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An organisation-wide approach to training community practitioners in breastfeeding.


The promotion of initiation and duration of exclusive breastfeeding is supported by Healthy people, healthy lives (DH, 2010a), which highlights the need to increase breastfeeding rates, that breastfeeding is a priority in the Healthy Child programme (DH, 2009), and that employers should support breastfeeding. The NHS operating framework (DH, 2010b) also includes performance measures during this transition year and breastfeeding is a supporting measure under quality.

While almost three-quarters of women initiate breastfeeding, most give up earlier than they wished, and less than 1% of babies are exclusively breastfed to the recommended duration of six months (Bolling et al, 2007). The importance of consistent and evidence-based practice by healthcare practitioners is well established (MacFadden et al, 2006) and is a key step in the achievement of UNICEF Baby Friendly Initiative (BFI) standards for maternity and community health organisations. The UNICEF BFI global standards set out the 'Ten Steps' to successful breastfeeding in the hospital environment. The community seven steps are a UNICEF UK BFI initiative for organisations seeking to provide services that are supportive of breastfeeding, and require that all staff in a service are trained to uniform evidence-based standards.

Yet fully achieving this standard can take as long as seven years from the certificate of commitment (Stage 1) to full accreditation, and requires sustained investment in training to ensure standards are maintained. The training model is to provide training to key staff who then run training workshops locally. Costs for attendance at the three-day breastfeeding management course is currently 380 [pounds sterling] per person, and 680 [pounds sterling] for the train the trainer course, as well as associated travel and accommodation costs. On-site training will have fewer upfront costs but will have costs of administration, venue, local travel and the trainer's salary, and both are likely to require additional staff to backfill for staff in training. This is a commitment that may be difficult to resource when set against other priorities. Even though there have been promising results from cost-benefit analyses of 'a structured programme that supports breastfeeding' (NICE, 2006), it is often not easy to demonstrate the return on investment in the short term.

Self-study training programme

A new breastfeeding self-study training programme was developed to support the training of local trust and children's centre staff. The pilot programme was commissioned by the regional infant feeding coordinator on behalf of NHS West Midlands, with the aim of testing if the new approach was feasible, acceptable and effective.

The opportunity for West Midlands services to bid to use the new approach resulted in two pilot sites--Walsall and Dudley. During the initial months of the programme, the training materials were assessed in their use by one of the sites during an accreditation visit by UNICEF UK and updated to meet learning outcomes for progress toward the BFI standards.

After developing a comprehensive self-study training programme and an objective test of breastfeeding knowledge (Wallace, 2008), the new approach was demonstrated to produce at least as effective knowledge outcomes as the traditional workshop-style training (Wallace et al, 2009). Some of the experiences of staff using this approach to training, spanning the maternity unit and community midwives, community heath visiting and children's centre staff, have been published elsewhere (Wallace et al, 2011).

This paper concentrates on the results and challenges for community practitioners in the NHS and children's centres in this pilot service development programme.


The programme aim was to support the trusts and children's centres to achieve the rapid training of around 75% of their staff over a one-year period. Data from the objective knowledge test were used to test effectiveness. An independent evaluation using interviews with key managers and practitioners was used to assess acceptability and feasibility.


Health Behaviour Research breastfeeding training programme

The programme consisted of a printed self-study workbook (Law, 2009a) in which the learner could read the material and view colour clinical photographs, as well as learn how to search and access additional web resources. Learning was consolidated by responding with written answers in the workbook to exercises. A DVD (Law, 2009b) was designed to support learning of the skills involved in the breastfeeding education of mothers. It uses clinical footage that shows optimal positioning and attachment, a mother demonstrating the skill of hand expression, the progress of a satisfying feed and baby-led feeding.

These materials were kept by the learner as an on-going resource. The workbook was 'marked'--given formative feedback on completed exercises and guidance toward areas for further knowledge and practice development--by BFI-trained clinicians provided by each trust or by Health Behaviour Research. Feedback was in hard copy or via a website.

Each learner's knowledge in the BFI learning outcomes topics were objectively assessed before and after they completed the training, and they had feedback that their learning as recorded in the workbook had been satisfactory. The Coventry University Breastfeeding Assessment (CUBA) is an online test covering knowledge of breastfeeding, practices and policies. It consists of 50 multiple choice questions addressing all key topics of the BFI training standards to successful breastfeeding, and includes video clips and clinical photographs. Open text questions allowed feedback on local good practice and barriers, and feedback on the programme that are not part of the test itself. After the test, instant individual feedback of the scores and areas for further study is given to the practitioner. This assessment is fully compatible with the self-study workbook and DVD.

The workbooks and DVDs for each learner, and the staff time for marking was supported by the project costs.

