nursery and stressed-baby care affects baby-mother bonding as well as initiation of breastfeeding (Lowellen and street 2010). Davis, Stichler and Poeltler (2013) have conducted a case study where educational intervention was integrated with best practices and clinical expertise for lactation support. To increase the breastfeeding rate, NCBH registered for the Baby-Friendly initiative (Ramatrishnan (2015, November) citing Breastfeeding, S. (1994). The initiative stated that it is important to increase the rate of newborns that are exclusively breastfeed and to decrease the use of supplemental baby formulas (Walls, 2015). Though there is no required breastfeeding rate to have a Baby-Friendly designation, the incorporation of certain practices that support breastfeeding is required in the hospital policy. Such approach includes practicing the ten steps to a successful breastfeeding (Robb, 2015) and (Lawrence, 2013). The hospital recently hired an International Board Certified Lactation Consultant (IBCLC) to support mothers who want to breastfeed. The breastfeeding consultant listens, offers advice that is unique to the individual situation, as well as empowers the breastfeeding mother to feel confident in her breastfeeding techniques (Flannery, 2014). The anticipation is that the Lactation Consultant will help train nurses on how to assist the mothers with breastfeeding difficulties, as well as playing a lead role in the journey to becoming a Baby-Friendly designated institution.
Nurses at NCBH have a huge job to do in term of increasing breastfeeding. Change is not easy and often times, change is resisted. The NCBH staffs have undergone a lot of changes recently. The addition of breast feeding initiative is another change some staffs are not willing to undergo right now. These staffs are not lazy but see the change as added work burden and extra source of stress. The change from postpartum and well-baby unit to couplet care, the implementation of the Golden Hour and breastfeeding in the first hour of life is viewed in a similar way. Therefore, approximately 95% of NCBH mother-baby nurses are not enthusiastic about breastfeeding. This lack of enthusiasm stems not only from the perceived increase in workload but also from inadequate educational preparation regarding breastfeeding, high patient to staff ratio, and the resistance from some postnatal mothers who are reluctant to breastfeed their babies. However, nurses’ attitude towards breastfeeding can still be influenced. Shinwell, Churgin, Shlomo, Shani, and Flidel-Rimon (2006) conducted a study that showed a 9% increase from 84-93% in breastfeeding rate when healthcare provider underwent an intensive breastfeeding course. Philip (2010) found that help from nurses and other healthcare professionals were needed to provide breastfeeding support especially among first time mothers. According to Keister et al (2008), structured breastfeeding education and breastfeeding peer support from nurses and knowledgeable peers, enhance breastfeeding.
North Central Bronx Community is populated mainly by African Americans, and the more recent immigrants from Caribbean, Jamaica and West Africa. Many of these people are from low income families and have a particular norm or even social stigma that is believed to militate against successful breastfeeding. In reference to this norm, Kaufman et al, 2010 stated that breastfeeding mothers felt embarrassed and ashamed of breastfeeding their infants in front of their family members. Race as well has been found to be a significant factor in Breastfeeding and according to Deenadayalan and Karpati (2010), many African American woman who do not breastfeed place higher value on formula than breast milk. The belief that formula is safe and has added nutrients is rampant in North Bronx Community culminating in the desire to receive free hand outs of baby formula. The Observation made by Kaufman et al (2010) that the belief in formula was much more entrenched through WIC programs which hand out free formulas holds true in the Community. Therefore the project seeks to discourage the distribution of baby formula in NCBH as a catalyst of improving breastfeeding (Nelson, Li, & Perrine, (2015).
The United States exclusive breastfeeding rate for the first six months postpartum in 2011 was 18.8% (Centers for Disease Control, 2015). This rate is far below the Surgeon General’s goal for Healthy People 2020 (Edelman, Mandle, & Kudzma, (2013). A goal for Healthy People 2020 is to have 81.9% of mothers’ breastfeeding their infants at hospital discharge (US Department of Health and Human Services, n.d). The breastfeeding rate of 15% at NCBH is not only below the national average but also falls short the objective of Healthy People 2020.
Purpose Statement
The purpose of this project is to increase the breastfeeding rate from 15% to 25% in NCBH mother-baby unit. The current rate of breastfeeding at NCBH is 15% and will be referred to as the baseline. This project proposes an increase of 10% from the current baseline through implementing practices that encourage breastfeeding. Beyond the achievement of the purpose, a long-term objective will be a successful pathway to earning a Baby-Friendly designation status (Breastfeeding, S. (1994).
Project Objectives
The objective of this project is to increase initiation of breastfeeding on all stable babies within one hour of birth. One hour period after birth is often called the Golden Hour and is very critical to the neonates in term of nutrition (Gams, 2015). There will be a least 10% increase from baseline in the number of mothers who initiated breastfeeding within one hour of birth. Thus, the objective will be deemed achieved with the increase from the baseline.
The project will also demonstrate an increase in the rate of skin-skin holding on all stable new-borns. Skin-to- skin holding helps in maternal infant bonding, provides the new born with necessary warmth and also accelerates breastfeeding initiation (Haxton, Doering, & Gingras, 2012). This objective will be deemed achieved if number or percent of mothers who perform skin-skin holding increases on discharge.
A third objective is to demonstrate an increase in the number of patients who are rooming-in with their babies. Rooming in, also known as couplet care, involves caring for both mother and her newborn in the same room (Beal, Dalton, & Maloney 2015). Rooming in has been noted to increase mother-baby bonding, provide warmth and increases breastfeeding initiation and duration (Davies 2015, June). The number of babies who will be roomed-in with their mothers for first 24-hours by hospital discharge will increase by at least 10% by the end of this project.
Demonstration of an increase in breastfeeding exclusivity is another objective of the project. An exclusively breastfeed baby refers to babies who are being feeding by their mothers with breast milk only (Joint Commission, 2013). It also refers to babies that solely derive their nutrition through breast milk (United States Breastfeeding Committee, 2013). Therefore by the end of the project, the number of babies who were exclusively breastfeed at the time of discharge by their mother or babies that obtain their nutrition exclusively from breast milk will increase by 10%.
Following an initial needs assessment of the target population, this project will develop and launch educational teachings/skill developments, and protocol changes. The project will use Kotter’s eight-steps of change model to affect the protocol changes (Appelbaum, Habashy, Malo, & Shafiq, 2012). Consequently the breastfeeding project will implement practice changes such as promoting immediate skin-skin holding on all stable newborns, increasing rooming-in and supporting mothers who want to breastfeed (Davis, Stichler and Poeltler (2013). Close attention will be paid to how these changes are to be implemented and their effects at increasing breastfeeding rate.
According to Nayir & UzuncarSili (2008), human-related factors, or interpersonal interactions, face-face contacts and close proximity are fundamental to the success of any evidence-based project initiatives. The project entails practice changes that need leadership and management interventions. Therefore, in order to achieve the project objectives, the support of these influential people in the organization is required. The management of NCBH will also help in influencing the mother-baby nurses to adhere to the above practice changes. There will be scheduled compulsory monthly meetings attended by at least 90% of post-partum staffs. All mother-baby nurses will receive published minutes to propagate skill development and practice changes. In addition to unit meetings, presentations on evidence-based breastfeeding studies will be done during grand rounds. Kothari, Hovanec, Hastie and Sibbald (2011) have suggested that current knowledge management in health care are concentrated on the use of information and communication technologies. Therefore, information and evidences on breastfeeding will be presented to the mother-baby nurses through one-to-one discussions, and intranet
APA level 3 heading. Significance/relevance to practice
Because of the short-and long-term medical and neurodevelopmental benefits of breastfeeding, the American Academy of Pediatrics (2012), has labelled infant nutrition as a public health issue, rather than a lifestyle choice. Neurodevelopmental outcomes have been known to improve by feeding infants human milk (AAP, 2012). A study conducted with children eight years of age through adolescence suggested that intelligence test results, brain white matter and total brain volumes are all greater in subjects who were fed with human milk as infants (America Academy of Pediatrics, 2012).
The Joint Commission (2010) and the New York State (NYS) Department of Health (2011) also require NYS hospitals to support breastfeeding exclusivity in order to maintain credentialing and reimbursement (Csont, Groth, Hopkins & Guillet, 2014). Fifty to seventy percent of NCBH practice revenue comes from NYS Department of Health (Muppalla & Capobianco, 2010). There will be no revenue to compensate the nurses if NCBH loses its credentialing and re-imbursement for services to low-income patients.
The current expectation of maternity services is to provide a high-quality, clinically effective and patient-centered care. High quality of care is not possible in the absence of evidence-based practice (Hyrkas & Harvey, 2010). Exclusive breastfeeding has been accepted as the most excellent way of infant nutrition. In a peer-reviewed research study to compare the risk for diabetes between breastfed infants 0-15 months of age and formula fed infants, Sadauskait, Kuehne, Ludvigsson, Padaiga, Jašinskien, and Samuelsson (2004) concluded that diabetes decreased in breastfed infants less than nine months of age. In a related development, breastfeeding also confers passive immunity to breastfed infants by allowing the infants to temporary acquire the mother’s immunity and are therefore able to fight infections (Davidson, London, & Ladewig, 2012). Also breastfeeding is estimated to prevent 13% of death per annual in children under 5 years of age that lives in low income countries (Mathur, & Dhingra, 2013).
