Health and Social Development, Faculty of (Okanagan)
Nursing, School of (Okanagan)
DSpace
UBCO
Andrews, Olivia
Master of Science in Nursing - MSN
University of British Columbia
Breastfeeding is recognized as the gold standard for infant feeding. Despite this, many infants are not exclusively breastfed for the first six months of their life. To improve practices that promote and support breastfeeding, the World Health Organization (WHO) released a designation system for hospitals and health centers to help improve overall breastfeeding rates and infant care. This study aimed to examine perinatal healthcare providers’ experiences in implementing the Baby-Friendly Hospital Initiative (BFI) in British Columbia. A qualitative descriptive approach was used to guide this study. Purposeful and snowball sampling methods were used to identify potential participants. This resulted in 12 semi-structured interviews with 11 registered nurses, and one midwife. Of these participants, seven held international certification as lactation consultants, and two participants reported being the Baby-Friendly Health Authority Leads at their hospital. The interviews were reviewed using a thematic analysis. This process resulted in four major themes with associated sub-themes: (1) misunderstandings, overcoming resistance, and accountability; (2) Challenges with Education, effective education, and competency checklists; (3) Importance of Leadership, senior management, BFI leads, and group effort; and (4) Considering the SDOH. These findings indicate that perinatal providers often struggle during the process of receiving the Baby-Friendly designation. However, despite the difficulties in implementing BFI, 11 of the 12 participants still felt that BFI practices were important. This study provides a basis for improved knowledge of BFI implementation and suggestions for overcoming barriers.
PERINATAL HEALTHCARE PROVIDERS’ EXPERIENCES WITH THE BABY-FRIENDLY INITIATIVE: A QUALITATIVE DESCRIPTIVE STUDY by Olivia Andrews BSN, The University of British Columbia Okanagan, 2022 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in The College of Graduate Studies (Nursing) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) December 2024 © Olivia Andrews, 2024 ii The following individuals certify that they have read and recommend to the College of Graduate Studies for acceptance, a thesis entitled: PERINATAL HEALTHCARE PROVIDERS’ EXPERIENCES WITH THE BABY-FRIENDLY INITIATIVE: A QUALITATIVE DESCRIPTIVE STUDY submitted by Olivia Andrews in partial fulfillment of the requirements of the degree of Master of Science in Nursing. Examining Committee: Dr. Marie Tarrant, Faculty of Health and Social Development Supervisor Dr. Suzanne Campbell, School of Nursing Supervisory Committee Member Rishma Chooniedass, School of Nursing Supervisory Committee Member Meggie Ross, Interior Health Supervisory Committee Member Eric Li, Faculty of Management External Examiner iii Abstract Breastfeeding is recognized as the gold standard for infant feeding. Despite this, many infants are not exclusively breastfed for the first six months of their life. To improve practices that promote and support breastfeeding, the World Health Organization (WHO) released a designation system for hospitals and health centers to help improve overall breastfeeding rates and infant care. This study aimed to examine perinatal healthcare providers’ experiences in implementing the Baby-Friendly Hospital Initiative (BFI) in British Columbia. A qualitative descriptive approach was used to guide this study. Purposeful and snowball sampling methods were used to identify potential participants. This resulted in 12 semi-structured interviews with 11 registered nurses, and one midwife. Of these participants, seven held international certification as lactation consultants, and two participants reported being the Baby-Friendly Health Authority Leads at their hospital. The interviews were reviewed using a thematic analysis. This process resulted in four major themes with associated sub-themes: (1) misunderstandings, overcoming resistance, and accountability; (2) Challenges with Education, effective education, and competency checklists; (3) Importance of Leadership, senior management, BFI leads, and group effort; and (4) Considering the SDOH. These findings indicate that perinatal providers often struggle during the process of receiving the Baby-Friendly designation. However, despite the difficulties in implementing BFI, 11 of the 12 participants still felt that BFI practices were important. This study provides a basis for improved knowledge of BFI implementation and suggestions for overcoming barriers. iv Lay Summary A qualitative descriptive study focused on perinatal healthcare providers’ experiences with the Baby-Friendly Hospital Initiative, and how they perceived the barriers, facilitators, and advantages of this designation when adapting this initiative to their practice. 12 perinatal healthcare providers were interviewed regarding their opinions the Baby-Friendly Hospital Initiative. The four themes of Misunderstandings, Challenges with Education, Importance of Leadership, Considering the SDOH, were evident in the data. The findings show that perinatal providers often struggle to receive the Baby-Friendly designation v Preface Under the guidance of my supervisor, Dr. Marie Tarrant, and, in collaboration with my committee members, Dr. Suzanne H. Campbell, Rishma Chooniedass, and Meggie Ross completed all components of this research. No generative AI was used for the drafting or preparation of this thesis or dissertation. The harmonized ethics application from the University of British Columbia Behavioral Research Ethics Board (H23-02411) and institutional approval from Interior Health, Providence Health, and Provincial Health Services were obtained prior to the start of data collection. vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface ............................................................................................................................................ v Table of Contents ......................................................................................................................... vi List of Tables ................................................................................................................................ xi List of Figures .............................................................................................................................. xii List of Abbreviations ................................................................................................................. xiii Acknowledgements .................................................................................................................... xiv Chapter One: Background ........................................................................................................... 1 Benefits of Breastfeeding .............................................................................................................. 1 BENEFITS FOR MOTHERS ...................................................................................................... 1 BENEFITS FOR BABY ............................................................................................................ 2 Prevalence of Breastfeeding ......................................................................................................... 4 Ten Steps to Successful Breastfeeding ........................................................................................ 5 ADAPTATION IN CANADA..................................................................................................... 7 BFI Impacts ................................................................................................................................... 9 Difficulties with Implementation ............................................................................................... 10 RESOURCES ........................................................................................................................ 10 Staffing .................................................................................................................. 11 vii Healthcare Provider's Role in BFI Implementation ................................................................ 12 PURPOSE ............................................................................................................................ 13 RESEARCH QUESTIONS ...................................................................................................... 13 Chapter Two: Literature Review .............................................................................................. 15 OVERVIEW ......................................................................................................................... 15 SEARCH STRATEGY ............................................................................................................ 15 CHARACTERISTICS OF THE LITERATURE............................................................................. 16 Findings ........................................................................................................................................ 17 POLICY ............................................................................................................................... 17 DESIGNATION .................................................................................................................... 18 Time....................................................................................................................... 19 Resources .............................................................................................................. 19 Leadership............................................................................................................. 20 Nurses Empowered ............................................................................................... 21 Collaborative and Credible Leadership ............................................................... 21 ATTITUDES AND KNOWLEDGE ........................................................................................... 22 Nurses Attitudes .................................................................................................... 22 Physicians Attitudes .............................................................................................. 23 Mothers Attitudes .................................................................................................. 23 EDUCATION........................................................................................................................ 24 Nurses Education .................................................................................................. 24 Mothers Education ................................................................................................ 25 viii EVALUATION OF EVIDENCE ............................................................................................... 25 IMPLICATIONS .................................................................................................................... 26 Chapter Three: Methods ............................................................................................................ 28 TIMELINE ........................................................................................................................... 28 METHODOLOGY ................................................................................................................. 29 SAMPLING .......................................................................................................................... 29 RECRUITMENT ................................................................................................................... 32 INFORMED CONSENT .......................................................................................................... 33 DATA COLLECTION ............................................................................................................ 33 DATA ANALYSIS ................................................................................................................ 34 RIGOUR .............................................................................................................................. 36 ETHICAL CONSIDERATIONS ................................................................................................ 37 Chapter Four: Results ................................................................................................................ 39 PARTICIPANT CHARACTERISTICS ....................................................................................... 39 MISUNDERSTANDINGS ....................................................................................................... 41 Overcoming Resistance ......................................................................................... 42 Accountability ....................................................................................................... 43 CHALLENGES WITH EDUCATION ........................................................................................ 44 Effective Education ............................................................................................... 45 Competency Checklists ......................................................................................... 46 IMPORTANCE OF LEADERSHIP ............................................................................................ 47 Senior Management .............................................................................................. 48 BFI Leads .............................................................................................................. 49 ix A Group Effort ...................................................................................................... 50 CONSIDERING THE SOCIAL DETERMINANTS OF HEALTH .................................................... 52 Conclusion ................................................................................................................................... 54 Chapter Five: Discussion ............................................................................................................ 56 MISUNDERSTANDINGS ....................................................................................................... 57 LEADERSHIP ....................................................................................................................... 58 EDUCATION........................................................................................................................ 59 SOCIAL DETERMINANTS OF HEALTH .................................................................................. 61 RECOMMENDATIONS .......................................................................................................... 62 Research ................................................................................................................ 62 Practice ................................................................................................................. 63 Leadership............................................................................................................. 65 LIMITATIONS ...................................................................................................................... 66 REFLECTION & REFLEXIVITY ............................................................................................. 68 Conclusion ................................................................................................................................... 69 References .................................................................................................................................... 71 Figures .......................................................................................................................................... 93 FIGURE 1 ............................................................................................................................ 93 Appendices ................................................................................................................................... 94 APPENDIX A: LETTER OF INFORMATION UNIT MANAGERS ................................................ 94 APPENDIX B: UNIT POSTER ................................................................................................ 96 APPENDIX C: LETTER OF INFORMATION FOR HEALTH AUTHORITY LEADS ........................ 97 x APPENDIX D: INTERVIEW QUESTIONS ................................................................................ 98 APPENDIX E: PARTICIPANT INVITATION LETTER ............................................................. 100 APPENDIX F: CONSENT FORM .......................................................................................... 101 xi List of Tables Table 1 Ten Steps to Successful Breastfeeding…………………………………………....5 Table 2 Literature Review………………………………………………………………...84 Table 3 Criteria for Trustworthiness………………………………………………….…..90 Table 4 Six Steps to Thematic Analysis………………………………………………………….91 Table 5 Timeline of Thesis……………………………………………………………….92 Table 6 Participant Characteristics ………………………………………………………40 Table 7 Overview of Themes…………..…………………………...…………………….41 xii List of Figures Figure 1 PRISMA Flow Diagram…………………………………………………………93 xiii List of Abbreviations BC British Columbia BCC Breastfeeding Committee for Canada BFI Baby-Friendly Initiative BREB University of British Columbia Okanagan's Behavioral Research Ethics Board CINAHL Cumulative Index to Nursing and Allied Health EBF Exclusive Breastfeeding HCP Healthcare Providers IBCLC International Board of Lactation Consultant’s Medline Medical Literature Analysis and Retrieval System Online SDOH Social Determinates of Health SSI Semi-structured interviews UBC University of British Columbia UNICEF United Nations Children’s Fund USA United States of America WHO World Health Organization xiv Acknowledgements First, I would like to express my gratitude to my supervisor, Dr. Marie Tarrant, for your patience and support, despite the challenges that arose during the past two years. Your perspectives and expertise have made this an invaluable learning experience. Additionally, I would like to express my gratitude to my thesis committee members Dr. Suzanne Campbell, Rishma Chooniedass, and Meggie Ross. I am thankful for all the thoughts and experiences that you have shared with me to help me improve my writing and understanding of the research processes. I would also like to thank Sarah Coutts for her assistance with being a site lead and directing me to appropriate contacts. I would like to thank all participants who volunteered for their time in my study. Thank you for sharing your perspectives and ideas on how to improve the implementation of the Baby-Friendly Initiative. Finally, my friends and family thank you for your support and encouragement over the past two years. 