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1 JOGNN R ESEARCH Use of a Web-based Education Program Improves Nurses Knowledge of Breastfeeding Barbara J. Deloian, Linda Orkin Lewin, and Mary E. O Connor Correspondence Mary E. O Connor MD, MPH, Westside Family Health Center, 1100 Federal Blvd, Denver, CO Mary.O Connor@dhha.org Keywords breastfeeding knowledge nurses nurse practitioners midwives nursing students on-line education ABSTRACT Objective: To evaluate the baseline knowledge and knowledge gained of nurses, nursing students, midwives, and nurse practitioners who completed Breastfeeding Basics, an online educational program. Design: This study reports on an anonymous evaluation of an online breastfeeding education program developed and maintained to promote evidence-based breastfeeding practice. Participants: Included in the study were 3736 nurses, 728 nurse practitioners/midwives, and 3106 nursing students from the United States who completed one pretest or posttest on the Breastfeeding Basics website between April 1999 and December 31, Methods: Baseline scores were analyzed to determine if nurses baseline knowledge varied by selected demographic variables such as age, gender, professional level, personal or partner breastfeeding experience, and whether they were required to complete the website for a job or school requirement and to determine knowledge gaps. Pretest and posttest scores on all modules and in specific questions with low pretest scores were compared as a measure of knowledge gained. Results: Lower median pretest scores were found in student nurses (71%), males (71%), those required to take the course (75%), and those without personal breastfeeding experience (72%). The modules with the lowest median pretest scores were Anatomy/Physiology (67%), Growth and Development of the Breastfed Infant (67%), the Breastfeeding Couple (73%), and the Term Infant with Problems (60%). Posttest scores in all modules increased significantly (p <.001). Conclusion: Breastfeeding Basics was used by a large number of nurses and nursing students. Gaps exist in nurses breastfeeding knowledge. Knowledge improved in all areas based on comparison of pretest and posttest scores. JOGNN, 44, 77-86; DOI: / Accepted August 2014 Barbara J. Deloian, PhD, RN, CPNP, IBCLC, FAANP, Special Kids, Special Care, Inc., Castle Pines, CO. Linda Orkin Lewin, MD, is the Associate Chair for Educational Programs and an associate professor in the Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD. Mary E. O Connor, MD, MPH, is a pediatrician at Westside Family Health Center, Denver Health, and a professor of pediatrics, University of Colorado School of Medicine, Denver, CO. The authors report no conflict of interest or relevant financial relationships. Breast milk is recognized as the ideal nutrition for infants for the first year of life and beyond with complementary foods added at 6 months of age (American Academy of Pediatrics, 2012). Although the Healthy People 2010 objective of a 75% breastfeeding initiation rate at discharge from the birth hospital was achieved, the targets for breastfeeding duration and exclusive breastfeeding were not. The Healthy People 2020 objectives for breastfeeding will be more difficult to achieve with goals of 81.9% breastfeeding ever, 60.5% breastfeeding for 6 months, 34.1% breastfeeding for one year, 44.3% exclusive breastfeeding for 3 months, and 23.7% exclusive breastfeeding for 6 months (U.S. Department of Health and Human Services, 2010). Because nurses are at the bedside working with new mothers from the births of their infants to discharge from the hospital, they are key health care providers in supporting the initiation of breastfeeding. Nurses also provide the initial information about the importance of and benefits of breastfeeding through preconception education and prenatal, childbirth, and breastfeeding classes. Nurses are expected to have a core knowledge regarding health promotion, risk reduction, and disease prevention that includes the promotion of and support of a mother s breastfeeding efforts (Spatz, 2010). Previous researchers have shown that nurses are not well prepared for the role of providing breastfeeding education and support through traditional educational curricula (Ahmed, Bantz, & Richardson, 2011; Bernaix, 2000; Boyd & Spatz, 2013; Cricco-Lizza, 2009; Hellings & Howe, 2000, 2004; Register, Eren, Lowdermilk, Hammond, & Tully, 2000; Spatz, 2010; Spear, 2006; Weddig, Baker, & Auld, 2011). Lack of knowledge must C 2015 AWHONN, the Association of Women s Health, Obstetric and Neonatal Nurses 77