Nurses have a professional obligation to coach or educate mothers to breastfeed. There is a need for intervention in nursing practice with respect to how to encourage mothers to breastfed. Hospital practices like couplet care, skin to skin contact and the readiness to assist mother-baby nurses will help to generate a Baby-Friendly environment that can translate to the community. The creation of a Baby-Friendly environment demands recognizing gaps in practice as well as offering a solution in the current nursing practice (Bartick, Stuebe, Shealy, Walker, & Grummer-Strawn, 2009).
The purpose of the DNP project is not to identify gaps in the body of knowledge like the Ph.D. research project (Zaccagnini & White, 2011). The DNP proposes to fix a gap in our practice given the available evidence. One of the reasons why breastfeeding is not initiated within one hour of birth in NCBH is related to our criteria for stable babies also known as “stress care”. NCBH classifies 17 maternal/infant conditions as high risks that requires taken the infants to the nursery. These infants who are thought to have hypoglycemia are deprived of the best evidence- based practice breastfeeding process. At the Nursery they receive heel sticks every hour and whenever the destrostick is below 50mg, they are formula fed. Rozance & Hay (2012), described hypoglycemia in neonates as mainly transient and correctible by homeostasis. Transient hypoglycemia in a neonate is normal and a physiological process as seen in all mammalian newborns even in high- risk neonates (Rozance & Hay, 2012).
Failure to practice skin-to-skin holding is another gap in the organization. The first hour of birth is the golden hour and a critical period for the neonate. The golden hour should not be interrupted with routine care, such as weighing, foot printing and eye care, provided mom and her newborn are stable. Skin-to-skin contact (SSC) at birth is correlated with reduced crying, grimacing, improved bonding, thermoregulation as well as the initiation of breastfeeding (Haxton, Doering, & Gingras, 2012).
Rooming-in will allow the dyad to learn each other and will also promote breastfeeding.The implementation of the practice changes will bring a change in attitudes, policies, transformation of organizational culture through the evidence-based practices. The improvement initiative will help improve breastfeeding rate and earn the organization the Baby-Friendly designation. Nurses would then be champions of preventative health for both mothers and their newborn.
APA level 4 heading. Project questions
Given the proposition of educational assessment, skill development and practice changes by the project leader, the project question becomes clearer. “Does a change in skin-skin holding, rooming-in and decreased use of the nursery increase breastfeeding rate in the mother-baby unit”? An increase in the breastfeeding rate in this case means an increase in the number of mothers initiating breastfeeding immediately after birth and exclusively breastfeeding their babies at the time of discharge.
.
Evidence-based significance of the project
Basic science, clinical knowledge, and expert opinion all provides some kind of evidence. However, clinical decisions about breastfeeding that is based on research findings are more likely to result in desired patient outcomes across various settings and geographic locations (Youngblut & Brooten, 2001). Breastfeeding is known to protect infants from common diseases that bring them to the medical office (Bonuck, Arno, Memmott, Freeman, Gold, & Mckee, 2002). Data suggests that breastfeeding’s protective effects are greatest for otitis media, respiratory infections, and gastrointestinal (GI) illnesses (Bonuck et al., 2002). These conditions are referred to as ‘breast-feeding-sensitive morbidities’ and are the most common reason for pediatrics office yearly visits (Bonuck et al.).
. Kramer et al. (2001) discovered that skin rashes and atopic eczema in breastfed infants in the first year of were significantly reduced by 46% compared to a control group who did not breastfeed. Atopic eczema is associated with increased incidence of asthma among children. Asthma affects six million children in America (Thomas et al., 2009). The consequences of asthma admissions among children includes: loss of school and work hours, decreased quality of life, hospitalization, frequent emergency room visits and deaths (Thomas et al., 2009).
Mothers may also be attracted to the benefit of breastfeeding to themselves. Weimer (2001), in his seminal study, concluded that if 90% of new mothers had six months of breastfeeding exclusivity, 911 babies would be saved, and breast cancer among women reduced. Attempted breastfeeding and the duration of breastfeeding are linked to a reduction in breast cancer, especially for the woman who has the BRCA 1 mutation genes (Kotsopoulous et al., 2012).
Osteoporosis is a major health problem affecting approximately 10 million Americans (Kling, Clarke, & Sandhu, 2014). Casey (2015), found a reduction of 86% of postmenopausal low trauma fractures and bone fragility in mother who breastfed compared to those that did not. Bone fragility causes bone deformity as well as poor postures in post-menopausal women. The treatment of osteoporosis is also complicated and has a long- standing therapy. Treatment of osteoporosis ranges from hormonal replacement therapy (HRT) to bisphonate drugs and calcium replacement (Casey, 2015). These medications are not only expensive, but the inconveniences of being on long-term therapy results to non-compliance Significance of the project
Implications for social change in practice
Breastfeeding as a form of nutrition has lacked acceptance and recognition in public places. In 2014, Pope Francis drew worldwide attention when he instructed mothers to breastfeed their hungry babies in church. He encourages mothers to breastfeed their young without thinking twice because they are the most important people (Sky News as cited in Francome, 2015). As Bradbury-Jones and Taylor (2014) notes, social impact means changes in people’s way of life, political systems, community, and health practices. Change in people’s life here means changing the attitudes and beliefs of nurses towards breastfeeding as well as changing the mother’s awareness to accept breast milk as the best infant nutrition. Change in people’s life will ultimately translate to change in Community and the entire society.
The difficulty encountered in societal changes due to years of accumulated non- evidence based norms and prejudice is also seen in North Bronx Community. These non-evidence based norms and prejudice are also seen in patients that patronise NCBH. Changes in community practices are therefore very essential. Also NCBH is much politicized institution where people want to hinder any good change in practice that is not initiated by them. Thus, the very nature of the Community and the Hospital environment posed barriers to implementation of a change and much difficulty to the project. Therefore, efforts to implementation of a change are geared towards that factor. Many patients from North Bronx community feel that they are entitled to free samples. The free provision of formula by the Women, Infants, and Children (WIC) department has encouraged mothers to prefer formula feeding to breastfeeding. Since organizational changes translate to the Community, change will be evidenced by the better use of human resources.
NCBH has recently required the services of more mother-baby nurses due to the practice of keeping well babies in the nursery. When there is a minimal or no use of the nursery, nursery staffs will be pulled to work in the post-partum unit such that the over-all workload will be reduced because the mother and her infant will be taken care of as a unit. Post-partum mothers long to be with their babies and often frustrated when they are not able to do so.The frustration most of the time are directed towards the mother-baby nurses. Caring for the mother-baby dyad improves nurse-patient relationship.
The social benefits also extend to the community and family units. Breastfeeding is convenient, saves money, prevents environmental pollution and gives room for the family union. It reduces health care cost through money saved from a lower rate of employee absenteeism as the parent will no longer leave work due to the illness of the child (Weimer, 2001). The prevention of childhood diseases through breastfeeding, cause a markedly decreased in work absenteeism.
While exclusive breastfeeding could save 800,000 of children under the age of five from death in a year, the economic waste associated with commercial baby food is also enormous (Holla, Alessandro Iellamo, Gupta, Smith & Dadhich, 2015). In 2013, US58 billion was spent on commercial baby food including milk formula (Holla et al.). The money spent on formula can be used to care for post-partum mothers, improve obstetrical services as well as hire more breastfeeding consultants.
Definition of terms
The following definitions will be used in this breastfeeding project:
Exclusive breastfeeding: The process by which an infant is fed only on breast milk, excluding water, other liquids, and solids, with the exception of oral rehydration solution, drops/syrups of vitamins, minerals or medicine (WHO, 2015).
Human milk: Milk produced by a human female breast after childbirth as a nutrition for her infant (MedicineNet, n.d).
Baby-Friendly: “Baby-Friendly” is a designation a maternity site can receive by proving to external appraisers’ the facility’s compliance with the Ten Steps to Successful Breastfeeding (Philipp & Radford, 2006).
Evidence-based practice: Evidence -Based Practice (EBP) is the principle used in clinical decision to provide care based on individual perspective, clinical expertise and the best available research evidence (Phillips et al., 2013).
Mother-baby dyad: Two individuals or units considered as a pair, such as mother and her newborn (Medical Dictionary, n.d)
Skin-to-skin (SSC) care holding: “SSC is defined as the placing of the naked newborn prone on the mother’s bare chest at birth or soon afterward” (Puig & Sguasseron as cited in Haxton, Doering & Gingras, 2012, p.222). SSC is also done after the first hour of life.
Rooming-in Care (RIC): A hospital stay system whereby a mother and her newborn are kept together in one room for the duration of their hospital stay (De Faria, Magalhães, & Zerbetto, 2010).
Hyperbilirubinemia: A common term that refers to an elevated bilirubin level resulting in a jaundiced skin, and often necessitating phototherapy or exchange blood transfusion (Brethauer, 2010).
Assumptions
For the purposes of this project, it is assumed that evidence-based practice preventative health based on individualized care, breastfeeding support, protection, and promotion are the foundation of nursing practice. Additionally, the project’s presumption is that an effective nurse-driven practice change furthers advancement of the nursing profession. However, no assumption is made that the mere existence of breastfeeding knowledge drives practice changes, aids in breastfeeding promotion as well as support mothers to breastfeed their young.