1 Chapter One: Background Breastfeeding is an essential practice that provides optimal nutrition to support a baby's physical and neurological growth and development, as identified by the World Health Organization (World Health Organization [WHO], 2018). According to the WHO's recommendations (2015), exclusive breastfeeding (EBF) is the ideal feeding method for the first six months of life, which involves providing only breastmilk to the infant, except in cases where oral rehydration salts and medications are medically necessary. Once an infant is six months or older, food can be introduced while continuing supportive breastfeeding practices for up to two years (WHO, 2018). Despite these guidelines, the WHO (2022) estimates that only 44% of children worldwide are exclusively breastfed. Benefits of Breastfeeding Benefits for Mothers The literature reports several short- and long-term benefits of breastfeeding in mothers. Some frequently identified short-term benefits include uterine involution, decreased bleeding, and reduced risk of postpartum depression (Del Ciampo & Del Ciampo, 2018; Jonas & Woodside, 2016). Breastfeeding causes increased oxytocin, which is responsible for uterine contraction, subsequently decreasing the amount of blood lost postpartum and lowering the risk of postpartum hemorrhage (Almutairi, 2021). Furthermore, an emerging body of research has provided evidence for a connection between oxytocin, breastfeeding, and postpartum depression. Stuebe et al. (2013) revealed that women who breastfed their infants at two months postpartum demonstrated higher oxytocin levels. This increase in oxytocin corresponds with a noticeable reduction in self-reported 2 depressive symptoms compared to mothers who do not breastfeed. Similarly, Zelkowitz et al. (2014) observed that mothers with elevated oxytocin levels exhibited fewer symptoms of depression despite contending with heightened stress levels. This convergence of findings across multiple studies demonstrates the pivotal role of oxytocin and breastfeeding in the attenuation of postpartum depressive symptoms. Furthermore, breastfeeding has notable long-term protective effects against ovarian and breast cancer. Notably, a comprehensive review by Babic et al. in 2020, encompassing 13 case-control studies, revealed a 24% reduction in the risk of ovarian cancer associated with breastfeeding. Although this research domain is still growing, it is theorized that suppressing estrogen and ovulation curtails the environment for mutations. Beral et al. (2002) demonstrated a discernible correlation between extended breastfeeding duration and a decreased breast cancer risk. This phenomenon can be attributed to the temporary reduction in estrogen levels during lactation, which prompts a decline in cellular proliferation and minimizes the likelihood of mutations (Beral et al., 2002). Globally, 20,000 breast cancer-related fatalities can be averted by widespread breastfeeding adoption (Victora et al., 2016). Therefore, breastfeeding is pivotal for reducing the risk of breast cancer. Benefits for Baby Many researchers have found that breastfeeding improves infant health. The most frequently identified benefits include improved cognitive development, reduced risk of childhood obesity, reduced risk of type 2 diabetes, diarrhea, and acute respiratory infections (Tarrant et al., 2010; Nunez et al., 2023; Yan et al., 2014). Additionally, emerging studies suggest an association between increased breastfeeding and improved cognitive development. Luby et al.'s (2016) longitudinal study over 11 years 3 supported this association with improved cognitive development, in which breastfeeding, socioeconomic, and magnetic resonance imaging data were collected from 148 participants. The data showed that breastfeeding affected participants' IQ through increased gray matter development (Luby et al., 2016). These findings are similar to those of Nunez et al. (2023), who found that increased breastfeeding duration is positively associated with gray matter development and improved emotional regulation. These studies suggest that gray matter development is enhanced by breast milk intake in early childhood. Many systematic reviews have found that breastfed children are less likely to become obese (Binns et al., 2016). Yan et al. (2014) measured this impact by analyzing 17 studies on breastfeeding duration and its effect on obesity in children. Children who were breastfed for seven months had a significantly lower risk of becoming obese, whereas those breastfed for three months or less were only 10 percent less likely to be obese (Yan et al., 2014). This protective effect can persist into adulthood (Binns et al., 2016). Pneumonia and diarrhea are significant contributors to child mortality, particularly in children under five years of age (Morrow & Rangel, 2004). Studies have revealed the potential of breastfeeding to play a pivotal role in reducing the alarming statistics. Tarrant et al. (2010) found that infants exclusively breastfed for three months were less likely to be hospitalized for respiratory or gastrointestinal infections within the first six months of life. It has been suggested that breastfeeding could avert 72% of hospital admissions for diarrhea and 57% for respiratory infections (Victora et al., 2016). A higher aversion to hospital admissions significantly reduces the risk of illness and death among breastfed infants (Victora et al., 2016; WHO, 2018). The mechanism underlying this safeguarding effect is the transfer of maternal antibodies through breast milk and beneficial components such as lactoferrin (Morrow & Rangel, 2004). Due to 4 these factors, breastfeeding has emerged as a potent means of averting an estimated 823,000 infant deaths annually (Victora et al., 2016). Prevalence of Breastfeeding Globally, both early initiation and exclusivity of breastfeeding are increasing. Zong et al.'s (2021) secondary analysis of breastfeeding trends from 2000 to 2009 and 2010 to 2018 showed global increases in early breastfeeding initiation and duration. However, breastfeeding initiation and exclusivity vary considerably from region to region. Africa's early breastfeeding initiation is 55.8%, with a six-month exclusivity of 41.7%. The Americas sit at 61.2% and 43.9%, Eastern Mediterranean at 42.6%, 34.5%, European 67.0%, and 43.7%, and South East Asia/Western Pacific at 47.4% and 55.2%, respectively (Zong et al., 2021). All these countries have seen growth in exclusive breastfeeding rates, except for the Eastern Mediterranean (Zong et al., 2021). While the proportion of breastfed infants has increased over the years, these results are still below the WHO (2021) target of 50% of infants' EBF by 2025 and 70% by 2030. In Canada, 91% of parents begin breastfeeding; however, 15% stop within the first month of breastfeeding (Statistics Canada, 2022), and this number continues to decline over time. By six months, only 62% of infants are breastfed; of these, 35% are exclusively breastfed (Statistics Canada, 2022). The most common reasons reported for breastfeeding cessation include insufficient breast milk, inconvenience, fatigue, medical conditions, difficulty breastfeeding, returning to work or school, and self-weaning (Ricci et al., 2023; Statistics Canada, 2022). The current downward trend in breastfeeding rates indicates that breastfeeding support and implementation are insufficient in Canada. 5 Ten Steps to Successful Breastfeeding The WHO (2018) and United Nations Children's Fund (UNICEF) released a global Baby-Friendly Health initiative in 1991 to increase breastfeeding duration and exclusivity. This included a list of measures that were recently updated in 2018. The measures were divided into management procedures and clinical practices (Table 1). Each step is designed to support the best choice for the individual family unit by providing knowledgeable staff, proactive care towards potential barriers, and promptly establishing breastfeeding (WHO, 2018). Once the facility meets the rigorous standards set by the WHO and UNICEF, it can become a designated baby-friendly facility. Table 1 Ten Steps to Successful Breastfeeding Step 1 Communicating written infant feeding policies to staff and parents that comply with the International Code of Marketing of Breast Milk and Substitutes and establishing monitoring of breastfeeding versus formula supplementation Step 2 Ensuring staff competency when supporting breastfeeding. Ensuring that 80% of newborn care staff have received breastfeeding training and competency assessments in the past two years. Step 3 Discuss the importance of breastfeeding among pregnant families. Including explaining the recommendations of EBF for the first six months of life, the importance of skin-to-skin contact, early initiation of breastfeeding, rooming-in, positioning, and feeding cue recognition. 6 Step 4 Facilitating skin-to-skin for at least 60 min postpartum and breastfeeding as soon as possible. Step 5 Support the initiation and maintenance of breastfeeding. Including assistance with latching, positioning, and providing emotional support. Step 6 Do not supplement breastmilk feeding unless medically required, as breastmilk substitutes interfere with milk production. Step 7 To have the birth parent and infant room together. To help parents recognize feeding cues. Step 8 Support parents in recognizing feeding cues and feeding on demand. Step 9 Counsel parents on the use of bottles, teats, and pacifiers. To caution families regarding the potential interference of feeding cues, sucking reflexes, and oral hygiene issues. Step 10 Provide discharge support and care. Note. Adapted from the WHO Implementation Guidance (p.39-41), 2018, Institutional Repository for Information Sharing. 7 Adaptation in Canada Following the World Health Organization's release of the Baby-Friendly Initiative (BFI), the Breastfeeding Committee for Canada (BCC) was established to support and protect informed infant feeding practices through the implementation of the BFI (BCC, 2023). The BFI was first launched in British Columbia in 1998 (Dumas & Venter, 2017). Since 1998, 10 provinces and two territories have adopted the BFI in hospitals or community health services (BCC, 2023). Achieving the Baby-Friendly designation requires commitment and collaboration between healthcare professionals, administrators, and community stakeholders. In Canada, this process unfolds in stages, each with specific milestones designed to prepare facilities for adherence to BFI guidelines. It begins with the establishment of a multidisciplinary Breastfeeding/BFI Committee composed of administrators, direct care staff, and community members (BCC, 2022). This committee lays the foundation for implementing the BFI standards and developing a strategic plan to guide the facility (BCC, 2022). The next step is the self-assessment phase, in which facilities use the Breastfeeding Committee for Canada BFI Guideline Checklist and Implementation Guidelines. This evaluation highlights strengths and identifies areas for improvement, creating a roadmap for alignment with BFI standards (BCC, 2022). In some provinces, facilities can achieve recognition through a Certificate of Intent after forming a workgroup, appointing a BFI lead, and committing to implementing the BFI guidelines. They may also request a Certificate of Participation once a BFI Committee is in place, a self-assessment is completed, a work plan is developed, and breastfeeding metrics are reviewed, signaling active engagement in the process (BCC, 2022). Facilities seeking additional guidance can request an optional capacity-building visit from a BCC-certified Assessor (BCC, 2022). These visits, which can be virtual or in-person, involve a 8 Memorandum of Understanding and help facilities refine their approach and readiness for the subsequent stages. Facilities bear the costs of these visits, including honoraria, travel, and accommodations. After capacity building, the BFI pre-assessment stage prepares the facilities for external evaluation. This involves a detailed document review including policies, protocols, educational materials, and breastfeeding data submitted to a Lead Assessor. Following this, a site visit by the assessor evaluates the facility's practices and engages with staff and clients to determine readiness for the next phase (BCC, 2022). External assessment is the final evaluation phase and is conducted over two to five days by a team of certified assessors, depending on the size of the facility (BCC, 2022). This stage involved interviews with staff and clients, observations of practices, and a review of the monitoring data. If all standards are met, the facility is awarded a Baby-Friendly designation which is valid for five years. Facilities that do not fully meet the standards may receive a Conditional Designation and must implement an action plan within 90 days to address deficiencies. Those demonstrating significant progress but not fully meeting the criteria may receive a Certificate of Commitment valid for one year with possible extensions (BCC, 2022). Facilities achieving designation celebrate their success by sharing the milestone with staff and the community (BCC, 2022; WHO, 2018). A framed BFI Designation Award is presented, and the achievement is listed on the BCC website and communicated to UNICEF Canada. Maintaining the designation involves ongoing compliance, including annual reports on service changes and breastfeeding data, biennial interim reports addressing progress and barriers, and a complete reassessment every five years. This comprehensive and collaborative process ensures that facilities uphold high breastfeeding support and care standards during and after achieving the Baby-Friendly designation (BCC, 2022; WHO, 2018). Although this can be lengthy, more 9 than 20,000 facilities have received a BFI designated in 150 countries worldwide (Baby-Friendly USA, 2023). BFI Impacts BFI has demonstrated remarkable success in terms of both increased breastfeeding duration and exclusivity. Its effectiveness has been demonstrated in various studies. For instance, in a randomized trial focusing on breastfeeding promotion, an intervention model based on BFI principles was developed and implemented (Kramer et al., 2008). The initial year of data collection revealed substantial advancements in breastfeeding practices within the intervention group, with an impressive 72.7% engaging in any form of breastfeeding compared to the baseline of 60%. Moreover, the impact of exclusive breastfeeding was particularly noteworthy, with a substantial increase observed at the three-month mark (43.3%) among the intervention group as opposed to a mere 6.4% in the non-intervention groups (Kramer et al., 2008). A similar trend was identified by Camurdan et al. (2007), who evaluated the effects of BFI in a Turkish hospital, noting that breastfeeding duration for the first six months of life increased by a factor of 1.5 times due to BFI. Collectively, these findings highlight the significant positive influence of BFI on enhancing breastfeeding practices and exclusivity rates. Additionally, an exposure relationship has been demonstrated between the number of baby-friendly practices and the likelihood of improved breastfeeding rates (Perez-Escamilla et al., 2016). Tarrant et al. (2010) found that exposure to baby-friendly practices such as early breastfeeding initiation, only breastfeeding during the hospital stay, and providing breastfeeding information was a protective factor against breastfeeding cessation. This connection becomes even more apparent when considering the findings of Zhang et al. (2020), who observed that mothers who did not initiate breastfeeding during their hospital stay were over four times more 10 likely to discontinue breastfeeding by the 3-month mark, in contrast to those who initiated breastfeeding during their hospitalization. Building upon this, Wang and Chang (2023) emphasized that the prolonged duration of breastfeeding can be attributed to exposure to baby-friendly practices, which, in turn, bolstered maternal confidence. A review assessing the impact of BFI on health outcomes revealed a notable correlation between adherence to BFI guidelines and enhanced short-, medium-, and long-term breastfeeding outcomes (Perez-Escamilla et al., 2016). Among the BFI steps, step ten supports the transition from hospital to community (Table 1) and is a pivotal factor in sustaining breastfeeding practices. A comprehensive analysis conducted by Perez-Escamilla et al. (2016) emphasized that robust support for breastfeeding coupled with proactive promotion by well-informed individuals considerably bolstered the long-term sustainability of breastfeeding. In a separate cohort study by Zakarjia-Grkovic et al. (2018), implementing the BFI led to the most significant enhancement in the fourth step (Table 1), increasing infants' nursing attempts by promoting uninterrupted skin-to-skin contact. The findings of this study align with Bramson et al.'s (2010) research, which highlighted the significance of early skin-to-skin contact in promoting prolonged exclusive breastfeeding. However, despite the success of BFI in increasing breastfeeding duration and exclusivity, only 10% of infants are born at baby-friendly facilities, as countries have found it difficult to sustain (WHO, 2018). Difficulties with Implementation Resources Financial 11 The BFI promises to enhance breastfeeding rates, but its global adoption remains limited. The 2016-2017 Global Nutrition Policy Review conducted by the WHO (2017) revealed a notable obstacle: financial challenges associated with BFI. Various nations struggled with funding, burdening hospitals with costs related to assessments and other indirect expenses associated with the initiative (WHO, 2017). In Canada, to facilitate BFI application and designation, the BFI pathway is divided into eight major steps: Establishing a BFI Committee, Conducting BFI Self-Appraisal, BFI Pre-Assessment, BFI External Assessment, BFI Designation, and Maintaining BFI Designation, Reassessment, and Redesignation (BCC, 2022). Each step provides a facility criteria that must be met to continue on the BFI pathway. Each step requires time and resources to satisfy the requirements of the BFI pathway. Often, Pre-assessment fees can range from $1,000 (CAD) if conducted virtually to $3,000 (CAD) for standard in-person assessment costs (M. Ross, personal communication, November 15th, 2024). Additionally, the assessment stage costs $5,000 (CAD) for a medium-sized hospital, making the initial costs of BFI $6,000 to $8,000 (CAD) before including the resources needed to support this initiative or redesignate it in five years (M. Ross, personal communication, November 15th, 2024). Similarly, WHO (2017) estimated start-up expenses to be CAD $20,947, with reassessment costs of up to CAD $12,568 (Xe Currency Converter, 2024). While some nations received government aid for designation expenses, limited support was reported from the Americas and Europe, leaving facilities to bear the financial burden of the BFI (WHO, 2017). This economic strain may have contributed to the slow uptake of the BFI. Staffing Another commonly observed challenge during the implementation of BFI is the shortage of staff, which leads to a general lack of time available for patient intervention (Fok et al., 2020; 12 Pramono et al., 2022b). BFI initiatives require more time for different patient scenarios compared to previous breastfeeding education methods, which, in turn, increases the workload, especially when healthcare facilities are already dealing with inadequate staffing levels (Pramono et al., 2022b; Wieczorek et al., 2015). When staffing levels are insufficient, there is an elevated risk of patients not receiving necessary nursing interventions or limited care (Griffiths et al., 2018; Pramono et al., 2022b). Owing to the challenges posed by poor staffing and the comprehensive nature of BFI, some healthcare providers may not enthusiastically participate in the BFI designation process, even if they acknowledge the importance of breastfeeding. This lack of enthusiasm can be attributed to feelings of burnout (Lundeen et al., 2016; Wieczorek et al., 2015). Therefore, gaining insight into healthcare providers' experiences with BFI is essential to enhance BFI uptake and outcomes for providers and patients. Healthcare Provider's Role in BFI Implementation In Canada, EBF rates are suboptimal, and BFI has been identified as a possible solution to improve the promotion and duration of breastfeeding. However, a challenge is the limited number of hospitals designated as BFI facilities. In British Columbia (BC), there are few BFI-designated hospitals. As the BC Women's Hospital held this designation from 2008 to 2017 and is currently seeking redesignation, St. Paul's Hospital and Penticton Regional Hospital have BFI designations (BCC, 2023). Healthcare providers play a critical role in the successful adoption of BFI. When healthcare providers actively support and advocate for BFI, it is more likely that the challenges associated with its implementation will be overcome (Burnham et al., 2021). Staff nurses and 13 lactation consultants were particularly influential in ensuring BFI's effective implementation and positive outcomes. These professionals promote the benefits of breastfeeding, offer personalized support to mothers, and provide educational guidance (Global Breastfeeding Collective, 2016). Therefore, expertise and active involvement are essential for the successful implementation of BFI. Understanding healthcare providers' experiences and perceptions of the processes and practices associated with BFI is important for improving BFI adoption. This will facilitate the development of informed strategies for enhancing BFI uptake. Purpose There is substantial evidence for the benefits of breastfeeding for infants and breastfeeding persons, especially for a longer duration of exclusive breastfeeding. However, the exclusivity and duration of breastfeeding decreased significantly over the recommended six months, mitigating some of the previously identified health benefits. With support from healthcare providers and BFI steps, breastfeeding duration and exclusivity could increase, allowing mothers and infants to experience the full beneficial effects of breastfeeding. However, little Canadian research has been conducted on healthcare providers, such as staff nurses, lactation consultants, and health authority leads, leading to perceptions and experiences in implementing the Baby-Friendly initiative. Building this knowledge base is essential for addressing specific Canadian barriers to the BFI. Research Questions The specific research questions guiding this qualitative descriptive study are as follows: 14 1. What are the perceptions of British Columbia perinatal nurses, lactation consultants, and baby-friendly health authorities regarding preparation for implementing the Baby-Friendly Initiative? 2. What are the perceived facilitators and barriers for British Columbia perinatal nurses, lactation consultants, and baby-friendly health authorities in preparation for implementing the Baby-Friendly Initiative? 3. What are the perceived advantages and disadvantages of having a baby-friendly designation? 