In Practice Photo Wavebreakmedia Ltd / thinkstockphotos.com The Role of the Nurse- Physician Leadership Dyad in Implementing the Baby-Friendly Hospital Initiative IIn today s ever-changing health care environment, hospitals must find ways to integrate and align their interests with those of the providers who drive their business. Many hospitals are using the hospitalist model to deliver quality care, in which physicians are employees of a comprehensive care system (Singer, 2008). The hospitalist concept enhances the ability to implement ROSE ST. FLEUR JOYCE MCKEEVER and sustain evidence-based health care by standardizing care using in-house health care providers. Usually these providers possess expertise in the area in which they are based, such as obstetricians or certified nurse-midwives in labor and birth units. In the project we describe here, the hospitalist was a pediatrician who specialized in caring for breastfeeding women. Abstract: The concept of the nurse-physician leadership dyad incorporates the expertise of both nurses and physicians as leaders of change within health system environments. The leadership dyad model has been used traditionally in health care administrative settings to manage utilization of resources more effectively. Because the Baby-Friendly designation requires major cultural shifts in long-standing maternity care practices, an interdisciplinary approach to implementation is necessary. DOI: 10.1111/1751-486X.12124 Keywords: Baby-Friendly Hospital Initiative interdisciplinary leadership dyad quality improvement http://nwh.awhonn.org 2014, AWHONN 231
In Practice Rose St. Fleur, MD, FAAP, IBCLC, is a pediatrician with expertise in breastfeeding medicine, and medical director at the Center for Breastfeeding at Jersey Shore University Medical Center in Neptune, NJ. Joyce McKeever, MS, RN, IBCLC, LCCE, is the clinical program manager for the Baby-Friendly Hospital Initiative and the director of clinical services at the Center for Breastfeeding at Jersey Shore University Medical Center in Neptune, NJ. The authors report no conflicts of interest or relevant financial relationships. Address correspondence to: jmckeever@ meridianhealth.com. The leadership dyad model we will describe provides the opportunity for nurses, physicians and administrative staff to work together toward affecting changes in hospital practices. Physicians become more integrated into an interdisciplinary team, and can participate in incorporating current research into clinical practice; real-life examples of such integrations already have been put into action successfully (Teufel, Garber, & Taylor, 2007). For example, one hospitalist group used the quality improvement process to address outcomes of elderly patients with acute coronary syndrome. Hospitalists developed protocols and measures to establish an institution-wide program standardizing care for patients at high risk for adverse outcomes (Whelan, 2010). The leadership dyad consisted of two highly committed individuals who embraced a similar passion for realizing effective change in hospitalbased breastfeeding support The hospitalist model was already in existence at our organization, Jersey Shore University Medical Center (JSUMC), thereby creating opportunity for the development of the nursephysician leadership dyad for the implementation of the Baby-Friendly Hospital Initiative. Background The Baby-Friendly Hospital Initiative was developed by the World Health Organization (WHO) and the United Nations Children s Fund in 1991 as a global recognition for hospitals using practices that support, promote and protect breastfeeding and optimal infant nutrition (United Nations Children s Fund, 2014; WHO, 2013). Awareness of the importance of modifying hospital practices to provide breastfeeding support has since gained reinforcement from several organizations throughout the world. In the United States, the Centers for Disease Control and Prevention (CDC, 2013) monitor breastfeeding rates beginning at the first 2 days of life, acknowledging that such rates reflect on the quality of hospital care practices. In 2010, JSUMC made a strategic decision to pursue Baby-Friendly Hospital designation to improve quality of care and assure the practice of current evidence-based standards supported by the Baby-Friendly Hospital Initiative. At that time, there were fewer than 100 hospitals in the United States with the designation of Baby- Friendly, and no hospitals within the JSUMC organization had earned such an achievement. To accomplish the goal of attaining Baby- Friendly Designation, the chief nurse executive created an organizational role of clinical program manager for the Baby-Friendly Hospital Initiative. The position was filled by a nurse who was an International Board Certified Lactation Consultant (IBCLC) with clinical and management background in maternal/child nursing. At the same time, a pediatrician with expertise in breastfeeding medicine was identified, and hospital administration tasked both leaders with educating the nursing and physician staff in the concepts of the Baby-Friendly Hospital Initiative and directing the hospital team toward Baby-Friendly designation. Characteristics of a Successful Leadership Dyad The theory defining the function of a management dyad is best illustrated by the authors Zismerand Brueggemann. They defined the word dyad as two persons involved in an ongoing relationship or intervention; the relationship or intervention itself (Zismer & Brueggemann, 2010, p. 14). At JSUMC, the leadership dyad consisted of two highly committed individuals who embraced a similar passion for realizing effective change in hospital-based breastfeeding support. Each individual leader had distinct roles, but ultimately, the dyad shared responsibility and accountability for the overall clinical quality and service execution of the Baby-Friendly Hospital Initiative (see Figure 1). The theoretical concepts behind this model reinforce trust, interdependence, open communication and mutual respect. Generally, the approach toward the creation of a dyad varies from one setting to the next. In some instances, an administrative team appoints the dyad, whereas in other circumstances, two committed leaders may simply find each other. At JSUMC, the leadership dyad was formed by a combination of both. 232 Nursing for Women s Health Volume 18 Issue 3
