breastfeeding policy and to support breastfeeding mothers. (Level of Evidence II-2) A. Breastfeeding Education should: 1. Include content that will facilitate the development of clinical skills, a theory base and reflective attitudes. Appendix M provides examples of exercises to facilitate self-reflection within the educational session. 2. Be based on a structure that includes: The Baby-Friendly™ Initiative; UNICEF/WHO Ten Steps to Successful Breastfeeding; Evidence-based practice; Adult learning theories; and Development of skills from novice to expert. 51 Nursing Best Practice Guideline B. Specific content should include information about breastfeeding assessment, support and management of problems. Examples of programs can be found in: WHO Breastfeeding Education module “Breastfeeding Management and Promotion in a Baby-Friendly™ Hospital: An 18-hour course for maternity staff”. Breastfeeding Education Series – Perinatal Partnership Program of Eastern & Southeastern Ontario. Universities/Colleges of Applied Arts and Technology. Educational resources – websites, journals, videos, on-line breastfeeding courses, etc. Appendix I provides a list of Internet resources, videos and recommended reading. Appendix N provides a list of on-line courses on the topic of breastfeeding. Discussion of Evidence Studies have shown a positive correlation between increased breastfeeding knowledge and skills in health care providers with increased breastfeeding initiation rates (Balcazar et al., 1995; Hartley & O’Connor, 1996; Humphreys et al., 1998; Rajan & Oakley, 1990). However, it is unfortunate that there is a minimal amount of time dedicated to basic breastfeeding training in health science programs resulting in health professionals being inadequately prepared to provide breastfeeding counselling or assistance (CICH, 1996; WHO, 1998). Consequently, health care organizations must take the initiative to provide adequate breastfeeding training to their health care workers. This will facilitate the delivery of effective breastfeeding guidance to ensure mothers receive consistent and supportive breastfeeding information (AWHONN, 2000; CICH, 1996). For the effective promotion of breastfeeding, training for health professionals needs to focus on increasing their knowledge and skills, as well as changing their attitudes about breastfeeding. Research has demonstrated that, in order for training to be effective, it must be mandatory and endorsed by senior management through the implementation of a breastfeeding policy (Iker & Morgan, 1992; Stokamer, 1990; Winikoff, Myers, Laukaran & Stone, 1987). WHO/UNICEF (1992) has recommended that health care providers should receive a minimum of eighteen hours of breastfeeding training and three hours of clinical practice. Furthermore, the training needs to encompass at least eight of the ten steps of the WHO Code. 52 Breastfeeding Best Practice Guidelines for Nurses Two studies have looked into the effectiveness of training. Altobelli, Baiocchi-Ureta and Larson (1991) measured the effectiveness of a twenty-hour staff training course, that used standardized breastfeeding educational materials, nine months following the training. They reported improvements in initial mother-infant contact and attachment at the breast, as well as reduced use of feeding supplements. Westphal, Taddei, Venancio and Bogus (1995) examined the effectiveness of a three week intensive breastfeeding training course. Through the use of a pre- and post-test, they found that most of the training participants demonstrated a significant improvement in their knowledge and attitude about breastfeeding. In addition, the researchers administered the post-test to the participants six months later and found they had a high retention of the training information. Both studies ascertained that increased education is only effective if accompanied by changes in practitioners’ attitudes and increases in skill level. Integrating self-efficacy enhancing strategies (e.g., opportunities to observe another woman breastfeed) into interactions with clients may improve the quality of care that nurses deliver (Blyth et al., 2002). Establishing a therapeutic relationship is key to the inclusion of these types of strategies in interactions with breastfeeding mothers, and should be considered as part of any educational strategy. The College of Nurses of Ontario provides direction in the Standard for the Therapeutic Nurse-Client Relationship (2000), and the Registered Nurses Association of Ontario (2002a) supports evidence-based care in the best practice guideline Establishing Therapeutic Relationships. It is the consensus of the development panel that encouragement and support should be provided to nurses willing to work towards an International Board Certified Lactation Consultant (IBCLC) designation. The International Board of Lactation Consultant Examiners credential is the recognized standard for mastery that has been established by experts in the lactation field (International Board of Lactation Consultant Examiners, 2001). 53 Nursing Best Practice Guideline Organization & Policy Recommendations Recommendation • 9 Practice settings need to review their breastfeeding education programs for the public and, where appropriate, make the necessary changes based on recommendations in this best practice guideline. (Level of Evidence