15 Chapter Two: Literature Review Overview A comprehensive literature review was conducted to gain insight into healthcare providers' viewpoints on the implementation and consequences of the World Health Organization's Baby-Friendly Hospital Initiative (BFI). The review included the views of nurses, midwives, lactation consultants, unit managers, and physicians working in the maternal and child health departments of their respective hospitals. The outcomes of this review will help draw attention to obstacles and facilitators in BFI implementation and the designation process. Search Strategy The literature review focuses on healthcare providers' (HCP) perceptions of BFI. Medical Literature Analysis and Retrieval System Online (Medline) and Cumulative Index to Nursing and Allied Health (CINAHL) databases were searched with the following key terms (and synonyms): healthcare providers (healthcare professionals OR clinicians OR nurses OR doctors), perceptions (OR attitudes OR opinion), baby friendly initiative (OR BFI OR BFHI OR baby friendly). Additionally, boolean operators AND were used to link ideas and OR to link synonyms to ensure an exhaustive search. The inclusion criteria were an abstract available, an article in English, and an article published between 2010 and 2022. This period was selected to ensure that only recent and relevant articles were included in the review. The final search strategy produced 87 articles: 48 from Medline and 39 from CINAHL. First, articles were imported into Covidence, a data-organizing software that allows further review. Second, 21 duplicate papers were removed, and the remaining 66 articles were further screened for relevance. Third, 42 articles were removed based on the title and abstract because of lack of relevance. At the same time, an additional 15 were excluded for various reasons, such as not measuring healthcare providers' 16 perceptions, not measuring attitudes surrounding the BFI, and not examining the BFI. Finally, a review of the selected studies' reference lists and Google Scholar were also searched to ensure an exhaustive approach, adding three articles for 15 (Figure 1). Characteristics of the Literature The 15 articles selected from the literature review were published between 2010-2022 (see Table 2). The locations of included studies were Australia (n=4), the United States of America (n=2), Austria (n=2), Canada (n=1), Singapore (n=1), Indonesia (n=1), England (n=1), Taiwan (n=1), Finland (n=1), and Namibia (n=1). Ten of the twelve studies included bedside nurses in their samples. The exceptions are Pramano et al. (2022b), who only focused on midwives, and Amadhila & Van Rensburg (2020), who focused on nurse managers' thoughts on the BFI implementation process. Esbati et al. (2020) included nurses, lactation consultants, doctors, nutritionists, dietitians, community health managers, physiotherapists, breastfeeding counsellors, breastfeeding advocates, complementary therapists and laboratory technicians. Pound et al. (2016) included all employees of a children's hospital with a working email address, which included healthcare providers, allied health members, unit clerks, and technologists. Although this literature review primarily focuses on healthcare providers' perspectives, the birthing experiences of birth parents and participants have also been examined in several studies. In the reviewed studies, no data were presented indicating that any of the study participants were identified as non-binary or a gender other than a woman; therefore, for this review, it is assumed that all participants who gave birth were identified as women and mothers, and the results will be reported as such. Ten of the studies were qualitative. All qualitative studies collected data from individual interviews or focus groups and then performed thematic analysis to identify key findings. Two of 17 the ten qualitative studies were derived from the same sample (Wieczorek et al., 2015; Wieczorek et al., 2016). Three studies were quantitative (Fok et al., 2020; Mäkelä et al., 2022; Pound et al., 2016). The three researchers used a quasi-experimental approach to collect data using pre and post-intervention questionnaires. Pound et al. (2016) created questions based explicitly on the BFI steps to implementation, while Fok et al. (2020) and Mäkelä et al. (2022) focused on demographics, knowledge, attitude, and practice. The remaining two studies used mixed-methods approaches. Huang et al. (2016) focused on identifying shared perspectives among staff members in the maternity units by creating statements from the BFI initiatives focusing on policy and supportive practices and requiring participants to rank them from most likely to least likely in their need for additional resources to support BFI implementation. Huang et al. (2016) followed this ranking by grading the participant's BFI designation experiences using factor analysis. Esbati et al. (2020) used an online survey to explore healthcare providers' perspectives on BFI implementation. Despite the unique approaches to data collection, the themes of policy, leadership, and knowledge were consistently identified as important influences on BFI. Findings Policy Eight of the 15 articles in the literature review were explicit in their unwavering support and recognition of the importance of BFI and the need for improved and aligned policies at all levels of health systems to promote BFI (Esbati et al., 2018; Esbati et al., 2020; Huang et al., 2016; Pramono et al., 2022a; Pramono et al., 2022b; Thomson et al., 2012; Walsh et al., 2010; Wieczorek et al., 2015). For example, Huang et al. (2016) found that study participants identified the need for a solid policy to support breastfeeding practices. In addition, participants in the 18 study by Esbati et al. (2020) perceived that Australian health policies currently do not support the designation or implementation of the WHO BFI, despite the understanding among HCPs that the BFI is a crucial program to promote breastfeeding. The literature highlights various policy limitations and challenges faced by designation. According to Esbati et al. (2020), participants in their study identified government and executive management support as essential for successful BFI implementation. The results of Esbati et al. (2018) and Esbati et al. (2020) have led to recommendations to increase support for the BFI by recognizing it as a health priority and providing monetary support. However, despite these recommendations, there is a reported lack of budget prioritization and support from executive management (Pramono et al., 2022a; Walsh et al., 2010) for BFI implementation, with some participants reporting that budget requests are rejected, and staff are told to do more with less (Walsh et al., 2010). Designation Nine studies reported that WHO-BFI hospital designation is the ideal standard for achieving breastfeeding outcomes by increasing staff and patient knowledge, as well as the initiation and duration of breastfeeding (Esbati et al., 2018; Esbati et al., 2020; Huang et al., 2016; Lundeen et al., 2016; Mäkelä et al., 2022; Pound et al., 2016; Pramono et al., 2022a; Thomson et al., 2012; Wieczorek et al., 2015). In addition, Lundeen et al. (2016) and Burnham et al. (2021) identified the BFI designation as a source of pride among staff. Burnham et al.'s (2021) study participants identified that the designation process is worthwhile because of its improved breastfeeding knowledge for staff and improved patient care outcomes. However, the process of achieving a designation faces several challenges. Some of the challenges identified in the literature include lack of time and resources. 19 Time In four studies, time was identified as a barrier to BFI implementation, which many study participants attributed to being short-staffed. Short staffing contributes to an increased and unmanageable workload, decreasing the time to support mother-child bonding and providing breastfeeding education (Fok et al., 2020; Pramono et al., 2022b; Wieczorek et al., 2015). For example, in the study by Pramono et al. (2022b), 23 midwives participating in two focus groups identified lack of time as a significant limitation in BFI implementation. Midwives attributed the decreased time spent with their patients to quick discharges and heavy workloads. In addition, participants identified that because of quick discharge and shorter education periods, mothers could not adapt to their new baby and receive support for more complex breastfeeding challenges. Similarly, Fok et al. (2020) found that the main barrier for nurses in their study was the lack of time to provide breastfeeding education owing to a heavy workload, which subsequently impacted breastfeeding initiation and duration. These findings are further supported by Pramono et al. (2022b), who concluded that time is a critical resource in hospitals and that policies must ensure that new mothers receive the time required to support BFI outcomes. Resources An examination of the literature has identified the need for resources as a significant challenge in implementing BFI. Additional staff were identified as a necessary resource to implement the steps required by the BFI (Amadhila & Van Rensburg, 2020; Esbati et al., 2018; Pramono et al., 2022a). Pramono et al. (2022b) and Esbati et al. (2019) found that nurses had difficulty spending adequate time with mothers and babies. In addition, the BFI goals of care, such as initiating skin-to-skin contact, only increase the demand for additional staff support 20 (Amadhila & Van Rensburg, 2020). Consequently, implementing the BFI is perceived as unrealistic for some hospitals because of insufficient staff (Amadhila & Van Rensburg, 2020). Leadership Participants of seven of the studies in the literature review identified the necessity of good leadership to implement the WHO BFI (Burnham et al., 2021; Esbati et al., 2018; Esbati et al., 2020; Lundeen et al., 2016; Pramono et al., 2022a; Thomson et al., 2012; Wieczorek et al., 2015). The three leadership areas most often identified in the reviewed articles were high-level leadership, nurse empowerment, and collaborative/credible leadership (Burnham et al., 2021; Esbati et al., 2018; Esbati et al., 2020; Walsh et al., 2010). High-Level Leadership Leadership and support from the highest levels of government and hospital administration were deemed critical in four studies (Burnham et al., 2021; Esbati et al., 2018; Lundeen et al., 2016; Walsh et al., 2010). In six studies, the participants recognized that the magnitude of the task of implementing the WHO's BFI requires strong leadership from the highest levels of administration (Esbati et al., 2018; Esbati et al., 2020; Walsh et al., 2010) and the resources necessary for such high-level support. Furthermore, when staff members did not feel support from upper-level management in pursuing BFI designation, they indicated that management did not fully understand the importance of the BFI and its close relationship with public health (Walsh et al., 2010). Maintaining breastfeeding rates is challenging as follow-up breastfeeding support is provided through public health clinics, maintaining breastfeeding rates is challenging (Esbati et al., 2018). Additionally, participants identified leadership changes as a challenge, as people in these roles may change jobs frequently, compromising the process of becoming a BFI-designated facility (Pramono et al., 2022a). 21 Nurses Empowered Burnham et al. (2021) and Lundeen et al. (2016) identify that the success of the BFI was directly linked to the level of empowerment given to the nurses. Empowering nurses with the authority and responsibility to implement the BFI, nurses felt increased accountability for its success and, therefore, invested more effort in the success of the BFI (Lundeen et al., 2016). For example, Lundeen et al. (2016) found that when nurses accepted BFI program leadership roles, they added to their investment and a sense of ownership of the BFI initiative. Consequently, a sense of pride was felt with the successful implementation of BFI practices (Burnham et al., 2021). In addition, participants indicated that nurse empowerment in implementing BFI resulted in a sense of ownership that enabled them to overcome unit barriers, such as resistance and culture shock (Burnham et al., 2021), which resulted in nurses being actively committed to increasing BFI implementation. Collaborative and Credible Leadership In addition to high-level leadership support and nurse empowerment, Wieczorek et al. (2016) and Thomson et al. (2012) determined that collaborative and credible leadership at all organizational levels is crucial for the successful implementation of BFI. Credible leadership is about being knowledgeable and accessible and about approaching challenges that help create an environment with shared values and trust (Thomson et al., 2012). Wieczorek et al. (2016) identify that effective collaborative leadership practices require the continuous investment of time and advocation; however, the long-term payoff is substantial. For example, Thomson et al. (2012) stated that credible leadership and strong advocacy are essential for the success of BFI, as the advocate must be able to gain the trust of mothers and staff members. This leadership and engagement in the BFI project led to a supportive, open environment that enabled BFI. The 22 result is that mothers who receive assistance and guidance from leaders ultimately increase their acceptance of BFI practice (Thomson et al., 2012). Attitudes and Knowledge Eight of the reviewed studies strongly emphasized the importance of knowledge in ensuring the success of the WHO BFI (Burnham et al., 2021; Esbati et al., 2018; Esbati et al., 2020; Fok et al., 2020; Lundeen et al., 2016; Pramono et al., 2022a; Pramono et al., 2022b; Wieczorek et al., 2015). The necessary expertise can be further categorized into areas concerning the perspectives of nurses, doctors, and mothers and the training provided to both nurses and mothers. Nurses Attitudes Four studies indicated that when an initial poor attitude towards BFI existed among nurses and pregnant patients, the success of the BFI was low. Wieczorek et al. (2015) findings show that the staff's attitudes directly affect the success of the BFI. Lundeen et al. (2016) and Wieczorek et al. (2015) attributed this resistance to staff discomfort with changing established practices, lack of confidence, and concerns over increased workload due to integrating BFI practices. However, Mäkelä et al. (2022) found that HCPs' attitudes towards BFI significantly improved after implementing BFI. Wieczorek et al. (2015) and Lundeen et al.'s (2016) findings support this as participants identified that committed transformational leadership could overcome staff's resistant attitudes. Wieczork et al. (2015) identified these leaders as change agents who passionately believe in the BFI and who can influence staff members who are resistant to the BFI. One method that change agents use to influence those who are resistant to change is to ensure that the BFI is a continuation of the best practices that they have always used merely based on using the most current information available (Mäkelä et al., 2022; Wieczork et al., 23 2015; Wieczorek et al., 2016). While the BFI implementation process was frequently characterized as gradual and with some resistance, as BFI practices became more prevalent, most nurses and other staff members recognized its benefits. Although this process can be lengthy, only a few individuals are necessary to significantly influence the success of the BFI implementation (Wieczorek et al., 2015). Physicians Attitudes Several studies have found that physicians' attitudes towards BFI may directly impact its success (Burnham et al., 2021; Lundeen et al., 2016; Wieczorek et al., 2015). Burnham et al. (2021) attributed physician resistance to a cultural change that interfered with the physicians' routines. Burnham et al. (2021) and Lundeen et al. (2016) identified the common practice of physicians was asking for the baby to be weighed right after birth instead of allowing immediate skin-to-skin contact between the infant and the mother, as the BFI requires so the physicians could continue their routine and close their delivery notes. The change in practice has subsequently made some physicians in studies resistant to BFI. Mothers Attitudes Mothers' attitudes are critical in improving breastfeeding outcomes. However, it is essential to recognize that many mothers arrive at the hospital with preconceived ideas about breastfeeding (Pramono et al., 2022b). Family members and cultural practices also influence infant feeding choices, which may conflict with BFI's goals (Pramono et al., 2022b; Walsh et al., 2010). Immediate family members, such as partners and grandparents, can substantially impact breastfeeding duration and exclusivity (Esbati et al., 2020; Pramono et al., 2022b). Preexisting attitudes among family members, particularly grandparents, such as a preference for bottle-feeding, have been frequently reported to influence breastfeeding initiation rates (Walsh et al., 24 2010). These attitudes are often seen as barriers, increasing the challenges for nurses in providing breastfeeding education (Pramono et al., 2022b; Walsh et al., 2010). Thus, nurses must educate new parents and grandparents about the firm's perceptions of breastfeeding (Esbati et al., 2020; Walsh et al., 2010). Education Esbati et al. (2018) and Wieczorek et al. (2015) identify that communicating the message of the BFI's public health impact would increase its uptake. Education can be divided into two parts: nurses and mothers. Nurses Education Nurse education is a crucial aspect of BFI. According to the second step of the BFI, all individuals involved in maternity care, including volunteers, must possess adequate knowledge to implement the infant-feeding policy (Breastfeeding Committee Canada, 2023). Various methods are used for nurse education, and one approach highlighted in the literature is participation in 20 hours of WHO/ UNICEF educational seminars (Fok et al., 2020). In Fok et al.'s (2020) multi-hospital study, the researchers observed that completing 20-hour seminars significantly improved knowledge, attitudes, and confidence among the nursing staff. However, the 20-hour seminars presented some challenges, such as experienced nurses who were already comfortable with their current practices but not as familiar with BFI often viewed the changes as excessive because they extended the time required to perform the tasks (Lundeen et al., 2016). In addition, due to existing staffing shortages and further time demands, nurses are less enthusiastic about acquiring the additional education necessary for BFI-related roles (Lundeen et al., 2016). 25 Consequently, despite most nurses reporting increased knowledge, less than 60% could implement their new training due to time constraints (Fok et al., 2020). This was primarily attributed to the increased time burden associated with the BFI requirements and the preexisting staffing shortage. Mothers Education Mothers who were educated about the benefits of breastfeeding were more receptive to BFI methods (Burnham et al., 2021). As previously identified, many mothers decide whether to breastfeed before giving birth (Pramono et al., 2022b), and their exposure to breastfeeding before birth heavily influences this decision. Burnham et al. (2021) identified that extensive quality education and increased community awareness of BFI's role acted proactively to break the stigma around breastfeeding. Therefore, by increasing the overall knowledge of some of the benefits of breastfeeding through education, mothers are more likely to start thinking about initiating breastfeeding earlier and throughout pregnancy (Burnham et al., 2021). Hence, it is important to include community awareness and comprehensive prenatal education in health visits throughout pregnancy (Burnham et al., 2021; Pramono et al., 2022a). Evaluation of Evidence Fourteen studies used purposeful sampling, which involved selecting participants based on specific criteria relevant to the research question. Pound et al. (2016) employed a convenience sampling method by emailing every paid employee at their hospital to participate in the study. Using convenience sampling may introduce a self-selection bias, as participants with a positive perception of or interest in the BFI may have chosen to participate in the studies. To diversify perspectives on the BFI and mitigate these biases, some researchers have encouraged 26 participation from those with both positive and negative experiences with the BFI in their data collection (Burnham et al., 2021). The transferability of the ten qualitative studies was moderately limited because of the variation in healthcare systems across different countries. It is important to note that only one of these studies was conducted within the Canadian healthcare system, which poses a challenge for applying the findings to the Canadian context. Despite this limitation, the findings of these studies offer valuable insights that can serve as a starting point for future Canadian research. The use of in-depth interviews in these studies effectively captured participants' experiences and identified consistent themes across all studies despite their vast geographical locations. To ensure the dependability and confirmability of findings, researchers commonly employ the triangulation method by utilizing multiple researchers and research methods, as mentioned in several studies. However, it is worth noting that none of the studies explicitly mentioned using audit trials to ensure replicability. The absence of audit trials raises concerns about the accurate reproduction of the studies. Therefore, future studies must consider incorporating audit trials to enhance dependability and confirmability. Implications The importance of the global uptake of BFI cannot be overstated. The existing literature highlights the formidable task of transitioning from conceptualization to successful implementation of a BFI-designated hospital, which requires concerted effort. Nevertheless, researchers have consistently suggested that BFI can enhance breastfeeding outcomes. Recognizing proven positive impacts on maternal and child health is crucial for increasing BFI uptake. BFI-designated hospitals have higher initiation and duration rates of 27 exclusive breastfeeding at discharge than non-BFI hospitals (Zakarjia-Grkovic et al., 2018). These positive outcomes can be attributed to education regarding BFI practices, including responsive feeding, exposure to baby-friendly practices, and enhanced maternal confidence (Wang & Chang, 2023; Zakarjia-Grkovic et al., 2018). However, only 20 hospitals in Canada currently hold a BFI designation (Quebec = 5, Ontario =4, British Columbia = 2, Manitoba = 1, Alberta = 3, Nova Scotia = 3, Newfoundland = 1, Northwest Territories = 1) (Breastfeeding Committee for Canada, 2023). Therefore, it is imperative to understand the barriers to BFI implementation in Canada. To strengthen the implementation of BFI and promote breastfeeding practices, it is essential to address policy limitations, time and resource constraints, leadership strategies, and knowledge gaps through further research. Understanding and resolving barriers and challenges related to policy promotion, alignment, and workload constraints can facilitate evidence-based recommendations and interventions that support successful BFI implementation. Additionally, exploring effective leadership strategies and addressing attitudes towards breastfeeding within healthcare settings can create an environment conducive to BFI adoption. These efforts have the potential to significantly improve breastfeeding outcomes for mothers and infants in Canada, positively affecting their health and well-being. 