2 R ESEARCH Use of a Web-based Education Program Improves Nurses Knowledge of Breastfeeding Nurses have knowledge gaps regarding caring for the breastfeeding preterm infant, for the healthy term infant, and for infants with jaundice and poor weight gain. be remedied before nursing practice can be changed. Bernaix (2000) found that the nurse s knowledge about breastfeeding and her attitudes were most influential in predicting her actual supportive behavior (p. 207) and consequently that knowledge must be accurate and complete to promote breastfeeding success and be considered to be helpful by the mother. The need for improved education in this area echoes the Surgeon General s 2011 Call to Action to Support Breastfeeding that recommended that breastfeeding education be provided for all health care clinicians caring for women and infants to support initiation and continuation of breastfeeding (U.S. Department of Health and Human Services, 2011). In the nursing literature, authors of small usually one-site studies have reported improved knowledge of nurses after completing an educational program on breastfeeding. Many of these have assessed knowledge and attitudes toward breastfeeding (Bernaix, Beaman, Schmidt, Harris, & Miller, 2010; Ward & Byrne, 2011). A few have shown improved breastfeeding care delivered after an educational program (Bernaix, Schmidt, Arrizola, Lovinelli, & Medina-Poelinex, 2008; Shinwell, Churgin, Shlomo, Shani, & Flidel-Rimon, 2006; Siddell, Marinelli, Froman, & Burke, 2003). For nurses to take advantage of educational opportunities to obtain the needed knowledge and skills to support breastfeeding within their work schedule, these educational opportunities must be easily available, of high quality, and costeffective. Computer-based education that can be completed by nurses when their time permits at work or at home can fill this need. Computerbased education for medical professionals has been shown to increase knowledge as well as or better than traditional lecture formats (Cook et al., 2008; Gerdprasert, Pruksacheva, Panijpan, & Ruenwongsa, 2011; Koch, Andrew, Salamonson, Everett, & Davidson, 2010; Lam-Antoniades, Ratnapalan, & Tait, 2009). Breastfeeding Basics, a free online educational program at has been shown to meet eight of the 11 breastfeeding knowledge competencies established by U.S. Breastfeeding Committee and to increase knowledge in other health care professionals (U.S. Breastfeeding Committee, 2010). This program has been described in prior publications (Lewin & O Connor, 2012: O Connor, Brown, & Lewin, 2011). The purpose of this article is to describe specific knowledge gaps related to breastfeeding among a large sample of nurses and nursing students who completed pretests on the Breastfeeding Basics website and to evaluate the knowledge gained by nurses who completed pretests and posttests for at least one module. Description of Breastfeeding Basics The Breastfeeding Basics website was developed by the physician authors with assistance from other health care professionals at Case Western Reserve University, Rainbow Babies and Children s Hospital, and University Hospitals of Cleveland. The website was designed in 1998 to 1999 for use by health care professionals, and content updates were completed in 2000, 2002, 2005, 2008, and Breastfeeding Basics is composed of seven modules: (a) Benefits and Barriers, (b) Anatomy and Physiology, (c) The Growth and Development of the Breastfed Infant, (d) Breastfeeding Around the World, (e) The Breastfeeding Couple (care of the newborn infant and postpartum mother), (f) The Term Infant with Problems, and (g) Breast Milk and Drugs. Each module has learning objectives, table of contents, didactic information in text form, with photographs, and case histories that require the learner to type in a free text answer to receive immediate feedback. References to the health care literature are given so that learners can study topics in more detail. It usually takes learners 2 to 4 hours to complete all seven modules. The pretests and posttests of each module are identical and are composed of three questions with varying numbers of correct multiple-choice answers. The learner is given the total number of correct answers achieved after completing the pretest, and all correct answers and references to the text are given after completing the posttest. Faculty who incorporate Breastfeeding Basics into a formal curriculum can receive their students pretest and posttest scores electronically to monitor completion of the course. There is no charge for use of Breastfeeding Basics website. Methods Recruitment and Data Collection Users of Breastfeeding Basics register for the course anonymously by picking a log-in and 78 JOGNN, 44, 77-86; DOI: /

