Introduction

Supporting, promoting, and protecting lactation and breastfeeding has emerged as a contemporary public health initiative.¹ Breastfeeding combines two crucial elements of infant survival: nurturing and nourishment.² Over 40 years of strong evidence acknowledges that breast milk is the ideal form of infant nutrition.^{3 4} According to the Lancet Child Survival Series, breastfeeding is ranked first among the top 15 preventative child survival interventions and it is recommended exclusively for the first 6 months.⁵

The World Health Organization (WHO)/United Nations Children's Fund (UNICEF) developed a Global Strategy in 2002, which serves as a framework of actions necessary to protect, support, and promote adequate feeding of all infants and children worldwide.⁶ The Baby-Friendly Hospital Initiative (BFHI) is one out of nine targets of the Global Strategy for Infant and Child Feeding and consists of 20 h of breastfeeding training based on The Ten Steps to Successful Breastfeeding.^{6 7} These 20 h of breastfeeding training are considered by the WHO/UNICEF as the minimum time of instruction that health care workers caring for a lactating mother should receive.⁸ Maternity facilities that successfully implemented the Ten Steps and the International Code of Marketing of Breast-milk Substitutes are rewarded and recognized as a “Baby-Friendly” facility.⁹ Whether maternity hospitals and birthing centers decide to earn the Baby-Friendly designation, the ultimate goal is to implement the Ten Steps and to train the maternal-child staff to effectively practice the steps.¹⁰ In the US alone, there are 182 hospitals and birthing centers that hold the Baby Friendly designation in which 6.9% of births occur.⁹ Globally, there are about 152 countries that have baby-friendly facilities; unfortunately, according to the WHO¹¹ no more than 40% of infants fewer than 6 months of age are breastfed exclusively.

Breastfeeding has become a prevalent topic due to recent studies that have found a deficit in the knowledge of healthcare workers in this area.¹² Nurses are the largest group of maternal-child staff that support mothers and babies to meet their lactation and breastfeeding needs.¹³ However, insufficient training in nursing programs has led to nurses in the field knowing very little in order to assist a mother. A recent study showed that lack of breastfeeding education has resulted in nursing students not knowing essential information needed to assist a breastfeeding mother.¹⁴ Several studies recommend implementation of effective training on breastfeeding support in all undergraduate curricula that lead to nursing and other healthcare degrees.^{14 15}

Besides acquiring new knowledge, nurses need to practice and develop clinical skills in order for them to gain confidence and assist a mother breastfeed in the real world.¹⁴ One methodology described in the literature that facilitates the development of skills among health care workers is the Objective Structured Clinical Examination (OSCE). The OSCE was first introduced by Harden in the 1970s as a way to assess clinical skills of medical students objectively, and has then been considered a strategy to assess clinical skills among an array of healthcare fields.¹⁶ The students in the OSCE progress through a number of timed stations as they perform the skills required of them from each station in which they are also scored based on their performance.¹⁶ An examiner is present at each station to assess students as they demonstrate specific sets of skills and behaviors in a simulated environment.¹⁷ This methodology is flexible and can be used in different settings (e.g. clinical, simulation, classroom).^{16 17}

The OSCEs, according to Smith et al.,¹⁷ have been favorably appraised in the literature and provide the potential for a holistic approach to assess clinical competence if they are well planned, achieve content validity, and are then properly executed. OSCE's are a meaningful assessment experience and opportunity for learning clinical skills.¹⁶