28 Chapter Three: Methods This study aimed to better understand the perspectives of nurses, lactation consultants, and health authority key leadership team members in implementing the Baby Friendly Health Initiative (BFI). While the WHO released the BFI in 1991, there are only a few Canadian hospitals with designations and minimal Canadian research on the BFI. This section describes the methodology of the study, including its design, inclusion criteria, sample, and setting. Recruitment strategies, data collection, data analysis, ethical considerations, and research rigour were explored in the context of the proposed study. Timeline See Table 5 for the timeline of checkpoints used in this thesis. The primary research questions were as follows: 1. What are the perceptions of British Columbia perinatal nurses, lactation consultants, and baby-friendly health authorities in preparation for implementing the Baby-Friendly Initiative? 2. What are the perceived facilitators and barriers of British Columbia staff nurses, lactation consultants, and baby-friendly health authorities in preparation for implementing the Baby-Friendly Initiative? 3. What are the perceived advantages and disadvantages of having a baby-friendly designation? 29 Methodology To address the research question, I selected a methodology that allowed the findings to remain as close as possible to the participants' experiences. I used a qualitative descriptive methodology that provided a rich description of the phenomenon while staying close to the findings (Neergaard et al., 2009; Sandelowski, 2010). This allows for a straightforward approach to understand others' experiences (Sandelowski, 2010) by accounting for the subjective nature of reality from person to person (Doyle et al., 2019). Using this approach, I gained a deep understanding of participants' experiences with the BFI. Sampling Purposeful sampling was used to recruit participants. Purposeful sampling allows for the identification and selection of individuals who can provide rich narratives to answer the research question (Palinkas et al., 2015). For this study, participants were nurses, lactation consultants, and Baby-Friendly Health Authority leads who were invited to participate. Additionally, snowball sampling was used as participants were able to recruit others to participate in this study. This study was conducted in three maternity units in British Columbia, Canada. Site 1 is an urban hospital used by a smaller working professional community that has held its BFI designation since 2023. Site 2 was an urban hospital specializing in women's health that delivered most babies across the province. It received its BFI designation in 2009, and has undergone multiple reassessments. Site 3 is a semi-urban facility that has recently received BFI designation. This study, conducted as part of a Master of Science in Nursing degree, primarily focused on nurses, lactation consultants, and BFI leads because their roles are central to implementing BFI principles within the Canadian healthcare system. These professionals were selected because 30 of their direct involvement in breastfeeding support, policy implementation, and educating families and staff, making their contributions indispensable for the initiative's success. Nurses are pivotal in implementing BFI principles because they are often the first point of contact for mothers and newborns in hospital and community health care settings. Nurses play a crucial role in providing immediate postpartum care, which includes promoting skin-to-skin contact between the mother and baby and supporting breastfeeding initiation within the first hour after birth, key practices foundational to the BFI's Ten Steps to Successful Breastfeeding. In addition, nurses educate parents by providing them with essential knowledge and emotional support to confidently address common breastfeeding challenges. Their frontline role enables them to observe and document breastfeeding practices and to ensure adherence to BFI standards. Nurses' frequent and direct interactions with families allow them to foster a supportive environment for breastfeeding, which is a cornerstone of the initiative. Their significant contributions to health promotion and central role in patient care make them indispensable participants in this study. Lactation consultants brought specialized expertise to breastfeeding and lactation management, making them another key group in this study. These professionals address complex breastfeeding issues such as latching difficulties, insufficient milk supply, and breastfeeding pain. Lactation consultants in Canada hold International Board-Certified Lactation Consultant (IBCLC) credentials, reflecting their advanced training and competence in lactation care. Their role extends beyond direct patient care, including training and mentoring healthcare providers such as nurses, on evidence-based breastfeeding practices. Lactation consultants advocate creating breastfeeding-friendly environments within healthcare facilities, ensuring that institutional policies align with BFI goals. Their specialized knowledge and ability to navigate 31 clinical and systemic challenges makes them vital to the BFI team. Their inclusion in this study provides valuable insights into practical and institutional obstacles to promoting breastfeeding. BFI leads play a critical role in BFI implementation, as they oversee the adoption and maintenance of BFI standards within healthcare organizations. Their responsibilities include • Developing and enforcing policies aligned with the Ten Steps to Successful Breastfeeding, • Monitoring adherence to these policies, and • Evaluation of their impact on maternal and infant health outcomes. Additionally, the BFI leads to coordinate training programs for healthcare staff and facilitates interprofessional collaboration to ensure consistency in breastfeeding support across departments. Achieving and maintaining BFI accreditation requires strong leadership and commitment to quality improvement, exemplified by the work of BFI leads. Their strategic oversight and ability to manage the complexities of organizational change make them an essential focus of this study. The exclusion of physicians in this study was a deliberate decision based on practical and conceptual considerations. In Canada, physicians typically bill for their time through MSP, making it logistically challenging to engage them in voluntary research studies. Unlike nurses, lactation consultants, and BFI leads, who are often salaried or funded through institutional budgets, the fee-for-service model tightly regulates physician time. This makes arranging interviews or focus groups with physicians difficult, without significant financial or scheduling accommodations. Furthermore, this study focused on nursing and allied health professionals, reflecting its context as part of a Master of Science in Nursing degree. While physicians 32 undoubtedly play an important role in maternal and infant care, their scope of practice and engagement with BFI principles differs from those of the study's target participants. By excluding physicians, this study can explore the nursing and allied health perspectives most relevant to implementing BFI principles. The inclusion criteria for participants at these sites were as follows: • A nurse or lactation consultant who provides care at the selected Baby-Friendly Hospitals • Has at least six months of experience with the BFI processes Nurses or lactation consultants with minimal BFI experience, such as students, and those with less than six months of experience working in a unit that is or is becoming BFI-designated were excluded from the study. Guest et al. (2006) found that with a purposeful sample and the goal of understanding a particular phenomenon, 12 participants were sufficient to reach data saturation. To achieve data saturation in this study, the target was to enroll between 15 and 25 participants. This sample size was chosen because of the diverse composition of the study group, which included nurses, lactation consultants, and BFI leads, each with distinct roles within the healthcare system. As this study was voluntary, a $20 Starbucks gift card was used to incentivize participation. Recruitment After obtaining ethical approval, a letter of information (Appendix A) and a poster (Appendix B) were sent to the unit managers via email and Canada Post at the identified hospitals, inviting the participation of the unit's nurses and lactation consultants. Managers were asked to share this letter and poster through work emails and advertise the posters on staff lounges. All participants were invited to contact the primary study person to review their 33 eligibility and set up one-on-one interviews. Additionally, the BFI Health Authority leads were sent a letter of information (Appendix C) inviting their participation in this study. All potential participants were encouraged to ask questions if they were interested in participating or wanted further information. Informed Consent An informational letter via email (Appendix E) was provided to potential participants before committing to this study, inviting anyone interested in inquiring. When potential participants reached out to inquire about the study consent forms, the study’s purpose, voluntary nature, and right to withdraw at any point in time were explained (Appendix F). If a potential participant was interested, an interview was arranged and the consent form and demographic questionnaire (Appendix G) were emailed to the participant. This included contact information from both the principal and primary investigators. Before starting the interview, informed written consent was obtained from the participants and any questions were answered. The purpose of the audio recordings was described, and confidentiality was ensured. The participants were encouraged to ask questions during the interview or stop if needed. The data were collected through audio recordings of the Zoom calls and transcribed by the interviewer using Zoom transcription to ensure accuracy. In addition, I kept a reflexive journal to track my observations and thoughts during the interviews, thus allowing self-reflection and the completion of an audit trail. Data Collection Sandelowski (2000) recommended using semi-structured interviews (SSI) while using a qualitative descriptive methodology, as it allows participants to express their perspectives fully. Therefore, individual SSIs were conducted using Zoom software. Using Zoom as an interview 34 tool allowed for a larger geographical region to be included in this study. Individual interviews were selected rather than focus groups to avoid scheduling conflicts related to the nature of shift work and illicit an individual perspective. Each interview began with an overview of the study and an introduction of the interviewer. The interviews ranged from 15 to 50 min, with abundant time for participants to answer and ask questions. The interviews were open-ended questions with probes to encourage in-depth responses (Appendix D). The interview questions were developed based on the findings from the literature review and discussions with my thesis committee and adapted during the interview process based on themes that arose. The intention was to gather as much insight as possible from each participant. A final open-ended question was asked to allow participants to address anything they deemed important that was potentially missed in the interview. After each interview, I used Zoom's transcription feature to transcribe the most recently completed interview. The interviews were transcribed verbatim to avoid changing the participants' dialogue. However, when presenting the quotes in Chapter Four, de-naturalism was utilized to remove idiosyncratic elements of speech, such as stutters (Point & Baruch, 2023), to enhance the clarity of participant statements. It was anticipated that the interviews would be conducted over a six-to eight-week period. However, the process took 15 weeks due to staggered operational approvals and difficulties with participant recruitment. Data Analysis Thematic analysis of the transcripts was performed. Thematic analysis is a well-identified approach to exploring qualitative data. Thematic analysis uses keywords to identify repetitive 35 themes until research conclusions linked to the data are identified (Addom et al., 2016; Braun & Clarke, 2006). For the qualitative descriptive methodology, a semantic approach was used for thematic analysis. In other words, themes that were explicitly identified as being as close to the data as possible were identified (Braun & Clarke, 2006; Sandelowski, 2010). Braun and Clarke (2006) developed a structured six-step approach to conduct thematic analysis (Table 4), used in this study to identify patterns in healthcare providers' perceptions of BFI. The first step involves becoming acquainted with the data through a meticulous review and transcription of the audio-recorded Zoom sessions. This initial immersion identified emerging patterns and themes as transcripts were repeatedly examined (Braun & Clark, 2017; Braun & Clark, 2006). A comprehensive review of the transcripts has enabled the accumulation of potential thematic codes. The codes were compiled and organized using NVivo14 qualitative data analysis software. By grouping these smaller codes based on similarities, larger themes arise from the data. This often involved scrutinizing codes for consistency and fit within their assigned themes, even breaking down codes into subthemes if necessary (Braun & Clarke, 2006). Once themes were developed, they were compared with the data to ensure code consistency and accurate representation of the findings. This ensures validity in the themes, as inadequacies in coding typically appear at this stage, and adjustments to themes may occur (Nowell et al., 2017; Terry et al., 2017). Finally, the themes are defined and summarized, forming the fifth chapter of my thesis. The final stage involved articulating and connecting thematic analysis results to the original research question. 36 Rigour Ensuring research rigour is essential to prevent bias and maintain the accuracy of the findings. Morse et al. (2002) express the importance of attaining rigour in qualitative research by using verification strategies during the inquiry stage, as without rigour, research becomes worthless. Lincoln and Guba's (1985) criterion for trustworthiness is a common method to ensure rigor in qualitative research. The four criteria that comprise the concept of trustworthiness are dependability, credibility, transferability, and confirmability (Table 3) (Lincoln & Guba, 1985). Lincoln and Guba (1985) described dependability as the reliability of their findings over time. The primary measure to ensure the dependability of the research is the audit trail (Morse, 2015). Creating an audit trail will allow for an external review of the steps and outcomes of this study. The dependability of the research in this study was addressed using audio recordings of all interviews, which allowed for verbatim transcription. Additionally, I used field notes and a reflexive journal to help provide context for the interviews when reviewing the transcripts. These dependability methods can create an audit trail as they allow my thought process to follow. Credibility is defined as the plausibility and truthfulness of a finding (Tracy, 2010). Some ways to ensure credibility include thick descriptions and peer debriefing (Tracy, 2010). I gathered detailed descriptions by asking participants for further details during the interviews, and closely reviewed the coding and themes with my supervisor. Debriefing with my supervisor subsequently increased credibility, as they brought a different perspective to the coding and interview processes (Korsthens & Moser, 2017). For example, after reviewing the initial interview transcripts with my supervisor, it was suggested that I ask more open-ended questions and use specific probes, such as Tell me more about that, to help participants share more about their experiences. 37 Transferability is the ability to apply study findings to other contexts (Morse, 2015). It was important to collect rich data using field notes to make the research transferable to other settings. I completed this by keeping detailed notes on the participants’ responses to the questions, including their reactions and changes in body language when their video remained during the interview. This allowed me to find areas of discussion that would be further probed in the interviews or with subsequent participants. In addition to helping transferability, I included the context of the research sites and how the participants were recruited to help other researchers decide whether the findings of this study are transferable to their site of research. Korsthens and Moser (2017) describe confirmability as "the degree to which other researchers could confirm the findings of the research" (p.121). Measures of confirmability include triangulation and audit trials (Morse, 2015). Lincoln and Guba (1985) suggested using memo writing and reflection to avoid personal bias and increase the confirmability of a study. Therefore, during this study, I was self-reflexive and kept a journal of my thoughts and choices during the interview process. This helped me stay organized and avoid personal bias in the data, as I could explore my thoughts about how the interviews went and ideas that I wanted to explore further. Ethical Considerations Before proceeding, this study was approved by the University of British Columbia Okanagan's Behavioral Research Ethics Board (BREB) (UBC REB Number H23-02411), UBC Children's and Women's Research Ethics Board, Providence Health Care, and Interior Health. The primary contact holds a Tri-Council Policy Statement Conduct for a Research Involving Humans Course on Research Ethics (TCPS 2: CORE) certificate as per the university guidelines. 38 Participants were given consent forms (Appendix F) that reviewed the study’s purpose, procedures, potential risks, and confidentiality. Additionally, I obtained verbal consent at the beginning of each interview and explained to the participants the right to refuse or withdraw from the study at any point. The participants were given a $20 Starbucks gift card for participation. The research findings will be shared with the participants who indicated that they would like to receive the results once the thesis was completed. Other measures were taken to ensure the safety and confidentiality of the participants. Data were collected on a UBC-licensed Zoom account. The Zoom servers used to interview participants were in Canada. Zoom records audio and video files; however, the video files were not retained, and the audio-only files were transferred to Microsoft OneDrive. Additionally, participants could leave their cameras off during the interviews. The interviews were transcribed verbatim and all participants received pseudonyms in the interview notes and written reports for identification purposes. All contact information and audio files were stored on a secure, password-protected computer. Only the study team will have access to the raw data. All data were retained and stored according to the BREB guidelines. 39 Chapter Four: Results This chapter describes the study sample using an overview of the demographic forms completed by nurses and lactation consultants who participated in the interviews. In addition, it will present the thematic findings from interviews with the participants who shared their experiences with the Baby Friendly Hospital Initiative (BFI). Participant Characteristics Participant recruitment was conducted between January 28 and May 15, 2024. During the 15 weeks, 12 semi-structured interviews were conducted. Although the initial plan outlined in Chapter Three aimed to enroll 15 participants, recruitment was difficult because of the study's focus on a highly specific target population. The recruitment process was terminated after 15 weeks. However, data saturation started to occur as many themes were repeated throughout all interviews. Three hospitals with BFI designations in British Columbia were included in this study. Eleven of the 12 participants had backgrounds as registered nurses, six reported holding certifications as International Board of Lactation Consultants (IBCLC), and two reported being the Baby-Friendly Health Authority Lead for their hospital. In contrast, one participant had a background in midwifery and held IBCLC certification. Eleven participants reported having more than six months of experience in their roles. The twelfth left this blank on the demographic form. However, based on their explanation of their work experience, it was evident from their interviews that they had worked for more than six months as healthcare providers. Participants' experience in their roles ranged from 1.5 to 39 years, with an overall median of four years worked in their current role. Therefore, all participants met the inclusion criteria and were included in the study. 40 Table 6 Participant Characteristics Primary Role Years in Position Gender Level of Education Nurse 22 F Postgraduate Nurse 1.5 F Bachelors Nurse 15 F Bachelors Nurse Left Blank F Bachelors Nurse 7.5 F Bachelors Nurse 13 F Bachelors Nurse 1.8 F Bachelors Lactation Consultant 4 F Bachelors Lactation Consultant 1.5 F Postgraduate Lactation Consultant 3 F Bachelors BFI Lead  20 F Postgraduate BFI Lead 7.5 F Bachelors Through data analysis, four major themes emerged from the interviews: (1) staff misunderstandings, (2) challenges with education, (3) leadership, and (4) the impact of the social determinants of health (Table 7). Participants’ quotes were used to illustrate their experiences and to support the findings within each theme and subtheme. To help protect the anonymity of the participants, randomized numeric coding, P1 through P12, was used to refer to the individual interviews. 