Training and assessment process

The training and assessment process for the practitioners included:

* Undertaking CUBA before training, which takes about 30 minutes in one sitting via the internet

* 10 to 12 hours' self-study using a printed workbook and the DVD

* Feedback to learners ('marking') on the workbook exercises

* A further CUBA assessment to show practitioners, and their managers, what impact the programme has had on their breastfeeding knowledge. Again, the practitioner receives instant feedback of their scores in each knowledge area at the end of the test.

Each manager received a detailed report of anonymised scores for all of their staff, giving the range and average knowledge levels of everyone who had completed the CUBA in the first six months of the pilot. Data also included the profession of practitioners, years since they had qualified and the recency of breastfeeding training to ensure training was being targeted at the widest range of staff rather than those who usually volunteer for training. This objective training needs analysis enabled managers to see areas of knowledge and practice that might need particular focus. Statistical data provides a reliable picture of breastfeeding knowledge, and differs from the BFI audit process, which is not designed to give numerical scores for whole staff groups.

Evaluation method

An independent evaluation was led by Dr Elizabeth Hughes and approved by Coventry University Ethics Committee. The aim was to establish the views of managers, infant-feeding leads and practitioners on the training system. A total of 26 managers and practitioners were interviewed using a semi-structured schedule, and data were analysed thematically by two researchers. The same approach was taken with 10 participants covering both sites and in the same roles as at baseline as far as possible after the programme, the numbers being limited by staff availability within the project timescales.

Analysis of markers' feedback

The workbooks were 'marked', ie when the workbook was completed the learner handed it in to be read and given structured feedback by a trained lactation expert or lead trainer at each site. From the 20% sample of workbooks moderated, participants appeared to be much more comfortable with the practice-based activities requiring decision-making than those related to theory requiring factual knowledge. Questions relating to the case histories, to aspects of their own practice and to the general support of breastfeeding mothers were generally answered more fully and more accurately. While simple anatomy of the lactating breast was mostly well known, physiology was less understood. The actions of the two key lactation hormones were not always well known and the functions of breastmilk components were sometimes given incorrectly. One activity directed the participant to two specific websites to identify a range of common drugs that are contra-indicated for breastfeeding mothers, but despite easy access to the information, many struggled with this. In response to early marking feedback, selected resources were provided via a dedicated website to improve access.


CUBA test scores

In the two healthcare economies, 322 practitioners completed CUBA before training and 184 completed training and the second CUBA test. Almost half (49%) of the participants were midwives, 23% were health visitors, 18% support staff, 5% nursery nurses, 3% neonatal nurses, 2% managers and 1% consultants. There was a good spread of ages, time since qualification and recency of breastfeeding training across all sites. When compared to those who completed the training and CUBA a second time, the characteristics are very similar, suggesting there was not a self-selection process occurring, which can be the case with on-demand training.

Midwives had higher total pre-training CUBA scores than health visitors and other groups. While years since qualifying was not associated with higher scores, having more recent training was. Those who had spent five years or more working with mothers and babies had higher total scores before training than those who had less experience. Most of the staff who did not complete the training attributed this to either changing or leaving jobs or to competing job priorities. There were no significant differences in pre-training scores between those who completed the training and second CUBA test and those who did not, suggesting that it was unlikely that having received feedback on scores affected motivation to undertake training and reassessment.

The pre-post training CUBA results show a statistically significant improvement in knowledge totals overall (F(1,183)=78.737, p<0.0005; mean pre-training score=57/100, mean post-training score=66/100). The results show the training was effective in improving knowledge outcomes.

Open questions about the programme

The open questions about the training were optionally completed by these who had finished the post-training CUBA. Thematic analysis revealed overwhelmingly positive comments about the content of the programme. Negative comments related to content that they felt was not relevant to their everyday practice, such as health visitors commenting that they do not provide prenatal or perinatal care.

Evaluation of acceptability and feasibility

Thematic analysis revealed key themes for the expectations of the programme from interviews with service managers, infant feeding advisers and practitioners. An illustrative quote is presented below for each of the themes identified.

Expecting the programme to increase initiation and duration rates:

'...and I'd hope that our breastfeeding initiation and also may[be] our statistics for continuing would get better (service manager).

Empower staff to better help mothers and infants:

'I think that this training can benefit women and I hope that health visitors see that ... this will have direct effect on women that we see, our clientele' (service manager).

Improve the consistency of practice:

'It's good in the sort of depth and knowledge it gives you, and it's good that because everybody in the trust will be doing it at roughly the same time that we're all doing it ... advice will be consistent and it should improve the service to the mothers' (health visitor).

Improve knowledge and confidence in frontline staff:

'I think it would help with their confidence, in being able to deal with breastfeeding issues rather than referring to me or the breastfeeding facilitators' (infant feeding lead).