Another assumption is that the lactation consultant will be effective and help the institution to improve their breastfeeding rate. It is also a supposition that the nurses will work and support the mothers to breastfeed. The project also presumed that the mothers and their significant others will be willing and interested in the breastfeeding process.
Limitations
The high patient census and a high patient to staff nursing ratio has led to a critical problem for transitional nursing, rooming-in and breastfeeding support. Staff nurses have faced challenging situations that have left little time for the extra effort and commitment needed for breastfeeding support. The short time frame of the project might affect its generalizability.
NCBH patients have known the hospital as a place where formula and breastfeeding are propagated together. A well-known term in the mother-baby arena is “I will do both”. Hence a different approach of exclusive breastfeeding will be a new phenomenon that will be a foreseeing limitation. The free samples of formula from WIC may also discourage the mothers in this community from exclusively breastfeeding even when they have information on the benefits of breastfeeding.
Summary
Practice changes have been proposed and advocated during the early postpartum period to increase breastfeeding rate and make NCBH a Baby-Friendly institution. These changes include skin-skin contact, early initiation of breastfeeding, rooming-in, minimal use of the nursery. The project will change any practice it identified that does not facilitate breastfeeding exclusivity. This project aims to implement the practice changes and note their effects on the breastfeeding rate at NCBH.
Section 2: Review of Literature and Theoretical and Conceptual Framework
Specific literature
Skin to skin or kangaroo care, transitional nursing, early initiation of breastfeeding, rooming in, hypoglycemia, practices that increase breastfeeding rate, were used in conducting a comprehensive literature review. These keywords and phrases were searched both as individual terms and in combination using PubMed, CINAHL Plus with full text, AHRQ evidence reports, Google scholar and Cochrane databases. Other databases searched include, American Academy of Pediatrics (AAP), American Academy of Breastfeeding Medicine (AABM), Association for Women’s Health Obstetrics and Neonatal Nurses (AWHONN). American Academy of Obstetrics and Gynecology (ACOG) and Baby-FriendlyUSA position statements were also searched. The selected resources were peer- reviewed journals published between 2010 and 2015. John Hopkins Nursing evidence based Practice Appraisal (JHNEBP) summary tool (Newhouse, Dearholt, Poe, Pugh & white 2007) were further tool used to scrutinized the data and finally were selected as evidence by their high quality, rigor and versatility. This publication will be further evaluated and summarized into tables
In a thirty-four randomized controlled trials involving 2177 participants, Moore (2012) of Cochrane database concluded that skin-skin contact is a psychophysiological process pertinent to future physiology and behavior. There was statistic significant of early SSC on breastfeeding with a 95% confidence interval (CI) 1.06 to 1.53 (Moore, 2012). The intervention benefited breastfeeding outcomes, cardio-respiratory stability and decreased in infant crying. Factors such as infant crying are one of the reasons why mothers demand a formula feeding, crying, therefore, hinders breastfeeding overall. Babies exposed to skin-skin contact interacted more with their mothers and cried less than babies receiving usual hospital care. According to Moore (2012), mothers were also more likely to breastfeed the first one to four months of post-partum period. An additional study conducted by Bramson et al. (2010), Exclusive breastfeeding was higher in mothers who had skin-skin contact for 1 to 15minutes with a 95% confidence interval (CI), 1.189-1.593, 16 to 30minutes, 95% CI, 1.468-1.888, 31 to 59 minutes, 95% CI, 2.061-2.695, and more 1 hour 95% CI, 2.905-3.405. Bramson et al. (2010) therefore, concluded that there is a dose-response relationship between early skin-skin contact and breastfeeding exclusivity. Skin to skin contact allows for several physiologic benefits that all contribute to maternal- newborn bounding during the postnatal period. Skin to skin contact, also known as kangaroo care between the mother and newborn has been shown to be associated with wide variety of physical and psychological benefits for both the newborn and mother (Brimdyr, 2011). According to Price, Warmer, Tribett & Carpenter (2015), skin to skin contact between the mother and newborn provides improved infant temperature, more stable glucose regulation, and increased maternal bounding
Literature relating to breastfeeding rate increase and rooming -in were reviewed. Rooming in has mother-baby care, couplet care and family-centered maternity care among others as its synonyms. Beal, Dalton, & Maloney (2015) citing Philips (2003) stated that 2 of Philips 10 principles of family-centered maternal care are of particular importance. Those principles are encouraging mothers to keep the baby with them at all times and having the same person caring for the mother- baby couplet as a single family unit. They also added that nurses should be embracing mother-baby couplet care because evidence shows benefits not only for the mother, babies, and families but nurses as well (Beal, Dalton, & Maloney 2015).
Rosen (2015) talked about United Methodist Health Ministry Fund supported five hospital care practices that support breastfeeding. The practices include (1) immediate and sustained skin-to-skin contact between mother and baby after birth. (2) The newborn infants are given no food or drink other than breast milk unless medically indicated (3) practicing rooming-in (4) giving no pacifiers or artificial nipples to breastfeeding infants, (5) and providing mothers options for breastfeeding support upon discharge. They limited the use of these strategies for medically stable term infants to improve initiation, duration, and exclusivity of breastfeeding. Rosen (2015) went on to state that family education was a real barrier to successful implementation of the processes early in the study. Facilitators of Breastfeeding are family-centered prenatal education, community-wide education and collaboration. Others are in hospital bedside patient education, and utilization of breastfeeding follow up clinics. These measures can accomplish management of patient and family members (Rosen 2015). Both duration and exclusivity of breastfeeding can increase through the reduction of barriers to in hospital breastfeeding (AAP, 2012; DHHS, 2011).
Davis, Stichler, and Poelter (2013) in their study at a California Hospital described methods to increase the rate of exclusive breastfeeding. They advocated educational intervention integrated to best practice and clinical expertise for lactation support. Guided by Baby-Friendly USA (2013), educational initiative, the study reported exclusive breastfeeding rate increase from 53%- 70.4 % one year after completion of a change project.
Most literature also portray the immediate postpartum period as very vital. Such terms as transition period or golden period have been used to describe it. Himani, Kuar and Kumar (2011) researched the effect of initiation of breastfeeding within 1 hour of delivery on maternal-newborn bounding. 218 dyads enrolled with a control of 109 dyads that initiated breastfeeding 1 hour after birth and the experimental group which consisted of 109 dyads that initiated breastfeeding within 1 hour after birth. Maternal bonding was assessed at 24 and 48 hours after delivery using John Condin and Carolyn Corkindale’s Maternal Postnatal Attachment (MPA) scale. The control group at 48 hours after birth had an MPA score of 74.5 whereas the experimental group had a score of 83.3. This result indicated a significant difference and the research team recommended initiation of breastfeeding within 1 hour of birth, whenever maternal and the newborn health allows, to promoting optimal maternal- newborn bonding. Himani, Kuar and Kumar (2011) further suggested that bonding occurs because breast milk has similar smell to amniotic fluid which the new has been sensitized to detect.
Kayla Johnson (2015) found mothers who initiated breastfeeding within the first 2 hours after birth seemed more content and confident in their parenting abilities at one year of birth. Importantly, this transition process, which routinely separated well newborns from healthy postpartum mothers for admission care, had the potential to interfere with bonding and breastfeeding success (Bittle, Forward and Power 2015).
Magri and Hylton-McGuire (2013) conducted a study of change in care delivery model for maternity practices in New York State Regional Perinatal Center.This study detailed barriers and solutions to support exclusive breastfeeding. Both current processes and best practices investigated including obtaining pre and post change data with a result showing an increase of between 6%-44% after necessary, evidence-based practice (EBP) change were made. Those changes were in leadership support, education, staff involvement and data reporting (Magri and Hylton-McGuire, 2013).
Rounding is a practice of visiting patients every hour and offering care within a standardized protocol (Halm, 2009). It has been like autonomous intervention and surveillance mechanism to keep patients safe and comfortable by proactively meeting their needs (Halm, 2009). It has demonstrated positive evidence, as a postpartum Mobility assessment and as a tool for implementing changes though rounding itself is beneficial as changes in patient rounding frequency has shown. Nurses at the bedside can be empowered to initiate evidence – based approaches to improving outcome and quality of life for the mothers and their families (Clapp, 2015). Nicolas, Crow & Balakas (2015), posited that reviving and sustaining Family-centered care needed incorporation of observation and feedback from family advisors. A consistent process of rounding and education for team members about expectations for participation were also needed. General literature
The review includes other relevant articles that are not specific to increasing breastfeeding rate. The American Academy of Paediatrics (AAP, 2012) released a position statement and recommended that infants be fed only breast milk for the first six months of life. This paper also recommended continuation of breastfeeding with supplementary nutrition for the whole first year of the infant’s life because of the many benefits of breastfeeding. This recommendation has not been adhered to in many places due to barriers of all sorts. A study by Palaniapian, Feldman-Winter, and Knapp (2010) found some barriers to breastfeeding like pain, latching problem, milk supply and misinformation easily corrected. Barriers like lack of self-efficacy, lack of desire, return to work issue are difficult to correct. These researchers also found that African American women reported easily correctible barriers 23% of the time when compared to non-African American women who reported them 42 % of the time. Lack of desire was reported by African American women 55% of the time as reason for not breastfeeding their babies and therefore bringing up the racial-cultural angle to breastfeeding barriers Palaniapian et al. (2010).