41 Table 7 Overview of Themes Themes Subthemes Misunderstandings Overcoming Resistance Accountability Challenges with Education Effective Education Competency Checklists Importance of Leadership Senior Management BFI Leads A Group Effort Considering the SDOH Misunderstandings From their first encounter with the BFI, 11 participants described drastic changes in their understanding over time. Specifically, P8 identified that "we all have had the same misunderstanding that it is only about breastfeeding. It pushes women to want to breastfeed or breastfeed, and it is just to breastfeed, breastfeed, and breastfeed. That is what it is." This misunderstanding was reported in all interviews. It was a major source of pushback from staff nurses in the initial phases of the BFI designation process to the point where a nurse champion took a step back from their role as "she felt like she was kind of being seen as, like this breastfeeding Nazi' (P6)". The participants expressed this pushback due to a lack of understanding of the true meaning of BFI designation and fear that they would be forcing 42 birthing parents to breastfeed. Once time was taken to fully explore the initiative on the units, the participants articulated that their initial resistance and understanding of the BFI had changed to incorporate the idea that the BFI was to support families in meeting their goals during pregnancy and not pressure parents into a specific choice of infant feeding. While recognizing that not every family will breastfeed, the participants did not "want [lack of] support to be the reason people do not successfully breastfeed' (P12)". Once their understanding improved, participants agreed that the BFI was designed to support best practices and not just to push breastfeeding. Overcoming Resistance Although enhancing healthcare providers' comprehension improves their resistance, this approach requires considerable time and effort. Participant 11 identified that the initial response to hearing about the BFI designation left staff thinking, "Well, we're not unfriendly to babies. What's that even mean?" Repeated conversations had to occur to help people understand that the BFI was "a quality improvement framework, [and] then people started to be like, aha, okay, we get it now (P8)". This led to gradual changes in attitudes towards support in the BFI across units. P10 noted that when the nurses were charting, conversations about the challenges they were facing would occur, allowing for more collaboration and discussion of the BFI, thus allowing for a better understanding. So "there was this resistance, but eventually, we overcame, and, I mean, it was just, again, repetition, reminders, conversations that had to take place (P10)." Once the staff started to become actively engaged in the BFI, they reported that the standard methods felt more comfortable and were the easiest way to teach parents to breastfeed. One unique way to overcome resistance from staff nurses was by using a video series focusing on birthing parents' feedback to educate floor staff about their current practices. These videos gave families the opportunity to provide unbiased feedback about the care they had 43 received. Birthing parents were asked to avoid naming and blaming the nurses or physicians. For example, one mother in the videos spoke about the overnight separation from her twins, which the staff thought would help her sleep. "Just having her [the mother] talk about what it was like and how she felt when they took the twins out of her room and that the nurses said she'd sleep better, but she didn't sleep at all, and she worried about her babies and, and then she talked about, what that was like it was, it was much more powerful than us trying to explain to the nurses, you know, like, this is what the research says because, of course, there's that kind of feedback (P3)." Not all feedback about the care practices received by families was positive from these videos. This made them an effective tool to help overcome nurses' preexisting beliefs about breastfeeding and current postpartum care practices, as nurses care about their families' experiences. Hearing about how their practices could be improved and aligned with BFI literature was the start of making an effective change. Accountability A reported sense of accountability after BFI was successfully implemented in these units. Eight participants discussed this issue both directly and indirectly. On a macro level, P10 stated that the "BFI holds you to a certain level of accountability… for health organizations, and because of that accountability, there would be many changes needed to be successful." By having this designation, participants felt that breastfeeding had to be taken more seriously by management, as this global designation was one way of advertising their hospital to expecting parents and encouraging them to give birth at their hospital. Moreover, because this designation brought more families to the hospital, it subsequently helped to increase funding for the unit, reinforcing that having a designation proved the value of their work. 44 At the micro level, similar ideas from P2 and P9 were directly expressed, and the BFI designation provided them with a sense of personal accountability. They discussed their desire to contribute to the team in receiving and maintaining the designation. With this designation, P2 described the practices as always just in mind to provide BFI care. While P9 stated it "keeps staff accountable, and it keeps us kind of all on the same level in terms of education and the way that we're treating our patients." They found that the BFI was a protective mechanism to encourage breastfeeding for the parents by consistently encouraging them and other staff to find out what works for the breastfeeding parent when challenges arise. Challenges with Education The importance of providing education to both staff and patients was widely discussed in all interviews. To meet step two in the BFI, ensuring that 80% of the staff has education to support breastfeeding parents, many different approaches have been used. The most reported methods include skill workshops, in-services, online modules, and written materials to be reviewed at the nursing station. These approaches were reported to be beneficial to the basic knowledge of the staff by providing a broad idea of what to expect, but educating the entire staff proved difficult. One participant described attempts to hold in-services on the unit by stating: "It ended up just being a lot. This kind of [just] did not stick because it was a lot of work. We would prepare our talks and presentations, and then we would go in, and there would only be, like, two nurses available. So it wasn't a good use of our time to do that (P6)." Another participant described that coordinating group education through the hospital was difficult by stating, "We struggle a bit, even though it's paid time [it can be difficult] to get nurses to come, and that doesn't apply to everybody, but it does apply to some (P3)". Even if participants completed the modules, there were still challenges, such as the information not being 45 absorbed or nurses simply clicking on the modules, resulting in new education not being utilized in practice. "They're just trying to get it done. We still had to verify the competencies of staff. [This] ended up being a bit more work' (P8)". Effective Education When participants were probed further about how education was effectively introduced into practice, six participants identified that, through trial and error of multiple methods, one-on-one discussions had the largest impact. While this one-on-one education approach was considered more effective, it was also deemed time-consuming and therefore had to be strategically used. Participants from each hospital identified effective one-on-one education in some form of peer mentoring, which relied on staff interested in the BFI to disseminate knowledge. In some cases, this was the formal role of either receiving funding to become an IBCLC or joining the BFI committee. Others informally assumed this role based on their experiences, personal interests, and seniority. Once the nurses who had undergone additional training received their IBCLCs designation, they became "the champions of the unit… There is so much value placed on my new designation and my new knowledge of education (P10)." The participants even noticed that the senior nurses they had gone to previously were using them as a resource. The participants mentioned that the presence of nurses certified as IBCLCs provided more reliable access to support and expert knowledge across all shifts. This arrangement created opportunities to address the challenges in the unit using BFI-informed expertise when such issues arose. Whether this support was formal or informal, it was described by P2 as "huge because, of course, they have more experience than I [have] ever had. Whenever you get feedback from an experienced nurse, that is always helpful." By having nurses with this additional training, the overall ability of 46 nurses to overcome clients' breastfeeding challenges and continue to support breastfeeding parents improved. The need for increased staff education led to further discussions regarding the need for improved lactation consultant hours for participants whose hospitals did not provide the opportunity to receive additional funding for floor nurses to receive IBCLC training. Participant 4 went as far as undergoing IBCLC training and paid for the training to improve their education. While P1 identified that they felt that IBCLC coverage "is really lacking. I feel like we want to breastfeed, designated it should be seven days a week. We need to have support on the weekends, and 8 hours is just not enough." This was further supported by two other participants who noted that IBCLCs were only on the unit four days a week. When discharged home, IBCLC appointments were available in 2 – 3 days, which nurses felt was not quick enough: "When you're going to have to feed your baby 16 times before that two days comes up… immediately would be better (P11)". Although the goal of becoming a BFI-designated unit does not provide IBCLC training to every nurse in the unit, it is beneficial to have nurses with lactation training. It allowed nurses to use their peers for support regardless of the time of day, as at least one nurse on the unit would have this additional training. When participants had someone to turn to when challenges arose, they felt that they had access to the knowledge needed to successfully implement the BFI. In turn, "staff were more confident in being able to teach them [patients], and in turn, they [nurses] look[ed] more confident in learning the information (P9)." Competency Checklists Four participants identified using a competency checklist to ensure nurses had the minimum education required to implement the best practices. Creating a competency checklist allowed participants who played an active role in BFI designation to ensure that the most 47 important information was stressed to bedside nurses and provided time for these important steps to be reviewed together. The participants who reviewed the checklist with staff nurses found it valuable as it helped everyone understand what was expected of each staff member. Prior to the checklists "it didn't really seem to matter what they were reading in the textbook. However, they did not apply this. It was not until we kind of did that skills checklist, taught them how to apply it, and created a cultural shift within the unit that it made a difference (P6)". Similarly, P9 found that when she had to review questions and competencies with another person, "it helped my learning" and improved knowledge on the unit as "everybody picked up different things from what they learned during the process" and could apply it to their practice. Importance of Leadership All three hospitals' ideas on becoming BFI-designated hospitals originated differently. The three participants stated that their idea of becoming a BFI-designated hospital came from their new manager. Another participant identified that the Health Ministry of British Columbia had sent a letter stating that they wanted hospitals that provided maternity care to champion the BFI, leading to their BFI journey. The third hospital's interest was identified by a combination of the unit manager and a breastfeeding art expo. "The expo got a lot of the managers from different units, and for the health authority out, so she's [the expo organizer] able to talk up breastfeeding to senior executives within the hospitals and everything. And so, I think that also received a lot of attention in the right higher levels of the hospital that allowed us to push this forward. (P6)” 48 While interest in BFI came from vastly different sources, eight participants discussed the need for strong leadership to advance this designation. Senior Management Participants spoke about senior management's significance in getting everyone invested in becoming a BFI-designated hospital. P10 noted that "leadership strongly influences the time, energy, and money that is going to be directed towards the cause. And when you have a leader who's very keen and supportive, many changes can be made." When senior management was invested in the BFI and actively sitting on the BFI committees, changes were noticed, including the provision of resources such as staffing changes that would include an additional nurse on the unit to help support the pursuit of BFI designation. P3 highlighted the importance of senior management in keeping the staff accountable. As you cannot force staff to step up in receiving and maintaining the designation, the amount of emphasis that senior management put on the various factors around baby friendliness was identified as essential to prevent straying from the goal. The intentions of senior management were further discussed in three interviews. After a change in leadership and undergoing redesignation, P1 noted that they "had an extra nurse on the unit to help with breastfeeding… then it was like we got the designation, and it [the extra nurse had] just disappeared," which was further discussed by Participant 3, who noted that many staff members were unhappy with the way the management-in-charge had arranged staffing when undergoing designation, as there had been an extra nurse on the unit for the purpose of designation. However, once the designation was received, staff returned to the pre-designation level. Having extra resources for designation purposes only sends a negative message to the staff. Both participants reflected on the negative message this sent to the nurses working on the unit 49 that, despite all the efforts to receive a designation, the management support was only temporary and that they were left to maintain these practices without this extra support once the hospital had received the recognition. This initiative requires people to be passionate and able to continuously push for change. This need is demonstrated in the following excerpt. "You need people who are dedicated to pushing [through challenges] because even once you go through designation, it's, in some senses, almost tougher [to] continue the BFI practices once you have been designated. Before you were[designated], everyone's kind of aware, oh, yeah, we're working on this … [and now is like] okay, we checked that off, and then we've got all these other problems that we're working on or other initiatives (P3)." Two other participants echoed the need for people willing to push through challenges. P10 felt that if senior management were behind the BFI designation process, "You can move mountains, I would say, which is what I think our manager did. She really wanted the designation." Similarly, P7 felt that proactive and supportive leadership when navigating the BFI designation process made it easier. These experiences illustrate that supportive senior management is crucial for the successful implementation and sustainability of BFI. Thus, these participants expressed the need for an environment in which leadership with dedication was maintained and management actively supported ongoing efforts, ensuring that the unit continued to meet and exceed the standards required for BFI designation. BFI Leads One reason participants felt that the BFI was successful was having a designated position to help drive the initiative forward. The following excerpt demonstrates this. 50 "A dedicated position. 100%... I work on other projects, but my focus is on BFI. During the initial stages of trying to become designated, my entire portfolio was just the BFI. Suppose that the position is not present. I do not think we would be successful (P8)." Similarly, eight participants identified that having a passionate BFI leader was essential for overcoming barriers during the designation process. "Having a leader or a person that's implementing BFI that really does feel passionately about it and can kind of explain why it's such an important initiative goes a long way (P11)". P6 described their BFI lead as "a force to be reckoned with who doesn't take no for an answer. So she was really influential, and she just has the respect of everyone." While P11 stated their BFI lead "is so passionate. When she's explaining to people why we are doing this, it's so hard to have anything other than support for it because it really seems like best practice." By having these people who really cared about the BFI, they were able to "really get the ball moving (P4)," and they would go to senior management when needed or "happily sit down with us and go through different techniques (P2)" on the unit. This combination of enthusiasm, action, and unwavering commitment to the goals of the BFI enabled the BFI leads to navigate challenges effectively and drive meaningful change. Consequently, their leadership was deemed instrumental by the participants in the hospital's successful BFI designation, demonstrating the critical role of dedicated, passionate individuals in implementing and sustaining health initiatives. A Group Effort While senior management support and passionate BFI leads were consistently identified as strong prerequisites for success, participants from all three hospitals described the group effort required to achieve this designation. Each hospital had a breastfeeding committee, often led by nurses, midwives, and lactation consultants. The groups met monthly to discuss successes and 51 areas for improvement. As the designation approached, nurses took on tasks such as educating staff in various hospital departments about breastfeeding support, ensuring compliance with the BFI guidelines, and putting up educational posters for patients and families. They would have: "assigned leaders to a specific task. So, you were responsible for talking to the staff on your line about, basically, that educational piece. However, there were also other leaders responsible for making sure that bottles were not sitting out next to the warmer because that was not BFI. Or putting up posters for patients and family members to know about the steps of BFI and that we are a BFI unit and things like that (P9)". Similarly, P11 reported being part of the committee and going: "around with a clipboard and sitting there and be like, okay, we're going to go run through a couple of questions that you might be asked, like, what would be your best answers? Okay, great job, and guys. Here are the talking points that we actually want to make sure that you guys get to if these kinds of things were to come up. So there's a lot of sort of those sort of, like, little mock interview questions, as well as getting in the habit of doing sort of more frequent, like, audits on things like our formula carts to make sure that we are not leaving things lying around on top". These tasks require substantial investment in time and commitment to the BFI process. As P3 noted, most people are already spread thin in the healthcare system, thus posing a personnel challenge to the BFI. The comprehensive nature of the steps involved emphasized the necessity for a dedicated team to effectively attain the BFI designation. 