3 Deloian, B. J., Lewin, L. O., and O Connor, M. E. R ESEARCH password that links to an anonymous random identification number. The identification number links the pretest and posttest scores to the demographic information that participants provide, including sex, age group, location, and profession (from drop-down lists). Users are also asked questions related to their use of the course as a job requirement and whether they or their partner have ever breastfed an infant. Their log-in and password allows them to complete the course in several sessions and to review past material and past test results. Data are collected for analysis only on users who answer the demographic questions. Data Collection and Analysis For this project we included only users who identified themselves as student nurses, nurses, midwives, and nurse practitioners in the United States who registered for the course between April 13, 1999 and December 31, Because of the small of number of users age > 65 years in this population, age categories were combined into < 25 years, 25 to 40 years and > 40 years of age. For the pretest and posttest questions, each individual answer was computer scored resulting in 12 to 16 possible correct answers for each pretest and posttest. Baseline knowledge was assessed by pretest scores. The total pretest score was calculated by summing the total number of correct answers and dividing by the total number of possible answers. Due to low mean pretest scores and the clinical importance of the modules of Anatomy and Physiology, Breastfeeding Couple, The Term Infant with Problems, and the section of Growth and Development of the Breastfed Infant related to the preterm infant, we analyzed the individual questions on these pretests by calculating the median percentage correct for each individual answer to determine particular knowledge gaps. We also evaluated knowledge of hospital supports needed to promote breastfeeding in accordance with the Baby Friendly Hospital guidelines that is located in the Breastfeeding Around the World module. A percentage of < 80% correct on individual answers was considered low and was the threshold for comparison of paired pretest and posttest answers. Data analysis was completed using SPSS Statistics version Categorical variables were compared by chi-squared test. Due to non-normality of data, the comparisons of total pretest scores and demographic factors were performed using median scores, Mann-Whitney U, and Kruskal-Wallis There was no difference in baseline knowledge of breastfeeding between nurses, nurse practitioners, and midwives. tests. Paired pretest and posttest answers were compared using Wilcoxon Signed-Rank Test. This project was classified as exempt research by the Colorado Multiple Institutional Research Board. Results Participants Between April 13, 1999 and December 31, 2011, 19,671 health care professionals or health care professional students registered for Breastfeeding Basics. Of these users, 9080 (46%) were nurses, nurse practitioners, midwives, or nursing students living in the United States. Data were analyzed on the 7570 (83%) of those learners who completed at least one pretest or posttest. The demographic characteristics of the participants are listed in Table 1. Demographic characteristics were significantly different for age, sex, job or school requirement, and personal/partner breastfeeding experience among the three groups of nurses and students. Baseline Knowledge Gaps Table 2 provides comparisons of the median total pretest scores (our measure of baseline knowledge) with demographic factors. There was no difference between nurses and midwives/nurse practitioners, but both had higher scores than student nurses. Having personal or partner breastfeeding experience, being older, being female, and using the course from 1999 to 2005 were all associated with higher pretest scores. Being required to take the course for a job or school requirement was associated with lower median pretest scores. Changes in Scores from Pretests to Posttests Median pretest and posttest scores are listed in Table 3 for all learners who completed the pretest and posttest in a module. Median posttest scores in all modules were significantly higher than pretest scores (p <.001 for all modules). The lowest median pretest scores (< 75% correct) were in the modules of Anatomy and Physiology, Growth and Development of the Breastfed Infant, The Breastfeeding Couple, and The Term Infant with Problems. JOGNN 2015; Vol. 44, Issue 1 79