The OSCE methodology can increase the knowledge and skills of healthcare students who provide support to breastfeeding mothers. Healer¹⁸ implemented the OSCE methodology with midwifery students from United Kingdom. In that study, the OSCE consisted of 5 scenarios of 15 min each where the students needed to listen, observe, and evaluate a given situation (e.g. milk supply, breast engorgement, sore nipples, supplementation with formula, and support with breastfeeding). Each student participated in role playing of one scenario and the scenarios were video recorded. The author concluded that the students’ knowledge increased and were more capable of providing breastfeeding support to women. In addition, Smith et al.¹⁷ used a two-station, 20-min duration OSCE (10 min each station) to assess breastfeeding competences among midwifery students. The scenarios included role playing about lactation and infant feeding with a client (e.g. usual/standard such as first feed post birth and other scenario with mastitis or engorgement). The results showed that the OSCE was an appropriate and valuable form of assessment for this topic and that the students increased their levels of breastfeeding skills and knowledge. The studies found in the literature evaluated the OSCE as an educational experience for the students and there was not a consensus about the most effective ways to implement the OSCE methodology among students. After an extensive literature search, the research team did not find studies that implemented the OSCE methodology for breastfeeding with nursing students. The purpose of this study is to analyze the development of an OSCE to increase breastfeeding clinical skills and the preliminary outcomes of its implementation.

Method

This is a quantitative descriptive study with a sample of twenty three undergraduate nursing students who participated in a breastfeeding OSCE. The students were enrolled in a maternal health nursing course at the School of Nursing and Health Studies, University of Miami. Prior to the completion of the OSCE, the students completed an online Breastfeeding Training (BT) course, which consisted of five online modules using the UNICEF/WHO/BFI 20-hours breastfeeding curriculum.¹⁹ These modules provided the conceptual breastfeeding knowledge that was assessed in the OSCE. In this article, only the OSCE results will be reported. The inclusion criteria were (a) being a University of Miami undergraduate nursing student, and (b) completing the online BT modules. This study was approved by the Institutional Review Board of the University of Miami.

The breastfeeding OSCE consisted of 10 stations where the students performed different clinical skills (see Table 1). Each station lasted 2 min, for a total of 20 min. Instructions for the OSCE were given at the beginning. There was a timekeeper who indicated that the students needed to move to the next station. In addition, there was a table in each station with the instructions, required materials, and a trained observer with a checklist. The observers were responsible for completing the checklist that assessed the student's clinical skills and organizing the station after each student completed the activity (30 s were assigned for this purpose). No interaction was allowed between the observer and the students.

The instructions at each station contained a description of a scenario that required them to perform a skill (e.g. match items, demonstrate proper milk let down, select correct interventions, etc.). The clinical skills being assessed in the stations ranged anywhere from selecting appropriate interventions for breast conditions such as mastitis to using a breast pump correctly and showing proper removal. In four of the stations the students were required to match items, in two stations they needed to mark the correct interventions and procedures on a sheet of paper that offered multiple answer choices, in three stations the students required skill demonstrations (e.g. hand milk expression, proper attachment and detachment of breast pump, and proper removal of the infant from mothers breast), and lastly one station required that the students pull out appropriate intervention items out of a container which had extra items that were distractors. Dummies (women and newborn) were used for the stations to facilitate the students demonstration when was needed (e.g. removal of the newborn from the mother breast).

Measures

Results

After the students completed the 10 breastfeeding OSCE stations, the observations were analyzed, codified, and the scores for each station were calculated (see Table 3). The stations with the highest score were: interventions for sore nipples, leaking and inverted nipples (station 4, M = 2.57, SD = .843), indicators of adequate latching (station 6; M = 7.09, SD = 1.443), and breastfeeding complications (station 7; M = 3.43, SD =.992). The stations where the students had the lowest scores were: pump set up to breast and how to remove it (station 1, M = 7.96, SD = 1.745), breastfeeding positions (station 5, M = 1.65, SD = .714), and removal of infant from the breast (station 8, M = 6.13, SD = 2.052).