Figure 1. Leadership Roles In Practice A leadership dyad will be most successful when both leaders are Passionate, knowledgeable and committed to project goals; Recognized leaders in the organization; Able to work collaboratively as a unit (i.e., when one person in the dyad speaks, everyone knows that he/she speaks for both partners); Role models for the behaviors and changes they wish to achieve. Challenges Implementing the Baby-Friendly Hospital Initiative requires hospitals to scrutinize their existing policies and procedures, and realign care practices based on current evidence-based research. To assist in implementation, the leadership dyad worked collaboratively to provide in-service education, written materials, online educational programs, physician and nurse staff lectures and open discussion forums. For example, at JSUMC, skin-to-skin contact had not been an established practice; previously, nursing staff were trained to put the baby on a radiant warmer immediately after delivery. Some nurses were resistant to changing practice because of concerns that babies might suffer from hypothermia. To address this issue, the early adapters The image of both leaders teaching alongside one another not only magnified the importance of the goal of implementing the Baby-Friendly Hospital Initiative, but also emphasized the required commitment of all team members, regardless of their rank or title were encouraged to implement skin-to-skin care and report on their experiences. Their stories of success inspired reluctant staff to be more receptive to the change in nursing process. At the same time, the leadership dyad developed didactic and skills training labs for nurses and physicians. The physician leader June July 2014 Nursing for Women s Health 233
addressed the concerns of the physician staff, while the nurse leader implemented process changes to help the nursing staff accomplish this goal. Both the physician leader and nurse leader were present in all forms of training; the physician leader didn t just train the physicians, nor did the nurse leader Once Baby-Friendly designation was achieved with the assistance of the leadership dyad, the next step was sustaining the gains and building on the foundation of change just train the nurses. Training together was a distinctive characteristic of the leadership dyad. The image of both leaders teaching alongside one another not only magnified the importance of the goal of implementing the Baby- Friendly Hospital Initiative, but also emphasized the required commitment of all team members, regardless of their rank or title. The presence of the dyad also encouraged team members to envision themselves as equal contributors to change. In so doing, the leadership dyad was able to achieve a strong, longlasting buy-in. Within 3 months, skinto-skin contact implementation rates increased from 0 percent to more than 80 percent. The leadership dyad continued to educate and monitor the practice even after it became ingrained into practice culture. Another challenge faced when implementing the Baby-Friendly Hospital Initiative was amending the practice of supplementing breastfed babies with infant formula without a justified medical reason. Published clinical guidelines from the Academy of Breastfeeding Medicine (ABM) exist regarding the use of infant formula when medically indicated, yet liberal feeding of infant formula is still traditionally practiced (ABM, 2009). Data collection was key in demonstrating the importance of this issue to staff; 57 percent of breastfed babies were supplemented with infant formula with no clear medical reason, even though it was perceived that supplementation was not used frequently. Together, the nurse leader and physician leader developed evidencebased educational programs on medical indications for infant formula supplementation. Such programs included physician lectures for pediatricians, obstetricians and medical residents on assessment of milk supply and support for mothers experiencing difficulties with breastfeeding. Although the majority of the physicians participated in the formal lectures offered, those physicians resistant to onsite lectures were given the opportunity to receive education from a list of options, including online education and skills labs offered at various times for their convenience. In addition, the leadership dyad revised the newborn admission orders to include both an order and a medical reason for infant formula supplementation documented in the medical record. The nursing staff were educated on the process change using didactic teaching and instruction on discussion points with the ordering physician. The leadership dyad closely monitored the practice change, and, as a result, the exclusive