4 R ESEARCH Use of a Web-based Education Program Improves Nurses Knowledge of Breastfeeding Table 1: Demographic Characteristics among Nurses, Nursing Students, Nurse Practitioners (NP) and Certified Nurse-Midwives (CNM) Who Registered for Breastfeeding Basics Student Nurse Nurse NP/CNM Statistical n = 3106 n = 3736 n = 728 Significance a Age < 25 yrs 1554 (50%) 499 (13%) 62 (8%) p < yrs 1288 (42%) 1750 (47%) 382 (53%) > 40 years 264 (8%) 1487 (40%) 284 (39%) Gender Female 2754 (89%) 3617 (97%) 691 (95%) p <.001 Male 352 (11%) 119 (3%) 37 (5%) Required for School or Work Yes 2801 (90%) 3089 (83%) 587 (81%) p <.001 No 305 (10%) 647 (17%) 141 (19%) Breastfeeding Experience Yes 673 (22%) 2386 (64%) 421 (58%) p <.001 No 2433 (78%) 1350 (36%) 307 (42%) Note. a Chi-squared test. The nurses had very good baseline knowledge of the benefits of breastfeeding, including its role in prevention of ear infection and allergies, its being cheaper than feeding formula, and its role in child spacing. Their knowledge about medication use by breastfeeding mothers was excellent with knowledge of the importance about the transfer of medications into breast milk and the effect of the drug on the infant. They also knew that breastfeeding is contraindicated with maternal use of illicit drugs such as heroin and cocaine. Table 4 presents the questions and individual answers with low pretest scores (< 80%) and their paired posttest scores. Gaps were present in knowledge of the anatomy and physiology of breastfeeding, breastfeeding in premature infants, and the importance of training all staff who care for pregnant and lactating women and children in breastfeeding support. Greater than 50% of nurses said that a mother who was positive for Hepatitis B should not breastfeed her infant, 50% of nurses said a mother should stop breastfeeding due to candida infection of her nipple, and 34% said breastfeeding should be stopped due to mastitis (all answers are incorrect). The nurses had knowledge gaps regarding the mechanism of jaundice in the first week of life in breastfed infants but had good knowledge of the recommendation to continue frequent breastfeeding in the jaundiced infant and that giving infants water does not prevent jaundice. There were significant gaps in the nurses knowledge of normal weight gain in the breastfed infant in the first 2 weeks of life. Posttest scores for all questions with < 80% correct on the pretest improved significantly (p <.001). Discussion Breastfeeding Basics was designed for use in pediatric and other medical residency programs, but surprisingly the largest groups of health care professionals using this program have been nurses and nursing students. Consequently this is the largest evaluation of the breastfeeding knowledge of nurses in the United States that we have found in the literature and the largest evaluation of an educational program for increasing breastfeeding knowledge of nurses. This project reveals significant gaps in the knowledge of nurses in the United States in many areas of breastfeeding. However, after using the Breastfeeding Basics website, participants knowledge increased statistically and clinically in all areas as measured by increased posttest scores. Breastfeeding Basics has the potential to improve the practice of nurses who work with mothers and their infants in hospital mother/baby units 80 JOGNN, 44, 77-86; DOI: /

5 Deloian, B. J., Lewin, L. O., and O Connor, M. E. R ESEARCH Table 2: Analysis of Total Median Pretest Scores a by Demographic Factors for 7046 Participants Who Completed at Least One Pretest Demographic Factors Number of Total Pretests Median Total Pretest Score Statistical Significance b Professional Level p <.001 Student nurse % Nurse % NP/CNM % Age p <.001 < 25 years % years % > 40 years % Gender p <.001 Female % Male % Required p <.001 Yes % No % Breastfeeding Experience p <.001 Yes % No % Year p < % % Note. NP = nurse practitioner; CNM = certified nurse-midwife. a The median total pretest score is the median of the score summing all correct pretest answers divided by all possible answers for all pretests completed. b Mann-Whitney U Test for 2 demographic factors and Kruskal-Wallis Test for 3 demographic factors. and neonatal intensive care units (NICUs), after delivery, and during the postpartum period. The recognition of nurses support of breastfeeding has evolved out of their key roles in lactation education, counseling, support, and management (Boyd & Spatz, 2013; Weddig et al., 2011). The National Council of State Boards of Nursing included breastfeeding education in the 2010 NCLEX-RN Detailed Test Plan for Candidates (Wendt, Kenny, & Schultz, 2010). Breastfeeding support is part of the midwifery scope of practice (International Confederation of Midwives, 2010), and this support has also been addressed by pediatric nurse practitioners (National Association of Pediatric Nurse Practitioners, 2013). Breastfeeding Basics can address the welldocumented