Having said this, the authors that propagated the benefits or studies on breastfeeding have failed to suggest how breastfeeding practices can be successful or established. It takes a mother to know about the benefits of breastfeeding, but it takes an effort and a compassion for a nurse to be patient, educating and mentoring these mothers to successfully breastfeeding their newborn. Davis, Stichler and Poelter (2013) explained ways to increase breastfeeding exclusivity by using educational intervention integrated with best practice and clinical expertise (Davis et al., 2013). The data examined here was exclusive breastfeeding rate. At the end of the study, an increase in exclusive breastfeeding rate from 53% to 70.4% at one -year post intervention was observed. These case studies significantly demonstrate the importance of registered nurse (RN) educational and support values to post-partum mothers.
Kervin, Kemp, and Pulver (2010) conducted a research on whether professional support increases BF in 160 women that gave birth within a 3 months period. The researchers used interviews at birth and at 3 months postpartum to measure breastfeeding support as a dependent variable, and breastfeeding behaviors as independent variable. The study concluded that while 82.9% intended to breastfeed, 77.4% actually breastfed in first 24 hours after birth and 69.5% breastfed till discharge from hospital (Kervin, Kemp, & Pulver, 2010). The study though significant has implication for future studies because it excluded types of support that either facilitates or creates barriers to breastfeeding.
Carling, Demment, Kjolhede, and Olson (2015) conducted a prospective observational study of 595 obstetrics population in rural central New York. The purpose was to determine whether infants with a higher obesity risk were more likely to be a members of a rising weight- for- length (WFL) z score trajectory if breastfed for shorter durations ( Carling, Demment, Kjolhede, and Olson (2015). They identified weight for infants (WFL) Z score 0-24 months by using maximum latent class models. Individuals with risk factors (p< 0.05 were included in obesity risk index. Logistic regression were performed to investigate breastfeeding at <2, 24,>4 months and weight trajectory across obesity risk factors (BMI, education, and maternal smoking during pregnancy). The result shows that high risk infants breastfed for < 2 months were more likely to belong to a rising rather than a stable weight trajectory (odds ratio, 2.55% CI 1.14-5.72 p=0.02). Carling, Demment, Kjolhede, and Olson (2015) therefore concluded that infants at highest risk for rising weight patterns appears to benefit the most from longer breastfeeding duration than infants with lower obesity risk index.
Baby-Friendly USA have promoted the idea of “Baby –Friendly” institutions for some years now. The organization recommends that hospital could earn “Baby –Friendly” status by improving on breastfeeding initiatives. They advised that hospitals should initiate programs and policies about breastfeeding. They also recommend that hospital staffs know about breastfeeding and train their staffs in such programs. As good a breastfeeding might sound, most studies done on breastfeeding are mainly observational cohort and systematic reviews. Thus, it questions the methodologic issues of quality and sometimes the size of the population (American Academy of Pediatrics, 2015).
Concepts, Models, and Theories.
Many related concepts, models and theories informed this project. They are current approaches on increasing the rate of breast feeding. The Pierre Bourdieu’s key theoretical concept, health belief model, theory of planned behavior, agenda setting theory, advertising theory, social expectation or social norms theory, diffusion theory, and Kotter theory just to mention but few. The Bourdieu’s concept of habitus is his unique way of showing the embodiment of social arrangements and past in persons. Human beings perceive and act according to their social experience (Power 2014 & Amir 2014. In Health belief model, providers use the principle of health belief model to encourage mothers to breastfeed (Rosenstock (1974) whereas in diffusion theory features birthing centers and baby-friendly hospitals were exclusive breastfeeding are done. As more people use these facilities, breastfeeding ideas begin to diffuse into the wider society and eventually become norms (Gladwell 2000).
Social expectation or social norms theory involves television, radio and print advertisement that portray breastfeeding in a way that make the practice a natural and normal part of everyday life (DeFleur & Ball-Rokeach 1989). Government and other agencies can use the advertising theory to make effective breastfeeding campaigns. Advertising theory has promise, support and core values as its three main basic concepts (Ogilvy 1964). Agenda setting theory help government agencies facilitate laws and regulations to support breastfeeding mothers and families (McCombs 1982).
Another useful theory is the theory of planned behavior (Donnan et al., 2013; Duckett et al., 1998; Giles et al., 2014; Janke, 1994; Kim, 1998; McMillan et al., 2008; Swanson & Power, 2005; Wambach, 1997) derived from the theory of reasoned action (Ajzen & Fishbein 1991; 1980) and posits that the strongest predictor of behavior is one’s intention. Intention is influence by one’s (1) attitudes toward the behavior, (2) subjective norms, and (3) perceived behavioral control (Smith, 2014).
A relevant theory to change and improve behavior or practice shown to be useful in breastfeeding projects is Kotter theory, a leadership model with wide applications (Marshall, 2014). Dr. John P. Kotter is a professor of leadership Emeritus at Harvard Business School that spent over 3 decades examining changes, looking at what promotes and impedes successful organizational change (Marshall, 2014). Kotter considers that organizational change can be managed using a dynamic, nonlinear 8-step approach (Campbell, 2008, Wilda, et al. 2011).These approaches are establishing a sense of urgency, forming a powerful coalition, creating a vision, and communicating the vision. Others are empowering people in the organization to act on the vision, planning for vision short-term performance improvements, consolidating improvements to produce more change and finally institutionalizing new approaches (Kotter, 1995). Kotter theory was derived from expansion of Lewin’s theory (Mc Ewen & Wills 2011). This theory posits change to be a campaign for Change management and was eventually used by Agency for Healthcare Research and Quality (AHRQ) in 2013 as the basis for the development of the training TeamStepps (AHRQ, (2013). He divides this model into three district steps.
Selection of Kotter change model was informed because unlike others it will enable us to gain insight and wisdom from experts in the change process from the business industry. It has the ability to be continuously adaptable at each critical step of the process. Thus Kotter change model was selected to guide and support behavioral changes necessary to promote success of implementation process (Marshall, 2014).
Theoretical Framework
The framework selected for this project is Kotter’s eight-step change model (Wilda, et al. 2011). Kotter’s eight-step change model was propagated in 1995 (Kotter, 1995).The urgency and the need for change are in recent studies about the benefits of breastfeeding. Jody and Godfrey (2009) are of the opinion that there is a necessity to set the stage by acknowledging that breastfeeding represents a complex process of interaction between mother and baby that is far more than nutrition. They stated that “breastfeeding is about creating a new person: immune system, brain function, socialization, and long-term health” (p.1307). There will be a discussion about articles, evidence, hospitals that have achieved baby-friendly status in small and large group meetings in the unit.
The establishment of a sense of urgency will lead to the formation of a powerful coalition that will guide and lead the change. This coalition will work as a team and as a point of contact for other registered nurses. A group of four nurses will be named breastfeeding champions, these nurses will be there as a support group, making sure that skin to skin is done, rooming in is in palace and that infants latch on the mother’s breast within first one hour of birth. Also, doctors and midwives will be part of this coalition. The coalition groups will help to propagate the organizational vision. The coalition will also work with the vision of increasing breastfeeding rate and ultimately earning the baby-friendly status. During this period of vision propagation, everyone’s concerns, obstacles, suggestions, and vision will be addressed. Meeting everyone needs, will help to broaden the vision and people will take it as their project and intervention. There will be a thorough discussion of Breastfeeding ideas in repeated and consistent communication. By making nurses aware of the vision and constant reminder, they will be able to gramps the vision in its fullness. Communication also involves being a role model and available to answer any question. Breastfeeding awareness can also be in different media formats such as posters, pamphlets, texts, interrupt emails and promotional messages and vision aids will help in establishing the vision of breastfeeding exclusivity.
Other stages of Kotter’s model of change are summated in empowering people in the organization to act on the vision. These will involve removing every obstacle that will hinder the change, creating new things in the system that will enable the change to take place. When we achieve the vision, the key players of the vision will be recognized and honoured. The team will also consolidate positive change result in order to produce more change. Credibility and confidence will be built among the staff as they are empowered to recognize that change has come.
The final stage of Kotter’s change model is the institutionalization of the new approaches. Nurses will be seeing doing more kangaroo care, helping mothers to put infants to the breast as well as practicing more rooming-in for mothers and babies. Practices and innovations will be put in place to continue with this period of successful implementation. This is to make sure that the improvement initiative stays until it becomes “in this organization we practice exclusive breastfeeding and do not allow bottle feeding expect is necessary”. Monitoring and evaluating the change will be done in the form of new employee performance appraisal and reward system to influence people to adhere to the new values.