52 Considering the Social Determinants of Health Social Determinants of Health (SDOH) are non-medical factors that impact a person's health, such as income, education, food security, and housing (WHO, 2024). The interaction between the BFI and social determinants of health was directly discussed in two interviews. The SDOH was initially raised when P5 expressed that the strongest indicator for health outcomes was the SDOH rather than breastfeeding; therefore, covering labels or keeping formula out of sight as a part of step one sent a harmful message to families that did not want to breastfeed. Rather, P5 felt that, while there may be some valuable information in the BFI, it is not a unique initiative and, overall, confusing. This is demonstrated in the following excerpt. "I hate it. I think it is confusing for new parents who just want to know if they should have iron. However, it does not focus on the social determinants of health. It discriminates against people who do not have the time or ability to breastfeed. I think it is just not family positive… The fact that we had to cover all the labels, and many of these first-time moms are just wondering if we have any recommendations. They hear various things about iron supplements and formulas or know how many calories their babies are getting. This information has not been well provided. It is so focused on breastfeeding as the number one, as the formula is locked away. What kind of message does that send? That it's as harmful as a narcotic?" This participant goes on to further discuss that babies born in BFI facilities are often part of families that can take an extended time off, afford lactation consultants, and most often do not use substances. Therefore, when bringing this initiative to hospitals that serve more diverse populations, this participant felt that the BFI neglected to consider families that come from lower socioeconomic backgrounds or struggle with substances, ultimately leaving families confused 53 and at risk for undernutrition. Furthermore, this participant felt because of the pressure the BFI places on breastfeeding "a lot of people will try [to breastfeed] while they're in hospital, [but] they already know that they're going to be supplementing the formula because they don't have maternity leave (P5)". A possible explanation for this is that some families facing high living expenses may not be able to afford extended parental leave. Therefore, the overall initiative was considered ineffective for this participant. Similarly, SDOH was discussed with P10, where it was possible to compare and contrast the impact of SDOH on the BFI. P10 works at two different sites, one more with a smaller community and higher socioeconomic status and another hospital where the patient population has a more diverse socioeconomic background with "a huge subset of immigrants, refugees, substance use disorder patients, some more vulnerable populations and communities of women and families that come in to deliver." They expressed that there is this narrative from hospital management that in this more diverse population, "they don't want to breastfeed" and posed the question, "Is it that they don't want to breastfeed, or is that they were never set up for success?" According to P10, recent statistics were collected from this hospital with a patient population of lower socioeconomic status, showing that the initial rate of bringing babies to the breast was "in the seventies or eighties, percent. And I think it speaks to how a lot of women still want that closeness." This participant expressed how knowing this created a feeling of failure to meet the needs of this population and voiced the amount of work required to correct the misinformation and changes required to make BFI practices more accessible. This participant felt that the BFI "positively influenced [their] thoughts and ideas about how we should be aligning more with BFI as best as we can to ensure better patient outcomes." P10's "initial reaction was let us copy and paste" the BFI practices they had learned at the BFI 54 hospital to this hospital with a lower socioeconomic background. However, P10 quickly realized that when you work with different populations, "you have to kind of be creative and think of different interventions, different ways to provide information, different ways to teach, different ways to do the same thing, essentially." For example, when teaching at a BFI-designated site, "I might mention something that is like a cool tool you can use, like a syringe or something that someone could buy if they were really keen and wanted to. Like a nifty cup, for example, branded things. But whenever I teach at [the other hospital], … I am very mindful of the things that I recommend that it would be accessible to anyone." The cut-and-paste approach does not work when working with different populations, as you must be mindful of who you are serving. For example: "You could provide all the English prenatal education you want in [this] area, but it is not going to be helpful because so many of our women are Punjabi speaking, or Afghan refugees…. Sure, we provide prenatal education, but it is all conducted in English. We missed the target here. A huge subset of our population will not find value in an English-speaking prenatal education class (P10)". The participants' experiences with the BFI highlight the importance of a flexible and inclusive approach that considers the diverse socioeconomic and cultural contexts of the families it serves. This tailored approach is crucial to ensure equitable support and positive outcomes for all families. Conclusion While the value of the BFI was not universally shared among the participants, all 12 study participants wanted to enhance the care they provided to their patients. The participants 55 highlighted the importance of staff perceptions, education, leadership, and social determinants of health, emphasizing the need to adapt BFI practices to the population being served. Initial resistance is often rooted in misunderstandings that gradually lead to acceptance and integration through effective education and dedicated leadership. Tailored approaches to education and support, especially in diverse socioeconomic contexts, are deemed essential. Despite these challenges, commitment to best practices and patient support remained consistent, reflecting a collective effort towards achieving and sustaining BFI designation. 56 Chapter Five: Discussion Breastfeeding provides numerous long-term health benefits for both the mother and infant, which is why the World Health Organization (2018) advocates six months of exclusive breastfeeding. The Baby-Friendly Initiative (BFI) was established to promote breastfeeding by creating an environment that supports breastfeeding (WHO, 2018). Camurdan et al. (2007) and Krammer et al. (2008) indicate that BFI has successfully increased the exclusivity and duration of breastfeeding. Introducing families to baby-friendly practices early in their hospital stay makes breastfeeding individuals more likely to continue breastfeeding (Tarrant et al., 2010). Further findings show that when hospitals implement BFI, exclusive breastfeeding rates increase (Shing et al., 2022). Consequently, healthcare providers play a critical role in promoting the success of BFI, as they are knowledgeable about the health benefits associated with these practices and can effectively communicate them to families. Despite the influence of healthcare providers, only a limited number of BFI-designated hospitals exist in Canada. Therefore, the barriers and facilitators to implementing the BFI in the Canadian context must be examined. is important This chapter explores the main interpretations of the findings, including (1) misunderstandings, (2) education, (3) the importance of leadership, and (4) considering the social determinants of health, and uses the literature to add context and further support the results. These interpretations will add to the BFI literature by providing insights into nurses', lactation consultants, and BFI leads' perceptions in British Columbia. This is followed by a discussion of the limitations of this study and its implications for future research and clinical practice. 57 Misunderstandings The study's results indicate misconceptions about BFI among healthcare staff that match a trend in the existing literature. Often, initial resistance stems from a widespread misunderstanding that BFI solely promotes breastfeeding and shames those who choose not to breastfeed, a misperception reported in interviews and previous studies (Lundeen et al., 2016; Wieczorek et al., 2015; Walsh et al., 2010). This misconception leads to skepticism and confusion among healthcare providers, as demonstrated by one participant's query about the purpose of the BFI since their practices were already intended to support babies' health. Overcoming these misconceptions and general resistance to change requires substantial time and effort, with repeated conversations and educational initiatives playing crucial roles. This experience was substantiated by Wieczorek et al. (2015), who highlighted the pivotal role of effective change agents in gradually influencing initially resistant staff members. As discussed by the participants, staff members gradually understood that BFI represents a comprehensive quality improvement framework. This shift in understanding was reinforced through practices such as structured discussions, which facilitated collaborative problem-solving and the positive dissemination of information about the BFI. Over time, resistance was tempered by persistent reminders and ongoing dialogue, leading practices to evolve into what was described as a standard practice that inherently made sense within their care contexts. Similarly, Mäkelä et al. (2022) emphasized the transformative impact of persistent educational efforts, noting significant improvements in healthcare providers' attitudes towards BFI post-implementation. 58 Leadership Successful implementation of the BFI depends on the leadership dynamics that shape organizational commitment and operational effectiveness. Senior management's proactive role in BFI implementation is exemplified by the strategic allocation of resources and cultivation of a supportive culture. For instance, Esbati et al. (2018, 2020) highlighted that hospitals with solid leadership commitment at the highest levels allocate the necessary funds and infrastructure and foster an environment in which BFI principles are integrated into daily practices. Similar to this study, keen management helped bring in resources that kept hospitals on track to become BFI designated. The extent to which the BFI designation process is funded, staffed, and implemented hinges on the impact of people in management decisions. These choices also determine how well BFI is sustained over time. For example, some participants expressed concern about resource allocation when they reported that, after receiving the designation, the extra resources they had to promote the BFI had disappeared. Although the literature review did not reveal instances of resource withdrawal following designation, this finding underscores the significance of maintaining the resources necessary to sustain BFI practices. After obtaining the designation, the BFI can be difficult to maintain if it is considered complete. One reason for removing BFI resources may be the high cost of becoming a BFI-designated hospital. It is estimated that the BFI designation process can cost approximately $6-8,000 CAD for a medium-sized hospital for pre-assessment and assessment. This does not include the resources needed for the initiative, maintenance, or redesignation costs (M. Ross, personal communication, November 15th, 2024). To cut costs once designation is achieved, hospitals may remove the extra resources that support the designation process, such as additional 59 staff members. While the upfront cost is significant, every USD 1 spent on increasing breastfeeding rates is estimated to have a return of $35 in social spending (Quesada et al., 2020). In Canada, researchers estimated that if 45% of babies were breastfed for four months and 75% of babies from the neonatal intensive care unit were breastfeeding at discharge, this would save $27 million (CAD) annually (Baby Friendly Initiative Ontario, 2013). The potential savings by investing in the BFI echo the participant's feelings that while there needs to be sufficient resources, the BFI is a worthwhile investment. Overall success in BFI implementation was observed when the role of BFI champions complemented that of supportive senior management. These individuals, like the leaders described by participants, are driving forces instrumental in driving day-to-day implementation efforts. BFI champions educate staff, ensure compliance with BFI standards, and motivate continuous improvements in breastfeeding support. Thomson et al. (2012) found that distributed leadership among passionate advocates throughout hospital units fosters a culture where every staff member feels invested in the success of BFI initiatives. By decentralizing leadership and empowering these champions, hospitals can overcome implementation barriers and create a network of advocates who sustain momentum and drive cultural changes over time (Wieczorek et al., 2015). By having these champions, there is assurance that BFI guidelines are not merely policies on paper but have become embedded in the organizational ethos, promoting sustained adherence to breastfeeding best practices. Education This study investigated perceptions of the challenges and effective strategies for educating healthcare staff and patients about breastfeeding within the BFI. Various educational methods such as workshops, in-service training, online modules, and written materials have 60 enhanced staff knowledge and readiness to support breastfeeding practices. Despite these efforts, achieving comprehensive staff participation proved to be challenging. For instance, the participants highlighted difficulties in scheduling educational sessions that aligned with the availability of all nursing staff. This aligns with findings from Fok et al. (2020), who stressed that while structured educational seminars improve nursing knowledge and confidence in breastfeeding support, practical barriers, such as staffing shortages and time constraints, hinder the implementation of BFI guidelines. The pivotal role of peer mentoring and specialized training, notably becoming an IBCLC, emerged as a strategy of success for some participants in this study. Nurses who underwent IBCLC training reported feeling significantly more equipped to support breastfeeding parents and emerged as a resource within their units. This finding is consistent with Burnham et al. (2021), who stated that formalized roles through specialized training enhance staff readiness and competence in breastfeeding support. The structured peer mentoring reported by the participants helped foster knowledge transfer and build confidence among the nursing staff. This was attributed to helping to build a supportive environment for breastfeeding initiatives. The practical implications of these findings are substantial for healthcare policies and practices. Addressing logistical challenges, such as ensuring consistent and accessible IBCLC coverage throughout the week, has emerged as a factor that enhances the continuity and effectiveness of breastfeeding support services. This approach was advocated by Burnham et al. (2021), who promoted structured mentorship and designated roles to facilitate effective breastfeeding initiation and continuation. By having HCPs assume ownership roles in BFI implementation, clear and consistent communication and expectations of BFI can be disseminated in practice with appropriate support to meet these expectations. However, adequate 61 staffing and support mechanisms are required to help individuals adapt to their learning needs. This subsequently allows hospitals to better meet the needs of breastfeeding families and improve the overall maternal and infant health outcomes. Furthermore, these efforts align with global breastfeeding promotion initiatives to improve public health outcomes. By enhancing educational strategies tailored to specific challenges within healthcare settings and supporting staff through peer mentorship and specialized training, institutions contribute to broader goals of increasing breastfeeding rates and promoting optimal infant nutrition (Burnham et al., 2021). Social Determinants of Health In the literature reviewed in this study, healthcare providers minimally discussed how SDOH and BFI interact. Participants in this study highlighted critical issues such as the fact that the BFI framework, designed to promote breastfeeding universally, may inadvertently exclude or disadvantaged families from lower socioeconomic backgrounds if adapted poorly. Two participants emphasized that the BFI could not be applied uniformly. Rather, it needs to be adapted to accommodate the specific socioeconomic and cultural contexts of the diverse population for which each hospital provides care. One concern raised by a few participants in this study is the prevailing narrative of healthcare management that immigrants and refugees are disinterested in breastfeeding, which leads to reluctance to invest in improved breastfeeding support for these populations. This misconception is particularly impactful, because the belief that these groups do not prioritize breastfeeding discourages efforts to enhance resources tailored to their needs. However, the idea that there is a disinterest is contradicted by Canadian research, such as that by Chooniedass et al. (2021) and Dennis et al. (2019), who demonstrated that immigrant women in Canada are more 62 likely than non-immigrant women to initiate and sustain breastfeeding. Disregarding the desire of immigrant families to breastfeed overlooks a substantial aspect of healthcare provision, especially considering that Canadian immigrants constitute 23% of the population (Statistics Canada, 2021). Moreover, Higginbottom et al. (2015) found that immigrant families face many systemic challenges in navigating the healthcare system, including a limited awareness of available services, transportation barriers, and language difficulties. These challenges contribute to the lower utilization of perinatal classes and could ultimately lead to decreased breastfeeding. Therefore, there is a pressing need for further exploration of how to make resources more equitable when implementing the BFI. Addressing these barriers and promoting awareness can better meet the breastfeeding needs of immigrant families, thereby improving health outcomes and promoting equity in health care delivery. Recommendations While breastfeeding-friendly initiatives have demonstrated positive outcomes for breastfeeding, additional Canadian-based data on the best practices for implementing and maintaining the BFI designation once it has been awarded is needed. Despite the limited information available on overcoming barriers to receiving and sustaining the BFI designation, I have formulated recommendations for research and practice based on study findings and global literature. Research In light of the previous discussions, gathering more data on the implementation and maintenance of the BFI in Canada is essential. Given the limited research conducted thus far, it is necessary to increase the number of BFI-related studies in Canada, such as longitudinal impact analyses, to evaluate the long-term effects of BFI on maternal and infant health outcomes (Fallon 63 et al., 2019). The long-term impact can be monitored by collecting national statistics that compare breastfeeding rates, maternal satisfaction, and infant health indicators such as obesity and infection rates, as well as health disparities spanning several years after BFI implementation. Furthermore, these studies could assess the cost-effectiveness of implementing BFI practices compared with traditional maternity care models by analyzing cost savings related to improved maternal and infant health outcomes, reduced healthcare utilization, and long-term healthcare expenses associated with diseases that can be prevented through breastfeeding. Practice The BFI is important for promoting optimal maternal and infant health outcomes through evidence-based practice. One significant challenge is the presence of misunderstandings and resistance among healthcare staff regarding the initiative's goals and implementation. Comprehensive educational programs should be developed beyond the basic 20-hour requirement (Baby-Friendly Initiative Strategy for Ontario, 2018). These programs should incorporate interactive workshops, case studies, and testimonials from diverse patient backgrounds to illustrate the holistic benefits of BFI beyond breastfeeding promotion (Semenic et al., 2012). One approach to incorporating case studies and diverse patient experiences into educational methods could include the use of open online educational resources (OER) designed to support hands-on learning. For example, Campbell et al. (2024) created five modules to cover topics ranging from pregnancy and lactation physiology to breastfeeding management under the expertise of IBCLCs and those involved in the WHO and a community of faculty and learners at the University of British Columbia. By using OER, learners can have continuous access to and practice with educational components that offer opportunities for independent study. This subsequently enabled learners to acquire essential competencies in collaborating with diverse 64 families on the sensitive matter of infant nutrition and breastfeeding prior to practical exposure (Campbell et al., 2024). To enhance education and competency among healthcare providers, personalized approaches are key. One-on-one mentoring and peer support programs should be expanded with experienced nurses and lactation consultants mentoring others. These initiatives enhance practical skills, build confidence, and create a supportive learning environment (Fok et al., 2020). Competency checklists should be integrated into regular performance evaluations, focusing on practical applications rather than on theoretical knowledge alone. In addition, ensuring the accessibility of educational resources to patients is vital. To accommodate diverse patient populations effectively, materials should be translated into multiple languages, culturally sensitive, and available in formats suitable for different literacy levels to accommodate diverse patient populations effectively (The Baby-Friendly Initiative Strategy for Ontario, 2018). In addition to education, recognizing that many families want to breastfeed can help HCPs stay motivated to pursue BFI. In a Canadian survey of 944 individuals who had given birth in the past two years, 94% intended to breastfeed once they had given birth (Delawarde-Saïas et al., 2024). The findings of Delawarde-Saïas et al. (2024) align with Canadian statistics that 91% of families initiate breastfeeding (Statistics Canada, 2022). Therefore, it is important to recognize that many families want to breastfeed. Families often stop breastfeeding due to challenges such as insufficient breast milk, inconvenience, fatigue, medical conditions, and difficulty in breastfeeding (Ricci et al., 