lack of breastfeeding education in associate or baccalaureate nursing curricula and in pediatric nurse practitioner programs (Ahmed et al., 2011; Boyd & Spatz, 2013; Spatz & Pugh, 2007). In a review of breastfeeding content in nursing textbooks, the authors demonstrated that breastfeeding information was often omitted and at times was inaccurate and inconsistent (Philipp, McMahon, Davies, Santos, & Jean-Marie, 2007). This lack of education may be related to the low pretest scores we found in the Anatomy and Physiology module. However, it appears that some nursing education programs are beginning to meet the recommendation to integrate breastfeeding throughout the nursing curriculum, including in anatomy and physiology, human development, nutrition, healthy lifestyles, pharmacology, maternal and child health, and community health nursing courses (Spatz & Pugh, 2007). Our results demonstrate the educational deficits found in previous investigations. In 2006, Spear evaluated the breastfeeding knowledge of 80 JOGNN 2015; Vol. 44, Issue 1 81

6 R ESEARCH Use of a Web-based Education Program Improves Nurses Knowledge of Breastfeeding Table 3: Comparison of Scores for all Student Nurses, Nurses, Nurse Practitioners, and Certified Nurse-Midwives Who Completed the Pretest and Posttest of the Modules Module Number Median Median Statistical Module (% completing) Pretest Score Posttest Score Significance a Benefits/Barriers 5674 (75%) 87.5% 93.7% p <.001 Anatomy/Physiology 5060 (67%) 66.7% 93.3% p <.001 Growth/Development of Breastfed Infant 3576 (47%) 66.7% 91.7% p <.001 Breastfeeding Around the World 3465 (46%) 86.7% 93.3% p <.001 Breastfeeding Couple 4761 (63%) 73.3% 93.3% p <.001 Term Infant with Problems 4507 (60%) 60.0% 86.7% p <.001 Breast Milk and Drugs 3569 (47%) 83.3% 91.7% p <.001 Note. a Wilcoxon Signed-Rank Test. The knowledge gained though Breastfeeding Basics can be the first step in improving clinical care to breastfeeding mothers and infants. baccalaureate nursing students who had completed their obstetric and pediatric nursing courses and found that 29% of these students believed mothers being treated for mastitis should stop breastfeeding until the mastitis was resolved. This was similar to our results (34%). Ahmed et al. (2011) similarly assessed baccalaureate nursing students at two programs who had completed maternal/child nursing didactic and clinical courses. They found that nursing students had greater knowledge of the benefits of breastfeeding but gaps in knowledge regarding physiology and breastfeeding management, which is similar to our results (Ahmed et al., 2011). Additionally, Hellings and Howe (2000, 2004) reported that nurse-midwives had more experience with breastfeeding mothers than did nurse practitioners, however for both groups the most important source of their knowledge was personal breastfeeding experience. Almost 75% of our participants had personal breastfeeding experience. However personal breastfeeding experience is often not sufficient to provide the depth of knowledge needed to counsel women about complex breastfeeding problems. In fact Szucs, Miracle, and Rosenman (2009) found that personal breastfeeding experience of health care professionals has been associated with use of non evidencebased practices. The accessibility of Breastfeeding Basics makes it ideal for supplying educational content to busy nurses, nurse practitioners, and midwives and to supplement other educational experiences of nursing students. Because of the lack of breastfeeding education in nursing curricula, individual hospitals or other employers need to set policies and practice standards to ensure that their nursing staff is knowledgeable and skilled in providing breastfeeding support for mothers and their infants. This often requires on-the-job didactic education and clinical training. The ability of an individual organization to accomplish this depends on the size of their mother/baby units, their commitment to supporting breastfeeding, and the commitment of the involved medical staff caring for mothers and infants. Using Breastfeeding Basics can help accomplish this didactic education, however, it needs to be combined with bedside experience and mentorship for nurses to improve their skills. Without education that includes evidence-based information, nurses may have variable practices when working with mothers and neonates. Weddig, Baker, and Auld (2011) used focus groups at eight hospitals to interview nurses from maternity, newborn, and NICUs about their breastfeeding knowledge. They found that though nurses reported being knowledgeable about breastfeeding, their knowledge was not actually based on evidence-based practices (Weddig et al., 2011). However, Bernaix (2000) found that the best predicator of supportive behavior for maternal breastfeeding was the nurse s knowledge of breastfeeding evidence and policy. Breastfeeding support by nurses continues 82 JOGNN, 44, 77-86; DOI: /