Section Three: Methodology

This is a project to increase breastfeeding rate at the postpartum unit at North Central Bronx Hospital that will have practice changes implemented through modified rounding. The project will implement practice changes approved by the organization’s leadership during nursing rounds and at all times during the duration of this project. The interaction between the DNP students with the Assistant Director of nursing during her practicum at the NCB informed this project. It also led to a meeting with the Director of nursing Mrs. Agyemang. NCB before this project is highly aware of the need to raise its breastfeeding rate due to a peculiar responsibility and mandate by the HHC of New York City which tied support and reimbursement to progresses made toward breastfeeding exclusivity and baby-friendly status (Philipp et al., 2001).
. Our expectation is that these practice changes would lead to increase in breastfeeding rate especially when implemented through a modified rounding (Melnyk & Fineout-Overholt (Eds.). 2011). Our progress will be easily identified because nurses at NCB records details of time of initiation, quantity and duration of breastfeeding throughout the postpartum stay of mothers at NCB. Therefore the pre-intervention and post- intervention breastfeeding status and rate can easily be compared to see the effects of the quality initiative.
. The change intervention is easy and has been familiar to NCB since it was approved by administrators, director and leaders of for breastfeeding improvement. The project will accomplish practice changes such as increasing the practice and duration of skin-skin contact, rooming-in and use of transitional nurses. Policies and protocols that serve as barriers to breastfeeding will be changed. Changes will be communicated through registered nurse, midwives and physicians education on the benefits, techniques and support of breastfeeding.
Project design/methods
This DNP project involves practices changes in the way we deliver care at NCB. Evidence-Based practice (EBP) changes (Melnyk & Fineout-Overholt (Eds.). (2011)( Burns, & Grove, (2010)( Polit & Beck (2008) couple with educating the staffs of the post-partum unit of North Central Bronx Hospital will be the target of this project. The designed is an improvement project model based on the creation of Breastfeeding Coalition and Champions (New York State Department of Health, retrieved 2015). The breastfeeding Coalition and Champions will facilitate, monitor and implement our practices changes. The Principles of Evidence Based Practice (EBP) (IOM, 2010) and quality improvement will be the main focus of our coalition. The coalition will also have the responsibility to change the cultures and norms of entire our study population.
Philipp, et al conducted a study of 200 complete medical records randomly selected by a computer were reviewed for 1995, 1998 & 1999 and postpartum infant feeding compared. Maternal and infant demographic were comparable for all the three years of the study. Exclusion criteria were medical records missing feeding data, HIV positive parents, NICU admission, maternal substance abuse, adoption, incarcerated or hepatitis C positive mothers. Four groups Neonates were assigned are exclusively breast milk, mostly breast milk, mostly formula and exclusive formula. Results were Breastfeeding increase from 58% (1995) to 77.5% (1998) to 86.5% (1999) whereas exclusive breastfeeding increase from 5.5% in 1995 to 28.5% in 1998 and to 38.5% in 1999. Breastfeeding initiation rate among US blacks mothers also increased from 34% in 1995 to 64% in 1998 to 74% in 1999. The research team, therefore, concluded putting into practice the ten steps to successful breastfeeding for baby-friendly status is an effective strategy to increase breastfeeding initiation rate in the US hospital setting.
Population and sampling
North Central Bronx Hospital (NCBH), founded in 1976, is a community family-oriented hospital serving a large and highly educated population in the Norwood section of the Bronx (HHC). North Central Bronx Hospital operates under the direction of New York City Health and Hospitals Corporation. It is located at 3424 Kossuth Avenue with a complete range of services including pediatrics, geriatrics, wellness and sexually transmitted disease and women’s health. Apart from being the best midwifery services of New York State, North Central Bronx Hospital was the first NYC hospital to receive a SAFE (Sexual Assault Forensic Examiner) (NCBH…(n.d.). Though NCBH is a trusted and reliable source of medical care, it has failed to raise its breastfeeding rate of 15% and barely struggling to meet the criteria for a baby-friendly institution.
The post-partum nurses working in this organization are not enthusiastic about breastfeeding. There is also lack of support by these nurses to the post-partum mothers that is required to achieve breastfeeding success. Couple with this barrier is organizational culture and practices which has hampered the breastfeeding process. Practices such as use of nursery, lack of skin-to- skin contact, as well as poor knowledge of what the benefits, techniques and processes of breastfeeding by the nurses have made the raising of breastfeeding rate impossible. The population would also include the physicians/advanced practice nurses and the newly hired lactation consultant. The breastfeeding consultant will work with the dyad and led in informal teachings and the conduction of in-service for the staffs.
Data collection (instruments and protection of human subjects)
Unlike the PHD thesis, data will not be collected to make the project reproducible. Data will be collected to measure effects of change in practice on breastfeeding rate. The purpose of the data collection therefore is for the evaluation of the program success, accountability to the stakeholders, to demonstrate quality improvement and also to provide clarity of the objectives of the program (W.K. Kellogg Foundation as cited in Zaccagnini & White, 2011). Data will be collected by using the outcome measures along with observations. Daily rounding will be performed by the nurse leaders who would approach the mothers inquiring if breastfeeding education and techniques were given to them. Daily rooming-in log will be analyzed monthly to know the number of babies who roomed in with their mothers. Also skin-to skin contact data will be collected through computer chart review as well as observational data collected monthly.
The New York City hospital Breastfeeding Hospital Collaborative (NYC BHC) offer useful methods and data sources. These includes (1) Breastfeeding initiation, exclusivity and formula supplementation of breastfed infants rates at the hospital. (2) Breastfeeding rates reported through local and State data sources. (3) Surveys of Mothers through local providers on infant feeding practices. (4) Survey of clinical staff on implementation successes and challenges. (5) Patients satisfaction surveys (AIM. (n.d.), the nature of this study this project makes it necessary to depend on the first of the above.
Instrument: Measure of personnel knowledge, attitudes and practice will be through the use of a Knowledge, Attitudes and Practice (KAP) score. (KAP score appendix). It was developed primary healthcare Reform Project (PHCR) of the United States Agency International Development (USAID) varies by key respondent characteristic and is positively associated with education (USAID, 2008). It therefore tells what people know about certain subject. Al-lela, Bahari, Al-abbassi, & Basher, (2011)’s study used descriptive statistics to tested reliability for internal consistency of KAP survey scoring using Cronbach’s alpha coefficient. They found good internal consistency ((Cronbach’s alpha=0.735); the test-retest reliability value was 0.812 (p<0.001)
The evidence- based-practice changes made in this project will be evaluated with the Evidence -Based Practice Implementation (EBPI) scale (Melnyk & Fineout- Overholt, 2011). This is an 18-item Likert scale survey used to evaluate progress made toward evidence base practice implementation. The scale range from one for strongly disagree and five for strongly agree. (See appendix). Other Benchmarks include Prenatal Core (The Joint Commission, 2015) and Breastfeeding Report Card (CDC, 2011).
Protection of Human Subjects
This project is not a research study but a practice improvement project and does not involved direct patient participation. Nevertheless, procedures were set in place to protect of human participants in project studies. The project will require approval from the director of research and administrative director of Human Genetics Lab of NCBH, Dr. Howard Nadel. Also, permission will also be sought from the Chief Nursing Officer Ms. Elizabeth Gerdts and Associate Director of Nursing of Women’s Health Mrs. Vera Appiah-Agyemang. Walden University Institutional Review Board (IRB) will also provide approval for the project. At completion of the project, the National Institute of Health (NIH) Office of Extramural Research will be issuing a certificate of completion.
Patient identifiers like names, Date of Birth (DOB) will be removed from Breastfeeding data obtained from EMR to protect patient information. These identifiers will be deleted from data before data analyzes to ensure confidentiality of patient information.
The safety of participants to the project will be very assured. The project participants are staff and management of the postpartum unit and, therefore, are already familiar with the postpartum unit environment. Our postpartum unit is a securely locked up unit that only allows access only to visitors permitted to visit by a patient and after thorough police screening. During admission, patients are asked to state who they want to be given access to visit dyad during the hospital stay. There is a police station located inside NCB whose function is solely for the safety of our patients and staff.
Data analysis (reliability, validity, and analytic techniques)
Data processing will be through descriptive statistics for mean, mode, median, SD, SEM and percentage and percentile for data analysis when necessary. Qualitative data analyzes will use data obtained from direct observation, open- ended survey that focused on the facilitators and barriers to breastfeeding and also those obtained from Medical records. These methods derive codes and themes directly from raw data rather than using predetermined categories (Kondracki, Wellman, & Amundson, 2002).
i. Reliability
ii. Validity
iii. Analytical techniques to answer guiding and/or research questions

Evaluation plan
Mission statement Goals Objectives Activities to meet objectives
Improving the educational breastfeeding level of maternity nurses To increase the breastfeeding rate from 15% to 25% through educational intervention among nurses Using SMART acronym:

95% of nurses in maternity unit through educational intervention will change their attitude towards breastfeeding and support mothers during breastfeeding process by the end of 2016.
There will be change in practices: such as increase time and rate of skin-skin, rooming-in and decrease use of nursery • Small and large groups power points presentations
• Use of Kotter’s model of change
• Holding breastfeeding support groups
• Educating mothers about breastfeeding in the antenatal clinic
• Limited use of the nursery.