2023; Statistics Canada, 2022). One way this has been combatted is through BFI practices. Parents who had given birth in hospitals that had high-level BFI practices reported feeling better prepared to overcome difficulties and ease accessing community resources compared to those who gave birth in hospitals with lower-level BFI practices (Groleau 65 et al., 2016). By giving birth at a BFI facility, Groleau et al. (2016) reported meeting their breastfeeding goals. Advertising the success of BFI through regular communication channels, such as newsletters, forums, or video series featuring patient stories that highlight real-world examples of how BFI positively affects patient care and outcomes, can remind HCPs of the importance of this initiative. Leadership Leadership and organizational support are the fundamental pillars of successful BFI implementation. Dedicated BFI leadership roles should be maintained with clearly defined responsibilities (Thomson et al., 2012). These leaders advocate for BFI within the organization, address staff concerns, and liaise with senior management to secure ongoing support and funding. Continuous engagement with senior management is essential (Lundeen et al., 2016; Thomson et al., 2012). They should receive regular education on BFI standards and why they are important, including their role in protecting BFI designation (UNICEF, 2023). It is included in updates on BFI outcomes and successes, reinforcing the initiative's impact on patient care and organizational goals. Moreover, visible leadership support is crucial. Senior management and designated BFI leads should actively participate in educational sessions and discussions, demonstrate commitment, and guide the staff. Their engagement helps align organizational goals with BFI principles by helping to build on their understanding of practice realities (Semenic et al., 2012), which can ensure ongoing support and resource allocation. Long-term Sustainability 66 Long-term sustainability plans should be developed to ensure that BFI practices are integrated into routine clinical practice beyond the initial designation phases. UNICEF UK (2023) released suggestions to help achieve sustainability in the BFI that could be applied to the Canadian healthcare system. The first includes a leadership team with an extensive understanding of BFI standards and the ability to educate and audit staff. This is intended to be a designated role(s) with a designated time to address the BFI to ensure success (UNICEF, 2023). Therefore, applying this to the hospitals in this study would create jobs with a set number of hours for a group of people to help maintain BFI practices, rather than asking staff to take on these roles in addition to their regular workload. The second applicable idea is centered around creating an environment that allows for ongoing learning and critique by providing systems for staff and patients to provide feedback, such as surveys and interviews. This allows staff recognition and provides an avenue of feedback between families, staff, and management (UNICEF, 2023). Using this approach, early misunderstandings or bad experiences by staff or patients can be identified and addressed by management, thereby addressing issues as they arise (UNICEF, 2023). This could promote a positive organizational culture by allowing every individual to hear other people's ideas about overcoming unit-specific barriers. Limitations One limitation of this study is that the nature of the qualitative description, while providing a detailed description of participant experiences, may not be generalizable to a larger population (Doyle et al., 2019; Neergaard et al., 2009). For example, contextual factors such as Canadian healthcare being managed provincially may make it harder to apply these findings to facilities nationwide, as each province will have different funding and standards. Therefore, the 67 purpose of this study was not to create large-scale generalizable findings but to gain insight into the views of a particular experience, adapting the BFI in British Columbia to help guide recommendations for practice. The present study encountered a significant challenge in recruiting participants. During the recruitment process, which was conducted over 15 weeks, I faced difficulties due to the limited pool of eligible participants. This study focused on three hospitals in British Columbia and targeted nurses, lactation consultants, and BFI leads who had experience with the BFI initiative and were willing to participate. As a result, recruitment had to be conducted in specific areas, such as perinatal units within the identified hospitals, and relied on the interests of the participants in the BFI. A broader social media advertising approach would not have been effective as it would have reached a population that did not meet the eligibility criteria. The recruitment process involved managers sending an initial email and placing posters in hallways, which proved to be relatively unsuccessful. The majority of the participants in this study were motivated to participate by another participant who had previously been interviewed rather than by recruitment efforts. After nine interviews, a cutoff date was applied to the interview phase to keep the study moving forward. Although the main findings were repeated in the majority of the interviews, social determinants of health (SDOH) emerged in only two of the interviews near the end of the interview process and were, therefore, limited to being explored in the context of those two interviews. In an ideal scenario, more interviews should be conducted to further explore participants’ perspectives on the BFI and SDOH. However, these findings can also be considered in light of other published studies. Additionally, snowball sampling in this study could have introduced a self-selection bias, mainly because individuals with positive experiences are more likely to participate or be 68 recruited. Snowball sampling involves asking initial participants to refer to others, often from their social networks. This method can inadvertently skew the sample as participants may naturally recommend others with similar experiences or perspectives, especially if they perceive them as favorable or relevant to this study. Conversely, individuals with negative or neutral experiences may be less motivated to participate because of a lack of interest or fear of their perspectives being undervalued. Such bias reduces the diversity of perspectives, which is important for holistic understanding. Reflection & Reflexivity As a novice researcher, I recognize that my inexperience in conducting qualitative research has impacted the quality of my interviews. Initially, I closely adhered to the interview script and did not always follow the lead of the participants to delve deeper into the topics. Although I became more adept at probing as the interviews progressed, I believe that I could have obtained more robust data from a few interviews. For instance, during my initial interviews, I asked a disproportionate number of yes/no follow-up questions. In contrast, as my experience grew, I left conversations more open-ended by asking if the participants could elaborate further. Although some interviews may have been less successful, I was able to generate findings that addressed my research questions. When conducting interviews and analyzing the findings, I was mindful of my stance on the BFI. Although the initiative was generally viewed positively in the research, not all healthcare providers had a favourable opinion. Based on the literature, I assumed that some providers might perceive BFI as forceful and shaming for families who choose not to breastfeed, resulting in mixed opinions among the interview participants. However, most interviewees expressed positive sentiments towards the BFI and emphasized the importance of proper 69 education to enable informed choices and respect for the family's preferences. Nevertheless, I was taken aback when a few participants expressed strong opposition to the BFI, and I wish I probed their thoughts more deeply. In hindsight, I should have prepared additional interview questions for participants with dissenting views on the BFI as this would have yielded more valuable data. Conclusion This study delved into the obstacles faced by healthcare providers when introducing the BFI in British Columbia. The main findings emphasize overcoming misconceptions about the BFI, the significance of comprehensive education and strong leadership, and the necessity of considering SDOH when adapting the BFI to individual hospitals. Misunderstandings about BFI often result in resistance from healthcare staff; however, this study found that ongoing education and structured discussions can effectively change perceptions and overall resistance towards the BFI. Strong leadership, resource allocation, and empowering BFI advocates favourably impacted the integration and maintenance of BFI principles. Furthermore, tailored educational strategies, peer mentoring, and specialized training were promising solutions that equipped healthcare providers to support breastfeeding initiatives while addressing logistical challenges and enhancing breastfeeding support services. Adapting the BFI to address SDOH is not just a tactic but a fundamental principle that ensures inclusivity and equity. This approach acknowledges the unique challenges faced by immigrant families, patients with substance use disorders, and those from lower socioeconomic backgrounds, making them feel equally valued by the healthcare system. 70 In summary, this research underscores the importance of addressing misconceptions, fostering strong leadership, enhancing education, and considering SDOH to successfully implement and sustain BFI, ultimately supporting breastfeeding families and improving maternal and infant health outcomes. 71 References Adom, D., Yeboah, A., & Ankrah, A. K. (2016). Constructivism philosophical paradigm: Implication for research, teaching and learning. Global Journal of Arts Humanities and Social Sciences, 4(10), 1-9. https://www.eajournals.org/wp-content/uploads/Constructivism-Philosophical-Paradigm-Implication-for-Research-Teaching-and-Learning.pdf Almutairi, W. M. (2021). Literature review: Physiological management for preventing postpartum hemorrhage. Healthcare, 9(6), 658. https://doi.org/10.3390/healthcare9060658 Amadhila, J. N., & Van Rensburg, G. H. (2020). Perceptions and experiences of nurse managers of the implementation of the baby and mother friendly initiative in Namibia: a qualitative study. International Breastfeeding Journal, 15(1). https://doi.org/10.1186/s13006-020-00336-2 Babic, A., Sasamoto, N., Rosner, B. A., Tworoger, S. S., Jordan, S. J., Risch, H. A., Harris, H. R., Rossing, M. A., Doherty, J. A., Fortner, R. T., Chang-Claude, J., Goodman, M. T., Thompson, P. J., Moysich, K. B., Ness, R. B., Kjaer, S. K., Jensen, A., Schildkraut, J. M., Titus, L. J., … Terry, K. L. (2020). Association between breastfeeding and Ovarian Cancer Risk. JAMA Oncology, 6(6). https://doi.org/10.1001/jamaoncol.2020.0421 Baby-Friendly Initiative Ontario. (2013, February). Business Case for the Baby-Friendly Health Initiative. BFI Ontario. http://www.bfiontario.ca/wp-content/uploads/2012/10/Business-Case-for-BFI.pdf 72 Baby-Friendly USA. (2023, February 3). The Baby-Friendly Hospital Initiative. Baby Friendly USA.https://www.babyfriendlyusa.org/about/#:~:text=More%20than%2020%2C000%20maternity%20facilities,earned%20the%20Baby%2DFriendly%20designation. Beral, Bull, Doll, Peto, Skegg, Colditz, Hulka, La Vecchia, Magnusson, Miller, Peterson, Pike, Thomas, & van Leeuwen. (2002). Breast cancer and breastfeeding: Collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50 302 women with breast cancer and 96 973 women without the disease. The Lancet, 360(9328), 187–195. https://doi.org/10.1016/s0140-6736(02)09454-0 Binns, C., Lee, M., & Low, W. Y. (2016). The long-term public health benefits of breastfeeding. Asia Pacific Journal of Public Health, 28(1), 7–14. https://doi.org/10.1177/1010539515624964 Bramson, L., Lee, J. W., Moore, E., Montgomery, S., Neish, C., Bahjri, K., & Melcher, C. L. (2010). Effect of early skin-to-skin mother—infant contact during the first 3 hours following birth on exclusive breastfeeding during maternity hospital stay. Journal of Human Lactation, 26(2), 130–137. https://doi.org/10.1177/0890334409355779 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa Breastfeeding Committee for Canada. (2022). Baby-Friendly Initiative Assessment Process and costs for ... Breastfeeding Committee for Canada. https://breastfeedingcanada.ca/wp-content/uploads/2021/07/Process-and-Costs-2021-July-9-2021.pdf 73 Breastfeeding Committee for Canada. (2023). Baby-friendly initiative designated facilities in Canada. Breastfeeding Committee for Canada. https://breastfeedingcanada.ca/wp-content/uploads/2023/04/Designated-Facilities-in-Canada-2023-march-31-1.pdf Burnham, L., Gambari, A., Beliveau, P., Ustianov, J., Parker, M. G., & Merewood, A. (2021). Perspectives of Nurses in Mississippi on Implementation of the Baby-Friendly Hospital Initiative. Journal of Obstetric, Gynecologic & Neonatal Nursing, 50(4), 392–401. https://doi.org/10.1016/j.jogn.2021.02.010 Campbell, S. H., Bernardes, N., Tharmaratnam, T., Willson, M., Krebs, C., Campbell, K., & Brophy, M., Silva, G. O. (2024). Effectiveness of interprofessional development of foundational lactation open education resources. Clinical Simulation in Nursing, 95, 101603. https://doi.org/10.1016/j.ecns. 2024.101603 Çamurdan, A., Özkan, S., Yüksel, D., Pasli, F., Şahin, F., & Beyazova, U. (2007). The effect of the baby-friendly hospital initiative on long-term breast feeding. International Journal of Clinical Practice, 61(8), 1251–1255. https://doi.org/10.1111/j.1742-1241.2007.00926.x Chooniedass, R., Tarrant, M., Turner, S., Lok Fan, H. S., Del Buono, K., Masina, S., Becker, A. B., Mandhane, P., Turvey, S. E., Moraes, T., Sears, M. R., Subbarao, P., & Azad, M. B. (2021a). Factors associated with breast-feeding initiation and continuation in Canadian-born and non-Canadian-born women: A multi-centre study. Public Health Nutrition, 25(10), 2822–2833. https://doi.org/10.1017/s1368980021004699 74 Del Ciampo, I. R., & Del Ciampo, L. A. (2018). Breastfeeding and the benefits of lactation for women’s health. Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics, 40(06), 354–359. https://doi.org/10.1055/s-0038-1657766 Delawarde-Saïas, T., Mercerat, C., Adamiste, M., Pigeon-Gagné, É., Delawarde, C., Nouchi, J., Comtois, J., Bakthy, S., & Poissant, J. (2024). Is there room for mothers’ agency in the choice to breastfeed? an analysis of mothers’s views on health messages promoting breastfeeding in Quebec. European Journal of Midwifery, 8 (January) https://doi.org/10.18332/ejm/174931 Dennis, C., Shiri, R., Brown, H. K., Santos, H. P., Schmied, V., & Falah‐Hassani, K. (2019). Breastfeeding rates in immigrant and non‐immigrant women: A systematic review and meta‐analysis. Maternal & Child Nutrition, 15(3). https://doi.org/10.1111/mcn.12809 Doyle, L., McCabe, C., Keogh, B., Brady, A., & McCann, M. (2019). An overview of the qualitative descriptive design within nursing research. Journal of Research in Nursing, 25(5), 443–455. https://doi.org/10.1177/1744987119880234 Dumas, L., & Venter, K. (2017). The baby-friendly initiative in canada status report 2017. https://www.breastfeedingcanada.ca/wp-content/uploads/2020/03/Status_report_Sept2017-English.pdf Esbati, A., Henderson, A., Taylor, J., & Barnes, M. (2019). The uptake and implementation of the Baby Friendly Health Initiative in Australia. Women and Birth, 32(3). https://doi.org/10.1016/j.wombi.2018.07.023 75 Esbati, A., Taylor, J., Henderson, A., Barnes, M., & Kearney, L. (2020). Perspectives about the baby friendly hospital/health initiative in Australia: an online survey. International Breastfeeding Journal, 15(1). https://doi.org/10.1186/s13006-020-00266-z Fallon, V. M., Harrold, J. A., & Chisholm, A. (2019). The impact of the UK baby friendly initiative on maternal and Infant Health Outcomes: A mixed‐methods systematic review. Maternal & Child Nutrition, 15(3). https://doi.org/10.1111/mcn.12778 Fok, D., Chang, H. F., Meng, L. Y., & Ng, Y. P. (2020). The Effect of a 20-Hour Baby-Friendly Hospital Initiative Training Program on Nurses’ Breastfeeding Knowledge, Attitudes and Confidence, in a Tertiary Hospital in Singapore. American Journal of Perinatology, 39(04), 379–386. https://doi.org/10.1055/s-0040-1716489 Government of Canada (2022, November 4). Canada’s Breastfeeding Dashboard. Health-infobase.Canada.ca. https://health-infobase.canada.ca/breastfeeding/ Government of Canada, S. C. (2022, October 26). Topics, 2021 census immigration, place of birth, and Citizenship. 2021 Census Topic: Immigration, place of birth, and citizenship. https://www12.statcan.gc.ca/census-recensement/2021/rt-td/immigration-eng.cfm# Griffiths, P., Recio‐Saucedo, A., Dall’Ora, C., Briggs, J., Maruotti, A., Meredith, P., Smith, G. B., & Ball, J. (2018). The association between nurse staffing and omissions in nursing care: A systematic review. Journal of Advanced Nursing, 74(7), 1474–1487. https://doi.org/10.1111/jan.13564 76 Groleau, D., Pizarro, K. W., Molino, L., Gray‐Donald, K., & Semenic, S. (2016). Empowering women to breastfeed: Does the baby friendly initiative make a difference? Maternal & Child Nutrition, 13(4). https://doi.org/10.1111/mcn.12370 Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? Field Methods, 18(1), 59–82. https://doi.org/10.1177/1525822x05279903 Higginbottom, G. M., Morgan, M., Alexandre, M., Chiu, Y., Forgeron, J., Kocay, D., & Barolia, R. (2015). Immigrant women’s experiences of maternity-care services in Canada: A systematic review using a narrative synthesis. Systematic Reviews, 4(1). https://doi.org/10.1186/2046-4053-4-13 Huang, C.-M., Hung, W.-S., Lai, J.-N., Kao, Y.-H., Wang, C.-L., & Guo, J.-L. (2016). Maternity staff perspectives regarding resource demands of breastfeeding supportive practices in accordance with the Baby-Friendly Hospital Initiative accreditation: a Q methodology approach. Journal of Advanced Nursing, 72(6), 1301–1312. https://doi.org/10.1111/jan.12928 Jonas, W., & Woodside, B. (2016). Physiological mechanisms, behavioral and psychological factors influencing the transfer of milk from mothers to their young. Hormones and Behavior, 77, 167–181. https://doi.org/10.1016/j.yhbeh.2015.07.018 Korstjens, I., & Moser, A. (2017). Series: Practical guidance to qualitative research. part 4: Trustworthiness and publishing. European Journal of General Practice, 24(1), 120–124. https://doi.org/10.1080/13814788.2017.1375092 77 Kramer, M. S., Fombonne, E., Igumnov, S., Vanilovich, I., Matush, L., Mironova, E., Bogdanovich, N., Tremblay, R. E., Chalmers, B., Zhang, X., & Platt, R. W. (2008). Effects of prolonged and exclusive breastfeeding on child behavior and maternal adjustment: Evidence from a large, randomized trial. Official Journal of The American Academy Of Pediatrics, 121(3). https://doi.org/10.1542/peds.2007-1248 Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage Publications, Inc. Lundeen, S., Sorensen, S., Bland, M., George, S., & Snyder, B. (2016). Nurses’ Perspectives on the Process of Attaining Baby-Friendly Designation. Nursing for Women’s Health, 20(3), 277–287. https://doi.org/10.1016/j.nwh.2016.03.004 Mäkelä, H., Axelin, A., Kolari, T., Kuivalainen, T., & Niela-Vilén, H. (2022). Healthcare Professionals’ Breastfeeding Attitudes and Hospital Practices During Delivery and in Neonatal Intensive Care Units: Pre and Post Implementing the Baby-Friendly Hospital Initiative. Journal of Human Lactation, 38(3), 537–547. https://doi.org/10.1177/08903344211058373 Morrow, A. L., & Rangel, J. M. (2004). Human milk protection against infectious diarrhea: Implications for prevention and clinical care. Seminars in Pediatric Infectious Diseases, 15(4), 221–228. https://doi.org/10.1053/j.spid.2004.07.002 Morse, J. M., Barrett, M., Mayan, M., Olson, K., & Spiers, J. (2002). Verification strategies for establishing reliability and validity in qualitative research. International Journal of Qualitative Methods, 1(2), 13–22. https://doi.org/10.1177/160940690200100202 78 Morse, J. M. (2015). Critical analysis of strategies for determining rigor in qualitative inquiry. Qualitative Health Research, 25(9), 1212-1222. https://doi.org/10.1177/1049732315588501 Neergaard, M. A., Olesen, F., Andersen, R. S., & Sondergaard, J. (2009). Qualitative description – the poor cousin of health research? BMC Medical Research Methodology, 9(1). https://doi.org/10.1186/1471-2288-9-52 Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic Analysis. International Journal of Qualitative Methods, 16(1), 160940691773384. https://doi.org/10.1177/1609406917733847 Núñez, C., García‐Alix, A., Arca, G., Agut, T., Carreras, N., Portella, M. J., & Stephan‐Otto, C. (2023). Breastfeeding duration is associated with larger cortical gray matter volumes in children from the abcd study. Journal of Child Psychology and Psychiatry, 64(7), 1067–1079. https://doi.org/10.1111/jcpp.13790 Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in Mixed Method Implementation Research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5). https://doi.org/10.1007/s10488-013-0528-y Pérez‐Escamilla, R., Martinez, J. L., & Segura‐Pérez, S. (2016). Impact of the baby‐friendly hospital initiative on breastfeeding and child health outcomes: A systematic review. Maternal And Child Nutrition, 12(3), 402–417. https://doi.org/10.1111/mcn.12294 79 Point, S., & Baruch, Y. (2023). (re)thinking transcription strategies: Current challenges and Future Research Directions. Scandinavian Journal of Management, 39(2), 101272. https://doi.org/10.1016/j.scaman.2023.101272 Pound, C., Ward, N., Freuchet, M., Akiki, S., Chan, J., & Nicholls, S. (2016). Hospital Staff’s Perceptions with Regards to the Baby-Friendly Initiative. Journal of Human Lactation, 32(4), 648–657. https://doi.org/10.1177/0890334416662630 Pramono, A., Smith, J., Bourke, S., & Desborough, J. (2022a). How midwives and nurses experience implementing ten steps to successful breastfeeding: a qualitative case study in an Indonesian maternity care facility. International Breastfeeding Journal, 17(1). https://doi.org/10.1186/s13006-022-00524-2 Pramono, A., Smith, J., Bourke, S., & Desborough, J. (2022b). “We All Believe in Breastfeeding”: Australian Midwives’ Experience of Implementing the Baby Friendly Hospital Initiative. Journal of Human Lactation, 38(4), 780–791. https://doi.org/10.1177/08903344221106473 Quesada, J. A., Méndez, I., & Martín-Gil, R. (2020). The economic benefits of increasing breastfeeding rates in Spain. International Breastfeeding Journal, 15(1). https://doi.org/10.1186/s13006-020-00277-w Ricci, C., Otterman, V., Bennett, T.