The need for protected learning time:

'I think the key one is ... allocation of time (health visitor).

After the programme, service managers and infant feeding advisers reported in several themes that the programme met their expectations.

Users feeling more knowledgeable, aware of the accuracy of their knowledge and any skill gaps:

'Well again it's testing your knowledge and it makes you realise what you know and what you don't know ... it made you think about things that you do ... do you actually know all the theory behind it and why you know what you know' (infant feeding adviser).

Being able to have an objective assessment of knowledge:

'I did the initial pre-assessment[CUBA] thinking well I'm sure I won't be too bad at this because I've just done the Baby Friendly and ... I didn't do as well as I thought I would (health visitor).

The workbook being an on-going resource for continuing learning:

'It's another resource, the information, the research is included in there as well, so if I need to refresh I have it on the shelf there' (practitioner).

The clinical demonstrations supported practice skills:

'I thought the expressing milk one [in the DVD] was really good' (infant feeding lead).

While acknowledging there are many influences in breastfeeding beyond training of clinical staff, there were comments about possible impact:

'I feel that the ... training has reflected in the statistics in prolonging breastfeeding in the first six weeks' (Infant feeding lead).

The themes relating to challenges were not about the content of the workbook and DVD, or being tested objectively for knowledge attainment. Rather they were concerned with logistical problems in managing the new programme on the sites, managerial issues and resistance and motivation to self-study.

There were initial delays in obtaining the workbook as revisions were required at the outset to meet new BFI criteria. There were also delays initially in turning around workbook marking, until additional marker capacity was provided. This affected the throughput of the programme and meant that some staff did not complete the second CUBA test, even though they had undertaken much of the workbook training.

While trusts varied in their approach, only one explicitly allowed time back for completion of self-study:

'We've given them two days off, when it's completed ... it needs to be given the two days off to do it ... not at the end (manager).

Managers and participants consistently reported that self-study was difficult without planned release of staff time. Some managers felt that although workshops required more time, it forced the issue of providing cover for clinical duties. This was linked to the next theme, as clinical duties were understandably prioritised over training:

'Because it's not that you've got to go there on this day, then you tend to think "Oh, this mum's in crisis, I must deal with it first and CUBA can wait another day". And the trouble is then CUBA waits another day and another day ... you're nearly there and you haven't done if (health visitor).

Although only the CUBA was online, learners were encouraged to search and use web links for additional resources. This proved difficult for some staff in work settings, and a small number of older staff needed to be supported to access a PC:

'It's the same things again, time, resources ... if we write "breasts" on our computer it blocks it ... it was just really difficult' (children's centre support worker).

Self-directed learning can be a challenge, particularly if expected in non-work time:

'I just found that doing it in your own time was time consuming to find answers and research the answers yourself (practitioner).

Resistance to self-directed learning as socially isolating:

'A lot of them don't like self-directed learning on their own. We found it better to organise more of them to start together ... share learning' (manager).


The programme is a new way to organise learning, and its effectiveness, acceptability and feasibility has been examined. The study was not designed to provide evidence of the impact of training on breastfeeding rates. The provision of identical training to all staff was felt to be a useful tool to drive up standards and consistency of practice. The workbook scenarios were valuable in facilitating problem-based learning with direct relevance to their everyday practice. The workbook and DVD were considered useful resources for future use, and may help to support continued application of knowledge into practice. While not tested by the current study, it is hoped that the gains achieved will contribute to improved practice and affect breastfeeding results in future.

The improvement in objectively assessed knowledge using the CUBA test pre- to post-training is clear. The aimed throughput was not fully achieved, largely due to logistical issues in delivering the updated workbooks and marking capacity until later in the year, and problems experienced by the trusts in managing to support self-study training against other priorities. One site achieved more than two-thirds of staff completing, and their lessons are shared below.

The programme was found to be acceptable and feasible, and the pilot programme and evaluation have shown that there are ways in which its delivery can be further improved.

It was hoped that the self-study method of training would have a positive effect on confidence levels among staff to continue to take responsibility for their own learning They reported being more confident in searching the internet for answers to questions in the workbook and in using this skill to address issues they came across in their clinical practice. We also found that undergoing a test of knowledge reduced complacency about relying on knowledge that may be outdated. A further example of an unexpected finding from the pre-training CUBA training needs analysis reports that were presented to trusts was that health visitors were no more knowledgeable than other practitioners about the section 'who breastfeeds', which tests public health evidence about the socio-cultural determinants of breastfeeding, yet this is core knowledge in health visitors' training. Trust staff who provided marking welcomed the insight it gave into what and how their colleagues learnt about breastfeeding.