7 Deloian, B. J., Lewin, L. O., and O Connor, M. E. R ESEARCH Table 4: Comparison of Paired Pretest and Posttest Scores of Individual Questions and Answers with Low Pretest Scores Question Percent Correct Percent Correct Statistical Significance Topic on Pretest on Posttest p value a Anatomy and Physiology, n = 5060 Suckling at breast stimulates prolactin which causes milk let-down 25% 55% <.001 Oxytocin causes milk ejection 66% 93% <.001 Glucose is major carbohydrate 58% 70% <.001 Low concentration of iron but is easily absorbed 48% 88% <.001 Growth and Development of Breastfed Infants, n = 3576 Preterm infants >1500 gm and >32 34 weeks grow well on human milk only Preterm infants born at 28 weeks will grow well on human milk only Preterm infants <32 34 weeks need fortified human milk to grow well Preterm infants <34 weeks need supplemental vitamin D and iron 66% 84% < % 85% < % 86% < % 89% <.001 Breastfeeding Around the World, n = 3465 Train all staff in breastfeeding support 79% 92% <.001 Train only direct care maternity staff in breastfeeding support 73% 86% <.001 Breastfeeding Couple, n = 4761 Wash nipples with only plain water 78% 81% <.001 Use moisturizing cream on nipple to prevent dryness and cracking 54% 91% <.001 Reasons for stopping breastfeeding Candida infection of the nipple 50% 91% <.001 Mastitis 66% 94% <.001 First visit at 3 5 days of age to check breastfeeding and jaundice Expect mother to be tired for first 2 3 weeks of breastfeeding 72% 91% < % 91% <.001 Term Infant with Problems n = 4507 Breastfed infants get jaundiced > infants fed formula 57% 88% <.001 Jaundice in first week is due to decreased bilirubin excretion in the stool 78% 92% <.001 Infants whose weight is a concern: those with weight loss > than 10 12% 77% 94% <.001 not back to birth weight by 7 days of age 66% 83% <.001 not back to birth weight by 14 days of age 50% 81% <.001 still losing weight after 10 days of age 78% 91% <.001 Note. a Paired Student s t Test. JOGNN 2015; Vol. 44, Issue 1 83

8 R ESEARCH Use of a Web-based Education Program Improves Nurses Knowledge of Breastfeeding from the hospital into the outpatient pediatric setting. Register et al. (2000) evaluated knowledge and attitudes of nurses in 27 pediatric offices. Although their knowledge of breastfeeding benefits was good, less than 50% of the nurses were confident in helping a mother who was concerned about her infant s weight gain, her milk supply, or medications she was taking. Most nurses (85%) reported that on the job training was their source of breastfeeding education (Register et al., 2000). Breastfeeding Basics has the potential to standardize nurses knowledge of breastfeeding and to ensure that knowledge is based on up-to-date evidence. Authors of several studies of breastfeeding educational interventions for nurses in NICUs have shown improved knowledge in their participants. In an ethnographic report of in-depth interviews of NICU nurses and their own exposures to breastfeeding, the investigator found that little personal experience with breastfeeding was associated with less supportive breastfeeding attitudes. However, breastfeeding educational programs were reported to change these attitudes and increase nurses ability to help breastfeeding mothers in the NICU (Cricco-Lizza, 2009). In several other studies, the authors found improved knowledge and measurable patient outcomes after breastfeeding education (Bernaix et al., 2008; Siddell et al., 2003). Ward and Byrne (2011) reviewed 15 breastfeeding educational programs around the world for health care professionals focusing on nurses and midwives and found that eight of eight who measured knowledge outcomes showed an increase, and five of six who assessed breastfeeding attitudes found improvement. In clinical breastfeeding outcomes, eight of eight had some decrease in in-hospital breastfeeding supplementation, and four of five found an increase in duration of exclusive breastfeeding. Similar studies of breastfeeding educational interventions for nurses in other settings showed improved knowledge of the nurses as well as improved attitudes, beliefs, and intentions to support breastfeeding in one report and improved care outcomes with increased breastfeeding initiation rates and increased maternal satisfaction in another study, respectively (Bernaix et al., 2010; Shinwell et al., 2006). Breastfeeding Basics could be used as the source of didactic breastfeeding information in similar situations