Hodges and Videto (2011), defines evaluation as “the systematic collection of information about actions, characteristics, and outcomes of programs to make judgements about the programs, improve program effectiveness and/or inform decisions about future program development” (p.205). Among the reasons why breastfeeding rate is not increasing in North Central Bronx Hospital is the lack of enthusiasm, compassion and poor attitudes among registered nurses (Seabolt, 2012). Organizational practices and failed culture often contribute to breastfeeding problems. Starting a program that will result in a change needs an initial problem analysis, planning as well as on-going evaluation. Through the use of KAP score, participants’ knowledge about breastfeeding was assessed.
The goal of the breastfeeding program is to increase the breastfeeding rate at North Central Bronx Hospital from 15% to 25%. The project leader proposes to make this possible by educating the postpartum nurses on the benefits and techniques of breastfeeding as well as incorporating a practice change that would help improve the breastfeeding rate. The practice changes include: initiation of skin-skin-contact immediately after delivery, couplet care as well as minimal use of the nursery. The implementation of these practices and their effects on the breastfeeding rate will be evaluated by using outcome evaluation method. An outcome evaluation method will focus on the long term goal of the breastfeeding program. Changes in nurses’ attitudes, impact on the organization, practice changes as well as unintended outcomes that arose as a result of the breastfeeding program would be measured.
Summary
The documented evidence of breastfeeding is the driven force of this breastfeeding initiative. The support of senior management and the wholehearted involvement of the project population are positive factors for the success of this project. The success of the breastfeeding project will be monitored by assessing medical records as well as personal observation during nurse’s rounds. A successfully implemented practice changes will have a positive effect on breastfeeding rate. The target is to increase the breastfeeding exclusivity rate and helping NCB to earn a Baby-Friendly status by these practice changes and support to mothers.
Section 4: Findings, Discussion, and Implications
Example First Heading
Present your results here. Section 4 should include
• Summary of findings
• Discussion of findings in the context of literature
• Implications
i. Policy
ii. Practice
iii. Research
iv. Social change
• Project strengths and limitations
i. Strengths
ii. Limitations
iii. Recommendations for remediation of limitations in future work
• Analysis of self
i. As scholar
ii. As practitioner
iii. As project developer
iv. What does this project mean for future professional development?
Summary and conclusions

This is an example of a table in APA style (see Table 1).
Table 1
A Sample Table Showing Correct Formatting
Column A
Column B Column C Column D
Row 1
Row 2
Row 3
Row 4

Note. From “Attitudes Toward Dissertation Editors,” by W. Student, 2008, Journal of Academic Optimism, 98, p. 11. Reprinted with permission.

This is an example of a figure labeled per APA style. Note that the label is placed under the figure itself. As with tables, refer to the figure by number in the narrative text preceding the placement of the figure (see Figure 1).

[place figure here]

Figure 1. This is a sample of a figure caption, with the figure number in italics and the caption in plain type, sentence case.

Follow these instructions to allow figure number and caption to update in the List of Figures.
1. Use the cursor to highlight the figure number and caption. (Figure 1. Caption text.)
2. Press Shift + Alt + the letter o). In the Mark Table of Contents Entry that comes up, you will see the figure information that you highlighted in the Entry box. Put A in the Table Identifier box. Put 1 in the Level box. Click the Mark button. Do not close the Mark Table of Contents Entry box. Work can be done while it is open.
3. Continue to follow this protocol for all figures. You will see parenthetical entry field coding beside each figure caption.
4. Close Mark Table of Contents Entry box.
5. After deleting the sample Figure 1 from the template List of Figures page, place your cursor on the page.
6. Open the References tab.
7. Left click Insert Tables of Figures.
8. In the Table of Figures box that comes up, put a check in the “Show page numbers” and “Right align page numbers boxes.” Remove the check from the hyperlink box. Put dot leaders in the Tab leader box. Under General, format is “from template.” Caption label is “Figure.” Put a check in the “Include label and number” box.
9. Click on the Options button. Remove check from “style” box. Put a check in the “Table entry fields” box. Put A in the Table identifier box. Click OK. Click OK again on initial Table of Figures box. When the dialog box appears asking if you want to replace the List of Tables, click No; if you don’t, the figures will appear on the List of Tables page rather than the List of Figures page.
10. The figures will appear on the List of Figures page. Select the entire list of figure (not the page heading), and choose plain type, removing all italics. If the captions themselves change, this whole process must be repeated. If only the page numbers change, do this:
a. Left click to place the cursor anywhere on the figures mentioned on the List of Figures page.
b. Right click “Update field.”
c. Place bullet in circle for option to update page numbers only.
d. Left click OK. The page numbers will update automatically.

Section 5: Scholarly Product
Section 5 is shared with the greater scholarly community. Examples of suitable documents include
• Manuscript for publication
• Project summary and evaluation report
• Grant proposal
• Program evaluation report