breastfeeding rate increased from 24 percent to 50 percent. Sustainability The efforts of the maternity team s journey to Baby-Friendly was rewarded with Baby-Friendly Designation in 2012, becoming one of only four hospitals in New Jersey to receive this designation. Once Baby-Friendly designation was achieved with the assistance of the leadership dyad, the next step was sustaining the gains and building on the foundation of change. According to Blattner and Wenneker, Sustainable success can best be achieved if the appeal is firmly rooted in the organization s strategy and its goals clearly linked to the organization s goals (Blattner & Wenneker, 2005, p. 15). As part of JSUMC s strategic goals, data demonstrating the sustainability of the Baby-Friendly Hospital Initiative are reported to the Board of Trustees Photo Stockbyte / thinkstockphotos.com 234 Nursing for Women s Health Volume 18 Issue 3
monthly, and progress is carefully monitored. In addition, community outreach support services in the region for follow-up breastfeeding medical care were expanded with the opening of an outpatient lactation clinic, the Center for Breastfeeding. The leadership dyad developed the mission and vision for the Center and currently heads this program, working to create policies and using clinical skills to provide comprehensive follow-up care. The development of the Center for Breastfeeding is an example of how the collaborative efforts of the leadership dyad can be used not only in a hospital setting for quality improvement, but also in an outpatient setting for the creation of additional care services (see Box 1). Conclusion The leadership dyad model is an effective strategy to facilitate change in today s health care environment. Because implementing the Baby- Friendly Hospital Initiative required an interdisciplinary approach, this dyad model was uniquely adapted and used to achieve designation at JSUMC. Medical centers that don t use the hospitalist model can achieve similar success by identifying physician or nurse champions who share similar passions, visions and values. In addition, this model can improve the quality improvement process by creating a specific role for physician involvement that fosters motivation for change. The academic and clinical expertise of both nurse and physician leaders assures that the nurse-physician leadership dyad engages all team members and key stakeholders to optimize cultural shifts in care practices. Acknowledgments The authors thank the leaders and members of the New Jersey Baby- Friendly Hospital Initiative project for their guidance and feedback, and the Communities Putting Prevention to Work program, a division of the Box 1. Leadership Dyad Strategies for Implementing the Baby-Friendly Hospital Initiative Collaborate on the mission and the steps to achieving it. Essentially figure out, What do we have to do and how are we going to do it? Create a task force to help carry out the mission. Identify key stakeholders and team members who will assist. Determine order of implementing the Ten Steps to Successful Breastfeeding. Start with easiest steps to achieve to have some early successes. Hold open forums to gauge progress. This allows staff to voice frustrations, offer suggestions and share accomplishments. Provide in-service education together on both shifts. This shows commitment of leadership team to achieve success. Conduct lunchtime learning sessions at physicians offices, which offers a collaborative approach to breastfeeding education. Meet weekly with management team on maternity unit. Monitor readiness with patient and staff interviews. Identify vulnerable areas through chart reviews and patient feedback. Hold mock surveys. Utilize guidelines and evaluation criteria from Baby- Friendly USA. Centers for Disease Control and Prevention, for grant assistance toward Baby-Friendly designation. NWH References Academy of Breastfeeding Medicine Protocol Committee. (2009). ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeeding Medicine, 4(3), 175 182. doi:10.1089/bfm.2009.9991 Blattner, S., & Wenneker, M.(2005). Getting physician buy-in even without direct authority. Physician Executive, 31(5), 14 18. Centers for Disease Control and Prevention (CDC). (2013). Breastfeeding report card 2013. Atlanta, GA: Author. Retrieved fromwww.cdc.gov/breastfeeding/data/reportcard.htm Singer, A. (2008, November 1).Hospital medicine groups must align business models. Managed Healthcare Executive. Santa Monica, CA: Advanstar Communications. Retrieved from http:// managedhealthcareexecutive.modernmedicine.com/managed-healthcareexecutive/news/hospital-medicinegroups-must-align-business-models Teufel, R. J., II, Garber, M.,&Taylor, R. C. (2007). Pediatric hospitalist: A national and regional trend. Journal of the South Carolina Medical Association, 103(5), 126 129. United Nations Children s Fund. (2014). The Baby-Friendly Hospital initiative. New York: Author. Retrieved from www.unicef.org/programme/breastfeeding/baby.htm Whelan, C. T. (2010). The role of the hospitalist in quality improvement: Systems for improving the care of patients with acute coronary syndrome. Journal of Hospital Medicine, 5(Suppl. 4), S1 S7. doi:10.1002/jhm.828 World Health Organization (WHO). (2013). Baby-Friendly Hospital Initiative. Washington, DC: Author. Retrieved from www.who.int/nutrition/ topics/bfhi/en Zismer, D. K., & Brueggemann, J. (2010). Examining the dyad as a management model in integrated health systems. Physician Executive, 36(1), 14 19. June July 2014 Nursing for Women s Health 235