thereby allowing nurse educators to focus on hands on teaching of breastfeeding. This study fills a gap in the published data on nurses breastfeeding knowledge. We found little specific information about breastfeeding knowledge of nurses in the United States to compare to the baseline pretest scores reported here. The lowest median pretest scores (< 75% correct) were in the modules of Anatomy and Physiology, Growth and Development of the Breastfed Infant, The Breastfeeding Couple, and The Term Infant with Problems. The last two modules cover care of the newborn in the hospital and immediate postdischarge care. Our findings support other studies that suggest nurses know the benefits of breastfeeding but need more education in how to support mothers breastfeeding both initially and through the first year of life. There are limitations to this project. This was not a randomly selected sample of nurses, however, it is a large sample size (7570), and 6477 (85%) of the nurses were required to complete the course for a job or work requirement. Using the same questions and answers in the pretest and posttest can cause improvement through familiarity. We attempted to minimize this effect by giving the users only the number of correct answers attained on the pretest but not telling them which answers were incorrect. Although these data show that Breastfeeding Basics can be used to improve knowledge, with this study design we are unable to determine if knowledge is retained or if the nurses changed their clinical practice based on the program. Use of Breastfeeding Basics needs to be combined with hands on training of nursing staff to enable them to help mothers effectively initiate breastfeeding and continue breastfeeding when problems such as jaundice and poor weight gain arise. A survey of teachers using Breastfeeding Basics in their curricula showed that 84% combined Breastfeeding Basics with hands on clinical care, and it is more likely that these combined programs will lead to practice changes (Lewin & O Connor, 2012). Furthermore, item analysis to determine the internal validity of the questions on the pre and posttests was not performed, but the knowledge gaps that were identified are similar to those reported by others, providing a measure of external validity to the test questions as a group. Other online educational programs have shown changes in patient care outcomes, and investigators found that knowledge gained and practice changes reported after use persisted for 6 and 12 months, respectively (Beal, Kemper, Gardiner, & Woods, 2006; Short, Suprenant, & Harris, 2006). Additionally, in a literature review of continuing medical education in the health professions, the authors concluded that there was ample evidence 84 JOGNN, 44, 77-86; DOI: /

9 Deloian, B. J., Lewin, L. O., and O Connor, M. E. R ESEARCH that online continuing education could lead to increases in knowledge and changes in practice patterns (Lam-Antoniades et al., 2009). Recently, investigators found that the addition of online educational materials in an undergraduate nursing course improved students learning as well as their comfort in working with patients. (Gerdprasert et al., 2011). We are cautiously optimistic that Breastfeeding Basics in combination with hands on training can improve care for mothers and their infants. Conclusion Breastfeeding Basics, an online breastfeeding education program, was used by a large number of nurses, nursing students, midwives, and nurse practitioners in the United States. Its use exposed gaps in their knowledge. By comparing pretest and posttest scores, knowledge improved in all areas particularly those with low pretest scores. Breastfeeding Basics can be used as part of a curriculum that includes hands on teaching as a first step in improving the ability of nurses to support breastfeeding mothers and infants. Improved breastfeeding support during the first year of life will help increase breastfeeding duration and improve the health of mothers and children. Acknowledgement Development of the Breastfeeding Basics website funded by the Northern Ohio Chapter of the March of Dimes and the University Center for Innovation in Teaching and Education, Case Western Reserve University School of Medicine. The authors thank Emil W. Brown for programming and continued maintenance of the website. REFERENCES Ahmed, A., Bantz, D., & Richardson, C. (2011). Breastfeeding knowledge of university nursing students. American Journal of Maternal Child Nursing, 36(6), American Academy of Pediatrics. (2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827 e841. Beal, T., Kemper, K. J., Gardiner, P., & Woods, C. 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