References
AIM. (n.d.). Retrieved from http://www.nyam.org/das-ny-programs/pdf/Fac- SheetBreast_FeedingNYSDOHFINAL.pdf
Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and
Human Decision Processes, 50(2), 179–11. doi: 10.1016/0749-5978(91)90020-T
Ajzen, I., (1997). Understanding Attitudes and Predicting Social Behavior
Ajzen, I., & Fishbein, M. (1969). The prediction of behavioral intentions in a
choice situation. Journal of Experimental Social Psychology, 5(4), 400–16. doi: 10.1016/0022-1031(69)90033-X
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social
behavior (p. 278). Englewood Cliffs, NJ: Prentice-Hall.
Al-lela, O. Q. B., Bahari, M. B., Al-abbassi, M. G., & Basher, A. Y. (2011).
Development of a questionnaire on knowledge, attitude and practice about immunization among Iraqi parents. Journal of Public Health, 19(6), 497-503.
American Academy of Pediatrics (2014). Clinical Report. Retrieved on 7/21/15 from
http://pediatrics.aappublications.org/conte nt/early/2011/02/28/peds.2010- 3851.full.pdf+htm
American Academy of Pediatrics. (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129(3), 827-841. doi: 10.1542/peds.2011-3552. Centers for Disease Control. (2013). Breastfeeding report card: United States 2013. Retrieved from
http://www.cdc.gov/breastfeeding/pdf/2013BreastfeedingReportCard.pdf
American Academy of Pediatrics. (2015). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129(3), 827-841.doi: 10.1542/peds.2011-3552. Retrieved on 3/2/15 from https://pediatrics.aappublications.org/content/129/3/e827.full.html.
Amir, L. H. (2011). Social theory and infant feeding. Int Breastfeed J, 6(7).
Appelbaum, S. H., Habashy, S., Malo, J. L., & Shafiq, H. (2012). Back to the future:
revisiting Kotter’s 1996 change model. Journal of Management Development, 31(8), 764-782.
Bartick, M., Stuebe, A., Shealy, K. R., Walker, M., & Grummer-Strawn, L. M. (2009).
Closing the quality gap: promoting evidence-based breastfeeding care in the hospital. Pediatrics, 124(4), e793-e802.
Beal, J. A., Dalton, M. F., & Maloney, J. A. (2015). Should Mother–Baby Rooming-In
be the Standard of Care? MCN: The American Journal of Maternal/Child Nursing, 40(2), 74-75.
Bonuck, K., Arno, P. S., Memmott, M. M., Freeman, K., Gold, M., & Mckee, D. (2002). Breast- Feeding Promotion Interventions: Good Public Health and Economic Sense. Journal of Perinatology, 22(1), 78.
Bradbury-Jones, C., & Taylor, J. (2014). Applying social impact assessment to nursing research. Nursing Standard, 28(48), 45-49. doi:10.7748/ns.28.48.45.e8262
Breastfeeding report card (2014). Retrieved on 7/19/15 from www.cdc.gov/breastfeeding/pdf/2014breastfeedingreportcard.pdf
Bramson, L., Lee, J., Moore, E., Montgomery, S., Neish, C., Bahjri, K., & Melcher, C. (2010). Effect of early skin-to-skin mother–infant contact during the first 3 hours following birth on exclusive breastfeeding during the maternity hospital stay. Journal of Human Lactation, 26(2), 130-137. doi: 10.1177/0890334409355779
Breastfeeding, S. (1994). Baby Friendly Hospital Initiative.
Brethauer, M. (2010). “Maternal Experience with Neonatal Jaundice.” MCN, the American journal of maternal child nursing 35.1 (2010): 8-14.
Burns, N., & Grove, S. K. (2010). Understanding nursing research: Building an evidence-based practice. Elsevier Health Sciences.
Carling, S. J., Demment, M. M., Kjolhede, C. L., & Olson, C. M. (2015).
Breastfeeding duration and weight gain trajectory in infancy. Pediatrics, 135(1), 111-119.
Carol, B. (2013). Referring to a Lactation Consultant (IBLC): When is it appropriate? Midwifery News, (71), 16-17.
Casey, G. (2015). Osteoporosis — fragile bones. Kai Tiaki Nursing New Zealand, 21(1), 20-24. Centers for Disease Control and Prevention (2015). Breastfeeding among
Clark, M. (2013). Clinical update: understanding jaundice in the breastfed infant. Community Practitioner, 86(6), 42-45.
Csont, G. L., Groth, S., Hopkins, P., & Guillet, R. (2014). An Evidence-Based Approach to Breastfeeding Neonates at Risk for Hypoglycemia. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 43(1), 71-81. doi: 10.1111/1552- 6909.12272
Davidson, M., London, M., & Ladewig, P. (2012). Olds’ maternal-newborn nursing and
women’s health. New Jersey: Pearson Education Incorporated. Print.
Davies, L. (2015, June). Implementing Complete Couplet Care. In Association of
Women’s Health, Obstetric and Neonatal Nurses (June 13-17, 2015). Awhonn.
Davis, S.K., Stichler, J.F., & Poelter, D.M. (2013).Increasing exclusive breastfeeding rates in the well-baby population. Nursing for Women’s Health, 16(6).doi:10.1111/j.1751-486X.2012.01774.x
De Faria, A. C., Magalhães, L., & Zerbetto, S. R. (2010). Rooming-in Care Implementation: difficulties faced through the perspective of a nursing staff. [Portuguese]. Revista Eletronica De Enfermagem, 12(4), 669-677. doi:10.5216/ree.v12i4.6328 free dictionary (n.d). Retrieved on 8/11/15 from http://medical- dictionary.thefreedictionary.com/dyad
DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communication (5th edition),
Chapter 8 (Socialization and Theories of Indirect Influence), pp. 202-227. White Plains, NY: Longman Inc., 1989.
Donnan, P. T., Dalzell, J., Symon, A., Rauchhaus, P., Monteith-Hodge, E., Kellett,
G. … Whitford, H. M. (2013). Prediction of initiation and cessation of breastfeeding from late pregnancy to 16 weeks: The feeding your baby (FYB) cohort study. BMJ Open, 3(8), e003274. doi: 10.1136/bmjopen-2013-003274
Duckett, L., Henly, S., Avery, M., Potter, S., Hills-Bonczyk, S., Hulden, R., & Savik,
K. (1998). A theory of planned behavior-based structural model for breastfeeding. Nursing Research, 47(6), 325–36.
Edelman, C. L., Mandle, C. L., & Kudzma, E. C. (2013). Health promotion throughout
the life span. Elsevier Health Sciences.
Francome, C. (2015). Unsafe Abortion and Women’s Health: Change and Liberalization. Ashgate Publishing, Ltd.
Gams, B. (2015, June). A6C-Beyond Baby Friendly: Implementation of the Power Hour!.
In Association of Women’s Health, Obstetric and Neonatal Nurses (June 13-17, 2015). Awhonn.
Giles, M., McClenahan, C., Armour, C., Millar, S., Rae, G., Mallett, J., & Stewart
Knox, B. (2014). Evaluation of a theory of planned behaviour-based breastfeeding intervention in northern Irish schools using a randomized cluster design. British Journal of Health Psychology, 19(1), 16–35. doi:10.1111/bjhp.12024
Gladwell M. The Tipping Point: How Little Things Can Make a Big Difference.
Boston: Little, Brown and Company, 2000, pp. 3-14
Halm, M. A. (2009). Hourly rounds: what does the evidence indicate? American
Journal of Critical Care, 18(6), 581-584
Haxton, D., Doering, J., Gingras, L. (2012). Implementing skin- to- skin contact at birth using the Iowa model. Nursing for Women’s Health, 16(3), 222-230.
Health and Hospital Corporation- North Central Bronx Hospital (n.d). Retrieved on 3/27/15 from http://www.nyc.gov/html/hhc/ncbh/html/home/home.shtml
Himani, Kaur, B., & Kumar, P. (2011). Effect of initiation of breast-feeding within
one hour of the delivery. Nursing and Midwifery Research Journal, 7(3), 99-110. Retrieved from http://medind.nic.in/nad/t11/i2/nadt11i2p53.pdf on 8/27/15.
Hirani, S.A., & Karmaliani, R. (2013). Evidence based workplace interventions to promote breastfeeding practices among Pakistani working mothers. Women & Birth, 26(1), 10-16.doi:10.1016/j.wombi.2011.12.005
Holla, R., Alessandro Iellamo, A., Gupta, A., Smith, J.P., & Dadhich. J.P. (2015). Investing in breastfeeding – the world breastfeeding costing initiative. International Breastfeeding Journal 10(8) 10:8 doi: 10.1186/s13006-015-0032-
Hodges, B. C., & Videto, D. M. (2011). Assessment and planning in health programs (2nd ed.). Sudbury, MA: Jones & Bartlett Learning.
Hughes, V. (2015). The Baby-Friendly Hospital Initiative in US Hospitals.ICAN: Infant, Child, & Adolescent Nutrition 7(4), 182-187.doi: 10.1177/1941406415592671. Retrieved on 8/4/15 from http://can.sagepub.com.ezp.waldenulibrary.org/content/7/4/182.full.pdf+html
Hyrkäs, K., & Harvey, K. (2010). Leading innovation and change. Journal of nursing
management, 18(1), 1-3.
Institute of Medicine (US). (2010). The Future of Nursing: Leading Change, Advancing
Health, Washington DC: National Academies Press.
Janke, J. R. (1994). Development of the breast-feeding attrition prediction tool.
Nursing Research, 43(2), 100–04.
Kaufman, L., Deenadayalan, S., & Karpati, A. (2010). Breastfeeding ambivalence among
low-income African American and Puerto Rican women in north and central 157 Brooklyn. Maternal Child Health Journal,14(5):696-704. doi: 10.1007/s10995- 009-0499-5
Keister, D., Roberts, K.T., & Werner, S.L. (2008). Strategies for breastfeeding success. American Family Physicians, 78(2), 225-232
Kervin, B.E., Kemp, L., & Pulver, L.J. (2010). Types and timing of breastfeeding
support and its impact on mothers’ behaviours. Journal of Paediatrics and Child Health, 46, 85-91. doi:10.1111/j14401754200901643.x
Kim, Y. (1998). The effects of a breastfeeding campaign on adolescent Korean
women. Pediatric Nursing, 24(3), 235–40.
Kling, J. M., Clarke, B. L., & Sandhu, N. P. (2014). Osteoporosis Prevention, Screening, and Treatment: A Review. Journal of Women’s Health (15409996), 23(7), 563- 572. doi:10.1089/jwh.2013.4611
Kotsopoulos, J., Lubinski, J., Salmena, L., Lynch, H.T., Kim-Sin, C., Faulkes, W.D.,….Narod, S.A.(2012).Breastfeeding and the risk of breast cancer in BRCA1 mutation carriers. Breast Cancer Research, 14:R42.doi:10.11861bcr3138
Lawrence, R. A. (2013). Is it time to celebrate?. Breastfeeding medicine: the official
journal of the Academy of Breastfeeding Medicine, 8(3), 247-248.
Lewallen, L.P., &Street, D. J. (2010). Initiating and sustaining breastfeeding in African
American women. JOGNN 39(6). doi:10.1111/j.1552-6909.2010.01196.x
Kramer, M.S., Chalmers, B., Hodnett, E.D., Sevkovskaya, Z., Shapiro, S., Jean-Paul, S.… Helsing, E. (2001). Promotion of Breastfeeding Intervention Trial (PROBIT): A Randomized Trial in the Republic of Belarus. JAMA. 2001; 285(4):413-420. doi:10.1001/jama.285.4.413.