Discussion

It is a consensus that breastfeeding provides major benefits for mothers and infants. Lactation and breastfeeding experts agree that healthcare professionals, especially nurses, have a major influence on a mother's decision to initiate and maintain breastfeeding.^{3 17 20 21} Nurses should be well-trained and equipped with the best evidence-based knowledge and skills techniques to promote, protect, and support breastfeeding mothers.¹³ The best evidence to date is the Ten Steps.^{4 22} To breastfeeding success, nurses should have the knowledge, attitude, and clinical skill in breastfeeding and lactation management to support mothers.^{18 23}

One big obstacle to train nursing students in breastfeeding is that clinical sites do not provide sufficient opportunities to achieve the clinical skills needed to support breastfeeding.^{14 24 25} In this study, the OSCE showed to be a very good methodology to increase nursing student's clinical skills, allowing to avoid the challenges of busy clinical environments and client safety issues. This finding is congruent with other studies conducted with other healthcare providers.^{26 27 28 29 30} The OSCE experience in this study was enjoyed by the nursing students evidenced by their positive feedback, as a good learning, valuable and practical experience similar findings were reported in Awaisu et al.,³¹ Branch,³² and Pierre et al.³³ studies.

The OSCE, in this study, provides a meaningful alternative strategy as it allows for individual assessments of a total group or class of students in a timely, controlled, and simulated environment. Consequently, students’ competence can be assessed in a non-threatening environment which minimizes risk and harm to an actual breastfeeding mother.^{17 34 35} Moreover, simulated environments supplement the need for clinical sites which are often hard to acquire for nursing students to practice breastfeeding skills.

The use of the OSCE, in this study, extends beyond students’ merely demonstrating skills, such as assisting women with position and infant feeding techniques; it involves students’ interactions to support breastfeeding women, communicate effectively, to respond to women's needs.¹⁷ In addition, in this study, students performed very well on identifying the indicators of proper latching, helping the breastfeeding mother when they have sore or leaking.^{36 37 38 39}

There were some stations in this study in which students did not performed well. For example, they had problems setting up a breast pump or removing an infant from the breast. This may be in part due to the instructions not being clear enough or because some of the students may have experienced nervousness, stress, and/or anxiety. These emotional reactions were reported in other studies in which the OSCE was utilized. It will be interesting to study these emotional reactions to the OSCE to find strategies to minimize or to avoid them.^{29 33 39 40 41 42} In the future, to reinforce the learning in the stations where students underperformed, the following strategies may be incorporated: (a) more visual content (e.g. pictures, videos, games) in the training, (b) online videos demonstrating the proper technique after they complete the stations, (c) students can request appointments for more one-on-one demonstration, and (d) proper technique for all stations can be discussed and demonstrated for the whole class as a form of review after the OSCE.

Limitations

Limitations of this study include the limited sample size. Since this was the first time that the OSCE methodology was implemented and efforts were made to accommodate the maximum number of students based on the resources available. The methodology required the presence of several observers and additional personnel (e.g. timekeeper) which could jeopardize the replication of the OSCE in other settings where the personnel available is limited. Future studies can incorporate technology to reduce the burden of the personnel dedicated to the OSCE. In addition, the sample was collected from one location, which limits the generalizability of the results. Another limitation is the study's design which limits inferential analysis of the results to prove the benefit of the OSCE.

Conclusion

The OSCE is an excellent method for teaching and assess clinical skills in the area of breastfeeding including mother and infant. The OSCE has been positively evaluated for objectivity in student assessment and provides a ‘hands on’ approach to assessing clinical competence in situations where the ‘real world’ clinical environment is not feasible to develop breastfeeding clinical skills performance. Scores and student feedback suggested that the OSCE can be a valuable tool to be used in other courses of the nursing undergraduate and graduate curriculum and not only in this University but in others as well as for healthcare workers who would like to learn for continuing education purposes in order help out breastfeeding mothers at their workplace and/or within their community.

Future studies can consider the implementation of the OSCE with community leaders or women in the community. Community leaders and women in the community, can be trained about breastfeeding using the OSCE. Future implementation of the OSCE can include online teaching via programs such as Zoom or Skype where the instructor can meet online with the breastfeeding mothers or pregnant women. The incorporation of online activities can also facilitate the dissemination of the OSCE to other communities or states in the U.S. and outside the U.S.