Becoming Breastfeeding Friendly Scotland: report

Scotland's results and the key recommendations for the continued protection, promotion and support for breastfeeding.

Theme 6: Developing coordinated, consistent and evidence-based learning outcomes across education and training programmes, based on role-appropriate competency frameworks

Recommendation 6: There are nationally coordinated, consistent learning outcomes for all groups who care for mothers and babies, both in service and pre-registration, and also volunteers and lay supporters. These outcomes are based on a competency framework for each group and underpinned by training and mentorship, supervision and monitoring; together these will ensure consistency for each group and appropriate, quality assured and standardised provision.

Relevant BBF Scotland Gear scores: Training and Programme Delivery: 2.5; Coordination, Goals and Monitoring: 3.0

Why are these recommendations necessary?

A Unicef UK review of the evidence found that Implementing 'standalone' training for staff will not change breastfeeding initiation or prevalence rates[66]. Rather, education should be delivered as part of a multifaceted package. To be effective, training for health and social care professionals should cover a set of evidence-based breastfeeding topics, including practical skills, and be integrated within all relevant pre-registration and in-service programmes[67].

Section two of the Action Plan under Improving Maternal and Infant Nutrition: a Framework for Action (2011) incorporates Unicef UK's Baby Friendly Initiative[68] (BFI) maternity, community and university standards as an evidence-based minimum way of improving breastfeeding support for mothers. The Unicef UK's Baby Friendly Initiative, a staged accreditation programme, which requires a minimum of 80% of staff to be trained on the essential topics and demonstrate this knowledge to accreditors, has been shown to raise breastfeeding outcomes in the short, medium and long term[69],[70].

Scotland has now achieved 100% accreditation at a service setting level for Unicef UK Baby Friendly Initiative; four of the largest neonatal units at full implementation of the neonatal Unicef UK Baby Friendly Initiative standards, with two further units at Stage 2 with smaller units to follow[71]. Moving beyond this, Unicef UK recommend continued action to strengthen and embed cultural change through progress to the Gold Achieving Sustainability award in order to maintain and extend these gains in breastfeeding rates[72] through a supportive culture of mentorship, supervision and monitoring. Further developing the focus on embedding supportive workplace cultures, the work of the Regional Coordinators who will oversee training and the recent e-learning modules aimed at the whole workforce, aim to deliver ongoing skills and knowledge to the workforce; the Scottish Improvement Science Collaborating Centre's (SISCC) work could further contribute to embedding coordinated, consistent standards and progression across professions.

At a university level, Scotland has made good progress towards the Unicef UK Baby Friendly Initiative University Standards programme for midwifery and health visitor/public health nurse education, delivering standardisation and quality assurance at pre-registration university level. The focus remains on midwifery and health visiting courses. In Scotland, these courses have predominantly achieved accreditation or are in the process, but associated professions are not covered, suggesting collaborative action is needed to extend these standards to these wider courses in order to working with mothers and babies.

This BBF Scotland review therefore identified some inconsistencies in the learning outcomes of pre and post service training across the professions involved in the care of mothers and babies not covered under Unicef UK Baby Friendly Initiative, whilst noting that at a post registration level, new blended learning packages have been developed to update staff and to strengthen understanding and broaden skills and confidence.

For volunteers and peer supporters, quality training is available, generally through voluntary sector organisations but, again, it is not coordinated and learning outcomes are not consistent. Online and other learning resources are available but lack coordination and currently have no independent source of verifying how far these are evidence-based, up-to-date or free from commercial interest. There is clear evidence of the need to deliver coordinated and integrated learning outcomes at trainee, pre-registration, post-registration and for volunteers, with a clear quality assurance, governance structures and means to monitor delivery and standards.

What do we want to happen?

  • National implementation of consistent and appropriate practice skills and learning outcomes for all roles who care for mothers and babies based on role appropriate competency frameworks which build on (and extend as appropriate) Unicef UK Baby Friendly Initiative core standards. This would include:
    • Students and trainee health professionals (pre-registration).
    • Health professionals, including neonatologists, obstetricians, paediatric nurses, paediatricians, dieticians and a range of support staffing roles.
    • Volunteers and lay supporters.
    • All other non-statutory practitioners working with mothers and babies.
  • The competency framework for each group should be underpinned by training and mentorship as well as supervision and monitoring.
  • The development and implementation should consider remote and rural working in the context of Scotland from the outset.
  • Evidence based e-learning module roll out.
  • Ensure GPs are encouraged and supported to undertake the new training available to them, with potential support from the GP Infant Feeding Network.
  • A mechanism for ensuring coordinated and consistent quality assurance and governance of volunteers, lay supporters and other practitioners is put in place, ensuring regular updates are recorded and supervision is in place.
  • To ensure that any resources developed and delivered are monitored for quality and compliance with the International Code of the Marketing of Breastmilk Substitutes and subsequent WHA resolutions with no training or sponsorship by commercial companies.

How will this be done?

  • Regional Coordinator positions are in recruitment at present to support and co-deliver this process, through NHS Highland overseen by the Scottish Government Breastfeeding Lead. Working with experts, develop and consolidate role-appropriate competency frameworks for those professions supporting mothers and babies; this should include collaborative action with peer and lay support providers to coordinate and bring consistency to learning outcomes and teaching resources, supported by the evidence.
  • Outputs to be disseminated through appropriate advocacy with professional bodies and universities.
  • Build upon the current development of blended learning materials and learning outcomes, together with the complementary (though separate) materials in development for paediatric nursing through Unicef UK's Baby Friendly Initiative and Scottish government e-learning modules.
  • Collaboration with the Unicef UK Baby Friendly Initiative and continued strategic level support from government to progress local standards towards the gold Sustainability award to embed progressive, evidence-based, multi-component policy and practice that is coordinated, consistent and in line with relevant standards.
  • The work should draw on evidence from improvement science for professional behaviour change through the Scottish Improvement Science Collaborating Centre.

What is the likely impact of these recommendations?

  • Women will be better supported to breastfeed and overcome barriers through the provision of consistent messages and highly skilled support across settings and staff, both professional and lay supporters.
  • Education providers will be supported by an evidence-based framework to provide and maintain consistent high standards, enabling consistent, coordinated education and practice skills development in place for all health professionals and lay supporters caring for mothers and babies in their pre or post-registration capacity.
  • Training standards will be integrated into a broader Unicef UK Baby Friendly framework in maternity, community, neonatal systems developing a stronger and more sustainable culture of ongoing service improvement.

Tailored, coordinated education & training for all those working with mothers and babies

Aim: learning outcomes for all those supporting mothers and babies are consistent, coordinated, role appropriate and monitored within an evidence based framework

Working with Unicef UK, Health Boards and key stakeholders, this recommendations set out to deliver the following objectives

  • Implement nationally consistent competency frameworks that are role appropriate and supported by mentorship and supervision
  • Collaborate with learning providers to standardise, deliver, maintain and monitor these learning and practice skill standards
  • Develop a mechanism track all those delivering care beyond statutory provision to remove the risk of unregulated care
  • Deliver governance and monitoring systems to ensure quality assurance for third sector provision
  • Support settings to embed Unicef UK BFI standards through Gold award accreditation for sustainability

What will success look like?

Based on best evidence, this would result in…

  • Women supported to breastfeed and overcome barriers by consistently highly skilled professionals and lay supporters
  • Education providers supported by an evidence-based framework to provide and maintain consistent high standards
  • Training standards which are integrated into the Baby Friendly framework in maternity, community, neonatal systems



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