The programme showed that self-study training is feasible, but requires planning and resourcing in the same way as the alternative workshop model for mass staff training to be achieved. The sites had fewer upfront costs in that they did not have to provide trainers, organise and resource workshops and backfill for two to three days for each person. However, they did need to brief and support staff, provide access to basic IT, and some time for their lead trainers to provide marking feedback. These logistical issues will be removed in the e-version of the programme, which will soon be released.

The trusts achieving the greatest throughput also had more infant feeding lead time, and took a planned approach to ensure that all staff were aware of when they would undertake the programme and how their work would be adjusted. All sites found it useful to organise learners to meet to discuss practice, their experience of self-study and the issues for practice and local policies raised by the content.

From this experience, we suggest that trusts should develop specific intranet pages devoted to policies, evidence and practice articles, current local breastfeeding statistics, and up-to-date information on local services to support breastfeeding that will maintain this interest in developing and maintaining knowledge on breastfeeding.

A systematic approach to training needs analysis and a rigorous approach to assessing breastfeeding knowledge and skills has great potential for efficiency and effective training. Given what is known about introducing large-scale changes in practice, visible and repeatedly reinforced organisational leadership can be expected to be essential to ensure prioritisation and resources. We suggest that community services provide access to computers at work, protected time, use learning sets and build up intranet pages for local breastfeeding data and policies.


The self-study programme is effective and acceptable. Feasibility in practice can be further improved by planning and resourcing self-study with improved IT and learner support, including short group updates and learning sets. The self-study programme is an alternative and complementary approach to workshop training.


* A self-study workbook and DVD, providing 10 to 12 hours of self-directed study in areas required for UNICEF UK BFI learning outcomes, is effective in improving objectively assessed knowledge

* The programme supports the understanding of real clinical problems and practical solutions, and helps learners to develop an understanding of the evidence base for their practice and how to update themselves

* Self-study programmes require resourcing and planning to be efficient, including planned study time, supported access to IT and support for group learning

Further resources

For information and resources about CUBA, Breastfeeding: essential support skills DVD, Breastfeeding workbook: a flexible learning approach and workbook marking scheme, see:


Funding was provided by the Department of Health West Midlands and West Midlands Public Health Observatory. The authors thank the leadership and commitment of the regional infant feeding co-ordinator Caroline Mansell, infant feeding leads Diane Woolliscroft, Jennifer Sutherland and Rachel Andrews, and clinical staff at the trusts in Dudley and Walsall.


Bolling K, Grant C, Hamlyn B et al. (2007). Infant feeding survey 2005. London: Information Centre.

Department of Health (DH). (2009) Healthy Child programme: pregnancy and the first five years of life. London: DH.

DH. (2010a) Healthy lives, healthy people: our strategy for public health in England. London: DH.

DH. (2010b) The operating framework for the NHS in England 2011/12. London: DH.

Law S. (2009a) Breastfeeding workbook: a flexible learning approach. Coventry: Health Behaviour Research.

Law S. (2009b) Breastfeeding: essential support skills DVD. Coventry: Health Behaviour Research.

MacFadden A, Renfrew J, Wallace LM et al.(2006) Does breastfeeding really matter? A national multidisciplinary breastfeeding knowledge and skills assessment. MIDIRS Midwifery Digest 17(1): 85-8.

National Institute for Health and Clinical Excellence (NICE). (2006) Postnatal care: costing report: implementing NICE guidance in England. London. NICE.

Wallace LM. (2008) Bridging the breastfeeding knowledge gap. Practising Midwife 11(2): 38-41.

Wallace LM, Dunn OM, Law S et al. (2009) Workbook versus workshop: testing a new method of delivering training for health visitors and midwives to achieve breastfeeding support knowledge and skills required to achieve UNICEF Baby Friendly standards. Practising Midwife 12(6): 47-9.

Wallace LM, Hughes E, Law SM et al. (2011) Meeting the challenge of delivering high quality breastfeeding training for all. Practising Midwife 14(1): 20-2.

Louise M Wallace PhD, MBA, BA Professor of psychology and health, Faculty of Health and Life Sciences, Coventry University

Susan M Law MSc, BSc, CertEd, RM, RN Senior lecturer in midwifery, Faculty of Health and Life Sciences, Coventry University

Puja Joshi BSc Research assistant, Faculty of Health and Life Sciences, Coventry University

Elizabeth Hughes PhD, BSc, DipHE Senior lecturer, Department of Health Sciences, University of York


Declared potential competing interests: The two lead authors are directors of Health Behaviour Research Limited, which developed the self-study training programme.
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Author:Wallace, Louise M.; Law, Susan M.; Joshi, Puja; Hughes, Elizabeth
Publication:Community Practitioner
Article Type:Report
Geographic Code:4EUUK
Date:Jun 1, 2011
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