http://www.mainecompact.org/documents/Faculty Rewards/Kotter Leading Change –
Marks, D., & O’Connor, R. (2015). Health professionals’ attitudes towards the promotion of breastfeeding. British Journal of Midwifery, 23(1), 50-58.
Marshall, M. L. (2014). The Impact of Implementation of an Evidence-Based Practice
Model in a Long Term Acute Care Hospital. . http://corescholar.libraries.wright.edu/nursing_dnp/3.
Mathur, N. & Dhingra, D. (2013). Breastfeeding. The Indian Journal of Pediatrics. doi:
10.1007/s12098-013-1153-1
McCarter-Spaulding, D.& Gore, R.(2009). Breastfeeding self-efficacy in women of
African descent. JOGNN 38(2). doi:10.1111/j.1552-6909.2009.01011.x
McCombs, M.E. (1982). The Agenda-Setting Approach. In: Nimmo, D. & Sanders,
K. (Eds.) Handbook of Political Communication. Beverly Hills, CA.: Sage.
McEwen M., & Wills M.E., (2011). Theoretical basis for Nursing. 3rd Ed, Wolters
Kluwer .Health/Lippincott Williams & Wilkins, Philadelphia P.A.
McInerney, C.M., & Gupta, A. (2015). Delaying the First Bath Decreases the Incidence of Neonatal Hypoglycemia…. Proceeding of the 2015 AWHONN Convention. JOGNN: Journal of Obstetrics, Gynecologic & Neonatal Nursing, 44S73- 4.doi:10.111/1552-6909.12650
McMillan, B., Conner, M., Woolridge, M., Dyson, L., Green, J., Renfrew, M., …
Clarke, G. (2008). Predicting breastfeeding in women living in areas of economic hardship: Explanatory role of the theory of planned behaviour. Psychology & Health, 23(7), 767–88. doi:10.1080/08870440701615260
Medical Dictionary (n.d). Retrieved on 8/17/15 from http://medical- dictionary.thefreedictionary.com/dyad
MedicineNet (n.d). Retrieved on 8/17/15 from http://www.medicinenet.com/script/main/art.asp?articlekey=38691
Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing and
Healthcare: A Guide to Best Practice. (2nd ed.) Philadelphia, PA: Lippincott Williams & Wilkins.
Moore, E. R. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews, (5), doi:10.1002/14651858.CD003519.pub3
Muppalla, S., & Capobianco, R. (2010). The Impact of Healthcare Reform on Payers’ Products, Provider Reimbursement, and Member Engagement. American Health & Drug Benefits, 3(4), 289-290.
Nathoo, Tasnim; Ostry, Aleck (2009). The One Best Way? Breastfeeding History, Politics, and Policy in Canada. Wilfrid Laurier Univ. Press. ISBN 978-1-55458- 171-
Naviglio, S., & Ventura, A. (2013). The science of breastfeeding: time for a change? Acta Pediatric, 102(8), 797-798. doi:10.1111/apa.12269
Nelson, J. M., Li, R., & Perrine, C. G. (2015). Trends of US Hospitals Distributing Infant
Formula Packs to Breastfeeding Mothers, 2007 to 2013.Pediatrics, peds-2015.
Newhouse, R. P., Dearholt, S. L., Poe, S. S., Pugh, L. C., & White, K. M. (2007). Johns Hopkins nursing evidence–based practice models and guidelines. Indianapolis, IN: Sigma Theta Tau International.
NCBH-About NCBH-NCBH History-Welcome to NYC.gov/City
… (n.d.). Retrieved from
http://www.nyc.gov/html/hhc/ncbh/html/about/history.shtml
Ogilvy D. Confessions of an Advertising Man. New York: Atheneum,
1964, pp. 89-103.
Palaniappan, A., Feldman-Winter, L., & Knapp, S. (2010, October 4). Barriers
to breastfeeding reported by exclusively formula feeding mothers. Retrieved from https://aap.confex.com/aap/2010/webprogrampress1010/Paper9969.htm
Philipp, B. L., Merewood, A., Miller, L. W., Chawla, N., Murphy-Smith, M. M., Gomes,
J. S. … & Cook, J. T. (2001). Baby-friendly hospital initiative improves breastfeeding initiation rates in a US hospital setting. Pediatrics,108(3), 677-681.
Philipp, B. L., & Radford, A. (2006). Baby-Friendly: snappy slogan or standard of care? Archives of Disease in Childhood. Fetal and Neonatal Edition, 91(2), F145–F149. doi:10.1136/adc.2005.074443
Phillips, A. C., Lewis, L. K., McEvoy, M. P., Galipeau, J., Glasziou, P., Hammick, M. … Williams, M. T. (2013). Protocol for development of the guideline for reporting evidence based practice educational interventions and teaching (GREET) statement. BMC Medical Education, 13, 9. doi: 10.1186/1472-6920-13-9
Philips, R. (2013).Women’s health care Physicians. American Congress of Obstetrics and Gynecologist. Retrieved from http://www.acog.org/About-ACOG/ACOG- Departments/District-Newsletters/District-IX/June-2013/Print-all
Polit, D. F., & Beck, C. T. (2008). Nursing research: Generating and assessing
evidence fornursing practice. Lippincott Williams & Wilkins.
Porter, M.L., & Dennis, B.L. (2002). Hyperbilirubinemia in the Term Newborn. American Journal of Family Physician 65(4):599-607
Power E. M. An introduction to Pierre Bourdieu’s key theoretical concepts.
Journal for the Study of Food and Society 1999, 3(1):48-52.
Ramakrishnan, R. (2015, November). Baby Friendly Hospital Initiative and breastfeeding
duration: An analysis of the Pregnancy Risk Assessment Monitoring System. In 143rd APHA Annual Meeting and Exposition (October 31-November 4, 2015). APHA.
Robb, Y. (2015). Would financial rewards encourage mothers to breastfeed their
babies?. Journal of Health Visiting, 3(2), 84-89.
Rosenstock, I. (1974). Historical Origins of the Health Belief Model. Health
Education Monographs, 2, 328-35.
Rosen, E. L. (2015, November). Success with the High 5 Initiative through Patient
and Family Engagement. In 43rd Biennial Convention (07 November-11 November 2015). STTI.
Rozance, P. J., & Hay, W. W. (2012). Neonatal Hypoglycemia—Answers, but More Questions. The Journal of Pediatrics, 161(5), 775–776. doi:10.1016/j.jpeds.2012.06.034
US Department of Health and Human Services. Healthy People 2020 leading health indicators: progress update. Retrieved on 7/25/15 from http://www.healthypeople.gov/2020/LHI/LHI-ProgressReport-
Sadauskait÷-Kuehne, V., Ludvigsson, J., Padaiga, Ž., Jašinskien÷, E., & Samuelsson, U.
(2004). Longer breastfeeding is an independent protective factor against
development of type 1 diabetes mellitus in childhood. Diabetes/Metabolism
Research and Reviews. 20(2), 150-157. doi: 10.1002/dmrr.425
Seabolt, L. (2012). Nurses for Breastfeeding: Policy Alert. South Carolina Nurse, 19(2), 11.
Smith, J. W. (2014). Food for Health: An Investigation of Infant Feeding Practices,
Breastfeeding Self-Efficacy, and Perceived Barriers and Facilitators.
Shinwell, E. S., Churgin, Y., Shlomo, M., Shani, M., Flidel-Rimon, O. (2006). The
effects of training nursery staff in breastfeeding guidance on the duration of 168 breastfeeding in healthy term infants. Breastfeed Medicine, 1(4):247-52. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17661605
Swanson, V., & Power, K. G. (2005). Initiation and continuation of breastfeeding:
Theory of planned behaviour. Journal of Advanced Nursing, 50(3), 272–82. doi:10.1111/j.1365-2648.2005.03390.x
The Joint Commission (2013) Core Measure Sets: Prenatal care. Retrieved from
http://www.jointcommission.org/assets/1/6/S11.pdf
Thomas, M., Kay, S., Pike, J., Williams, A., Rosenzweig, J.C., Hillyer, E., & Price, D. (2009). The Asthma Control Test (ACT) as a Predictor of GINA Guideline- Defined Asthma
Tyson, R.L. (2013). Where’s the Lactation Consultant? Increasing Exclusive Breastfeeding Rates by Empowering L&D Nurses. JOGIN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 42S21-2.doi:10.1111/1552-6909.12077
United States Breastfeeding Committee (2013). Implementing the Joint Commission Perinatal care Core Measures on exclusive breast milk feeding. Washington, DC: Author.
Retrieved from
file:///C:/Users/Augustine/Downloads/TJC-Measure-EBMF-2013-rev-USBC.pdf
U.S. Children Born 2001–2011, CDC National Immunization Survey.
Retrieved on 7/25/15 from http://www.cdc.gov/breastfeeding/data/nis_data/index.htm
Walls, M. (2015). The Maternal Infant Health Survey: Quality Analysis of Nursing
Practice as it Relates to the Baby-friendly Hospital Initiative.
Wambach, K. A. (1997). Breastfeeding intention and outcome: A test of the theory
of planned behavior. Research in Nursing & Health, 20(1), 51–59.
Weimer, J.P. (2001).The economic benefits of breastfeeding: A review and analysis. Food and Rural Economics Division, Economic Research Service, U.S Department of Agriculture, (FANRR-13), 1-20
World health Organization (2015). E-Library of Evidence for Nutrition Actions (e- LENA).Retrieved on 8/11/15 from http://www.who.int/elena/titles/exclusive_breastfeeding/en/
Youngblut, J.M., & Brooten, D. (2001). Evidence-based nursing practice: Why is it important? Publmed.gov 12(4), 468-476. Retrieved on 4/17/15 from http://www.ncbi.nlm.nih.gov/pubmed/11759419
Zaccagnini, M.E., & White, K.W. (2011). The Doctor of Nursing Practice Essentials: A
new model for advanced practice nursing (custom ed.). Sudbury; MA: Jones & Bartlett publishers.

The Publication Manual of the American Psychological Association, Sixth Edition, Chapter 7, includes numerous examples of reference list entries. For more information on references or APA style, consult the APA website or the Walden Writing Center website.

Appendix A: Title of Appendix
Insert appendix here. Appendices are ordered with letters rather than numbers.
The appendices must adhere to the same margin specifications as the body of the doctoral study. Photocopied or previously printed material may have to be shifted on the page or reduced in size to fit within the area bounded by the margins.
If the only thing in an appendix is a table, the table title serves as the title of the appendix; no label is needed for the table itself. If you have text in addition to a table or tables in an appendix, label the table with the letter of the appendix (e.g., Table A1, Table A2, Table B1, and so on). These tables would be listed in the List of Tables at the end of the Table of Contents.
If you include in an appendix any prepublished materials that are not in the public domain, you must also include permission to do so.

Curriculum Vitae
Include a copy of your curriculum vitae—your academic resume—here. The CV may be done in either basic outline form or full-sentence form. The CV must conform to the margin specifications of the rest of the document, be included in the pagination, and be listed in the TOC.

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