-L., Metcalfe, S., Darling, E., Semenic, S., & Dzakpasu, S. (2023). Rates of and factors associated with exclusive and any breastfeeding at six months in Canada: An analysis of population-based cross-sectional data. BMC Pregnancy and Childbirth, 23(1). https://doi.org/10.1186/s12884-023-05382-2 80 Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing & Health, 23(4), 334–340. https://doi.org/10.1002/1098-240x(200008)23:4<334::aid-nur9>3.0.co;2-g Sandelowski, M. (2010). What’s in a name? Qualitative description revisited. Research in Nursing and Health, 33, 77-84. https://doi.org/10.1002/nur.20362 Shing, J. S. Y., Lok, K. Y. W., Fong, D. Y. T., Fan, H. S. L., Chow, C. L. Y., Tarrant, M. (2022). The influence of the Baby Friendly Hospital Initiative and maternity care practices on breastfeeding outcomes. Journal of Human Lactation, 38(4), 700-710. DOI: https://doi.org/10.1177/08903344221086975 Stuebe, A. M., Grewen, K., & Meltzer-Brody, S. (2013). Association between maternal mood and oxytocin response to breastfeeding. Journal of Women’s Health, 22(4), 352–361. https://doi.org/10.1089/jwh.2012.3768 Tarrant, M., Kwok, M.-K., Lam, T.-H., Leung, G. M., & Schooling, C. M. (2010). Breast-feeding and childhood hospitalizations for infections. Epidemiology, 21(6), 847–854. https://doi.org/10.1097/ede.0b013e3181f55803 Terry, G., Hayfield, N., Clarke, V., & Braun, V. (2017). Thematic Analysis. In C. Willig & W. Stainton Rogers (Eds.), Qualitative Research in Psychology (2nd ed., pp. 17-35). Sage Publications. The Baby-Friendly Initiative Strategy for Ontario (2018). BFI Implementation Toolkit. https://breastfeedingresourcesontario.ca/sites/default/files/pdf/Res_Strategy_BFI_ImplementationToolkit_EN_2018.pdf 81 Thomson, G., Bilson, A., & Dykes, F. (2012). Implementing the WHO/UNICEF Baby Friendly Initiative in the community: a ‘hearts and minds’ approach. International Journal of Midwifery, 28(2), 258–264. https://doi.org/10.1016/j.midw.2011.03.003 Tracy, S. J. (2010). Qualitative quality: Eight “Big-tent” criteria for excellent qualitative research. Qualitative Inquiry, 16(10), 837-851. https://doi.org/10.1177/1077800410383121 UNICEF UK. (2023, January). Achieving sustainability standards and guidance - UNICEF UK. Achieving Sustainability Standards and Guidance. https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2018/04/Achieving-Sustainability-Standards-and-Guidance-Unicef-UK-Baby-Friendly-Initiative.pdf United Nations Children’s Fund. (2016). Breastfeeding: A Smart Investment. Global Breastfeeding Collective. https://www.globalbreastfeedingcollective.org/ Victora, C. G., Bahl, R., Barros, A. J., França, G. V., Horton, S., Krasevec, J., Murch, S., Sankar, M. J., Walker, N., & Rollins, N. C. (2016). Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. The Lancet, 387(10017), 475–490. https://doi.org/10.1016/s0140-6736(15)01024-7 Walsh, A. D., Pincombe, J., & Henderson, A. (2010). An Examination of Maternity Staff Attitudes Towards Implementing Baby Friendly Health Initiative (BFHI) Accreditation in Australia. Maternal and Child Health Journal, 15(5), 597–609. https://doi.org/10.1007/s10995-010-0628-1 82 Wieczorek, C. C., Schmied, H., Dorner, T. E., & Dür, W. (2015). The bumpy road to implementing the Baby-Friendly Hospital Initiative in Austria: a qualitative study. International Breastfeeding Journal, 10(1). https://doi.org/10.1186/s13006-015-0030-0 Wieczorek, C. C., Marent, B., Dorner, T. E., & Dür, W. (2016). The struggle for interprofessional teamwork and collaboration in maternity care: Austrian health professionals’ perspectives on the implementation of the Baby-Friendly Hospital Initiative. BMC Health Services Research, 16(1). https://doi.org/10.1186/s12913-016-1336-3 World Health Organization. (2015). Breastfeeding. World Health Organization. https://www.who.int/news-room/questions-and-answers/item/breastfeeding World Health Organization. (2017). National implementation of the Baby-Friendly Hospital initiative 2017. World Health Organization. https://www.who.int/publications-detail-redirect/9789241512381 World Health Organization. (2018, January 1). Implementation guidance: Protecting, promoting, and supporting breastfeeding in maternity and newborn services facilities: The revised baby-friendly hospital initiative 2018. World Health Organization. https://www.who.int/publications-detail-redirect/9789241513807 World Health Organization. (2021). Infant and young child feeding. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding World Health Organization. (2024). Social Determinants of Health. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1 83 Xe Currency Converter. (2024, November, 20th). convert US dollars to Canadian dollars. Xe Currency Converter. https://www.xe.com/currencyconverter/convert/?Amount=9000&From=USD&To=CAD Yan, J., Liu, L., Zhu, Y., Huang, G., & Wang, P. P. (2014). The association between breastfeeding and childhood obesity: A meta-analysis. BMC Public Health, 14(1). orhttps://doi.org/10.1186/1471-2458-14-1267 Zakarija-Grković, I., Boban, M., Janković, S., Ćuže, A., & Burmaz, T. (2018). Compliance with WHO/UNICEF BFHI standards in Croatia after implementation of the bfhi. Journal of Human Lactation, 34(1), 106–115. https://doi.org/10.1177/0890334417703367 Zelkowitz, P., Gold, I., Feeley, N., Hayton, B., Carter, C. S., Tulandi, T., Abenhaim, H. A., & Levin, P. (2014). Psychosocial stress moderates the relationships between oxytocin, perinatal depression, and maternal behavior. Hormones and Behavior, 66(2), 351–360. https://doi.org/10.1016/j.yhbeh.2014.06.014 84 Table 2 Literature Review Authors Origin Type of Research Purpose Methods Target Population Sample Size Major Themes Amadhila & Van Rensburg, 2020 Namibia Qualitative Descriptive To understand and describe experiences of nurse managers while implanting the BFI In-depth interviews with thematic analysis Nurse Management 33 Steps required for implementation of the BFI Perceived benefits of the BFI Challenges to implementation Recommendations for the BFI Burnham et al., 2021 USA Qualitative Descriptive To describe floor nurses perceptions of the BFI and designation process In-depth interviews with thematic analysis Floor Nurses 22 Difficulty with change Nurses empowered to take on leadership Patient education is essential to implementation Unexpected challenges with consequence 85 Authors Origin Type of Research Purpose Methods Target Population Sample Size Major Themes Esbati et al., 2018 Australia Qualitative Descriptive To understand healthcare providers perspectives about the BFI implementation Semi-Structured interviews with thematic analysis Healthcare practitioners (Nurses, Midwives, lactation consultants, managers, academics, and researchers that work in maternal care) 12 Need for improved policy and guidelines Leadership is required to implement the BFI Improve breastfeeding and BFI education Improve communication around the BFI Designation and redesignation process Implementation difficulties Esbati et al., 2020 Australia Mixed Methods Exploring Healthcare providers perspectives from an organizational change point of view Descriptive statistics and content analysis applied to an online survey Nurses, Lactation Consultants, Doctors, Nutritionists, Dietitians, Community health managers, physiotherapists, breastfeeding counsellors, breastfeeding advocates, complimentary therapists, and a lab technician 332 Policy and guideline support improvement needed Leadership is needed Essential to have breastfeeding education and knowledge Designation – more hospitals are needed but it has a heavy cost Difficulty with implementation Importance of multidisciplinary communication A need for improved care 86 Authors Origin Type of Research Purpose Methods Target Population Sample Size Major Themes Fok et al., 2020 Singapore Quantitative Evaluate the effectiveness of 20 hour BFI training courses Surveys pre and post education training were analyzed using Pearson’s Chi-squared tests. Nurses (maternity and neonatal) 140 than 148 2 yrs later which do I go with Improved Infant feeding knowledge No change in perceptions of importance of breastfeeding Increase in confidence in providing advice Huang et al., 2016 Taiwan Mixed Methods Understand maternity nurses opinions of the ten BFI steps A two-step approach. First step developed statements based of participant viewpoints. The second step had participants rank statements using a like hart scale. Registered Nurses, Head Nurses, Ward mangers, Physicians 60 Importance of implementing institutional policy Need for supportive maternal practices Need for continual breastfeeding support Increase resources for practices concerning a designated time period Lundeen et al., 2016 USA Qualitative Description Understand nurses experiences of becoming a BFI certified hospital A combination of questionnaires and semi-structured interviews Nurses 10 Resistance Culture Teamwork Pride 87 Authors Origin Type of Research Purpose Methods Target Population Sample Size Major Themes Mäkelä et al., 2022 Finland Quantitative To determine HCP attitudes before and after the BFI implementation Pre and Post-test questionnaires after UNICEF education course Nurses, Midwives, Pediatricians, Obstetricians 131 Increased Breastfeeding Attitudes Changes in hospital practices that better support breastfeeding Increased immediate skin to skin Pound et al., 2016 Canada Quantitative (Cross-Sectional Survey) To explore healthcare providers knowledge of the BFI Questionnaires that used multiple logistic regression Healthcare providers 651 Context – BFI needs to adapt to different circumstances Responsibility – social pressure to breastfeed Support- perceived responsibility of the staff members Pramono et al., 2022a Indonesia Qualitative Descriptive To understand midwives and nurses experiences with the BFI A focus group was conducted for one hour where a previously existing semi-structured questionnaire was adapted and used to explore experiences Nurses & Midwives 14 Rights of mother and child Dependency on leadership Lack of prioritization in the budget Inconsistent implementation across healthcare system Family and Cultural traditions 88 Authors Origin Type of Research Purpose Methods Target Population Sample Size Major Themes Pramono et al., 2022b Australia Qualitative (Cross-Sectional) Explore midwives experiences with implementation of BFI Two focus groups. Data thematically analyzed Midwives 26 Importance of breastfeeding Time constraints Continuity of care and structure of services Designation requirements Thomson et al., 2012 UK Qualitative Descriptive To identify the common perspectives among HCP about the BFI Focusing groups and individual interviews with thematic analyses Healthcare professionals 47 Need for credible leadership Engagement of key partners Changing attitudes and practices Consistent messaging Walsh et al., 2010 Australia Qualitative To examine barriers to the BFI Focus groups with thematic analysis Midwives, Nurses, Medical and Support staff 31 Personal views Designation process Hospital dynamics Bottle feeding culture Maternal employment 89 Authors Origin Type of Research Purpose Methods Target Population Sample Size Major Themes Wieczorek et al., 2015 Austria Qualitative To examine barriers of the BFI Semi-structured interviews with thematic analysis Midwives, Nurses, Physicians, Quality manager 36 Motives Leadership/promoters designation process Development and translation of knowledge Education for staff Barriers - Time - Personal experiences - Language & Literacy barriers - Expectations of mothers from relatives - Old habits - Inconsistency of the BFI with professionals/ services Wieczorek et al., 2016 Austria Qualitative To examine HCP approaches to breastfeeding, collaboration with coworkers, engagement with the BFI Semi-structured interviews with thematic analysis Midwives, Nurses, Physicians, Quality manager 36 Medicalization of childbirth and breastfeeding Naturalness of breastfeeding Interdisciplinary collaboration Lack of space 90 Table 3 Criteria for Trustworthiness Credibility The ability to establish confidence in the “truth” Transferability How does one show the applicability of findings to other contexts Dependability Showing the findings would be the same or similar if repeated Confirmability Ability to establish the degree of findings on participants, not biases, motivations, or interests of the researcher Note. Adapted from Naturalistic Inquiry (p. 289), by Y. S. Lincoln & E. G. Guba, 1985, Sage Publications. 91 Table 4 Six Steps to Thematic Analysis Familiarization Data transcription and repeatedly reviewing data, writing down initial ideas. Initial Coding Creating initial codes for data of interest and gather the terms. Identifying Themes Sort the code into different potential themes using a table, list or mind map. Consider the relationships between themes as this is where main or subthemes may become apparent. Reviewing Themes Reviewing the data to determine if there is enough to support the identified themes and reviewing transcripts for any missed data. Defining & Naming Themes Clearly define the meaning of each theme and determining sub themes vs a main theme. Summary of Findings Final analysis and write up findings (Braun & Clark, 2006) 92 Table 5 Timeline of Thesis January 2023 to August 2023 August 2023 to September 2023 October to November 2023 December to January 2024 February to May 2024 May to June 2024 June to August September to November 2024 Proposal first draft (Chapters1, 2 & 3) X Final Draft (Chapters 1, 2 & 3) X Proposal approved by committee X Ethics Approval X Data collection X Data analysis X Writing of findings (Chapter 4) X Writing of discussion (Chapter 5) X X Final draft approved X X Thesis submitted for defense X 93 Figures Figure 1 PRISMA Flow Diagram Identification Records identified through database searching (n=108) Additional records identified through other sources (n=6) Records screened (n=66) Full-text articles assessed for eligibility (n=30) Studies included in the literature review (n=15) (Qualitative = 10) (Quantitative= 3) (Mixed Methods = 2) Screening Eligibility Included Records excluded (n=42) Full-text articles excluded (n=15), with reasons: not measuring healthcare providers' perceptions, not measuring attitudes surrounding the BFI, and not examining the BFI Records after duplicates removed (n=93) 94 Appendices Appendix A: Letter of Information Unit Managers Hello, My name is Olivia Andrews, and I am a Registered Nurse currently working at Kelowna General Hospital. In addition, I am a student in the Master of Science in Nursing at the University of British Columbia Okanagan (UBCO). As part of my program requirements, I am working with my supervisor, Dr. Marie Tarrant, and a committee consisting of three nurses on a research study called a Qualitative Description of Healthcare Providers Experiences with the Baby-Friendly Initiative. The purpose of this study is to explore the thoughts and experiences of nurses, lactation consultants, and the Baby-Friendly health authority leads to the implementation of the Baby Friendly Hospital Initiative. The findings of this study will help build a Canadian body of knowledge around the Baby Friendly Hospital Initiative. I would like to invite nurses and lactation consultants from your unit to participate in an interview via Zoom from January 2024 to May 2024 I would like to ask you, the unit manager, to share the attached documents and poster via email, and display the poster on the unit. The interviews are completely voluntary and anonymous. To set up the interview, please contact me with oliviaan@mail.ubc.ca. A $20 gift card was offered to the participants. Olivia Andrews, BSN, RN Graduate Student, UBCO Master of Science in Nursing Email: oliviaan@mail.ubc.ca 95 96 Appendix B: Unit Poster 97 Appendix C: Letter of Information for Health Authority Leads Hello, My name is Olivia Andrews, and I am a Registered Nurse currently working at Kelowna General Hospital. In addition, I am a student in the Master of Science in Nursing program at the University of British Columbia Okanagan (UBCO). As part of my program requirements, I am working with my supervisor, Dr. Marie Tarrant, and a committee consisting of three nurses on a research study called a Qualitative Description of Healthcare Providers Experiences with the Baby-Friendly Initiative. The purpose of this study is to explore the thoughts and experiences of nurses, lactation consultants, and the Baby-Friendly health authority leads to the implementation of the Baby Friendly Hospital Initiative. The findings of this study will help build a Canadian body of knowledge around the Baby Friendly Hospital Initiative. The interview will be conducted in Zoom and will take approximately 60 minutes. If you would like to participate, please see the consent form and demographic survey attached to the email. Once those are filled out, please contact Olivia Andrews at oliviaan@mail.ubc.ca to set up the time for an interview. Please let me know if you have any questions regarding this study. Thank you, Olivia Andrews, BSN, RN Graduate Student, UBC Master of Science in Nursing Email: oliviaan@mail.ubc.ca 98 Appendix D: Interview Questions Date: ________________ Study ID:_____________ 1. Could you introduce yourself? • Please include which hospital/health authority, role in the BFI implementation process • How long you have been in your current role • Previous experiences that influenced your thought process regarding BFI 2. Where did the idea of becoming a BFI-designated hospital originate from? • Was it an individual who felt passionately or a group of people who felt passionately about the BFI? • If it were an individual, how did they convince others? 3. In your opinion, what made the BFI designation process successful in your hospital? • Hospital Structure and Process Leadership 4. Please describe the type of training you had and what your unit had to do prior to becoming a BFI. • Was this training completed during your work hours or during your own time? • In your opinion, was the training helpful? Why? 5. In your opinion, what are the positive changes you have seen with BFI? • How does the BFI specifically help with the identified benefit(s)? 6. Can you tell me about the challenges of implementing a BFI? • How can these challenges be addressed? 99 • Are these steps difficult to implement in the clinical practice? • Funding? • Short staffing? 7. Would you recommend that other hospitals be designated BFIs? Why or Why not? 8. What advice would you provide to others considering becoming BFI-designated facilities? 9. Is there anything else you would like to add? 100 Appendix E: Participant Invitation Letter Hello, We would like to invite you to participate in a research study to learn more about your thoughts and experiences regarding the Baby Friendly Hospital Initiative. My name is Olivia Andrews and I am currently a graduate student at UBC Okanagan. As part of my graduate program, I am working with my supervisor and committee on a study called the qualitative description of healthcare providers’ experiences with the Baby-Friendly Initiative. We ask you to hear your thoughts as you are a nurse or lactation consultant who has been directly affected by the Baby Friendly Hospital Initiative. Your knowledge and experience can help build a Canadian knowledge base around the Baby-Friendly Hospital Initiative. The interview will be conducted in Zoom and will take approximately 60 minutes. If you would like to participate, please see the consent form and demographic survey attached to the email. Once those are filled out, please contact Olivia Andrews at oliviaan@mail.ubc.ca to set up the time for an interview. Please let me know if you have any questions regarding this study. Thank you, Olivia Andrews, BSN, RN Graduate Student, UBC Master of Science in Nursing Email: oliviaan@mail.ubc.ca 101 Appendix F: Consent Form January 7 th, 2024 V.4 Appendix F: Consent Form Qualitative Description of Healthcare Providers Experiences with the Baby-Friendly Initiative Interview Consent Form Study team: Principal Investigator: Marie Tarrant, RN, MPH, PhD (Principal Investigator) Dean, Faculty of Health and Social Development UBCO Email: marie.tarrant@ubc.ca Co-investigators: Suzanne Campbell, PhD, RN, FCNEI, IBCLC, CCSNE Professor, UBC School of Nursing Email: Suzanne.Campbell@ubc.ca Rishma Chooniedass, BSc, RN, MN Assistant Professor, UBCO School of Nursing & Advisor to the Dean on Equity, Diversity, and Inclusion Email: Rishma@mail.ubc.ca Advisor: Meggie Ross, RN, MSN, IBCLC Penticton Baby-Friendly Initiative Practice Lead Email: Meggie.Ross@interiorhealth.ca BCWH Site Lead: Sarah Coutts Senior Lead Developmental Care NICU Email: Scouts-02@phsa.ca Primary Contact: Olivia Andrews, BSN, RN Graduate Student, UBCO Master of Science in Nursing Email: oliviaan@mail.ubc.ca Sponsors: 102 103 104 105 Appendix G: Demographic Form 106
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Tarrant, Marie
Perinatal healthcare providers' experiences with the Baby-Friendly Initiative : a qualitative descriptive study
Text