III) Consideration needs to be given to social, economic and cultural factors. Recommendation • 10 Practice settings/organizations should work towards being accredited by the BabyFriendly™ Hospital Initiative. (Level of Evidence III) Refer to Appendix O for details regarding the process for Baby-Friendly™ Hospital Initiative accreditation. Recommendation • 11 Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes: An assessment of organizational readiness and barriers to education. Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. Dedication of a qualified individual to provide the support needed for the education and implementation process. Ongoing opportunities for discussion and education to reinforce the importance of best practices. Opportunities for reflection on personal and organizational experience in implementing guidelines. In this regard,RNAO (through a panel of nurses,researchers and administrators) has developed the “Toolkit: Implementation of clinical practice guidelines” based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the RNAO Breastfeeding Best Practice Guidelines for Nurses. (Level of Evidence III) Refer to Appendix P for a description of the RNAO “Toolkit: Implementation of clinical practice guidelines”. 54 Breastfeeding Best Practice Guidelines for Nurses Evaluation & Monitoring Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. The following table, based on the framework outlined in the RNAO Toolkit: Implementation of clinical practice guidelines (2002c), summarizes some suggested indicators for monitoring and evaluation: Examples of evaluation tools that were used to collect data on some of the indicators identified above during the pilot implementation/evaluation of this guideline are available at www.rnao.org/bestpractices. 55 Nursing Best Practice Guideline Objectives Organization/ Unit Nurse Breastfeeding mother Financial costs Process • To evaluate changes in practice that lead towards improved breastfeeding practices. • Progress towards BFHI accreditation since implementation of guideline and elements of progress that administrators attribute to guideline implementation. • A standardized tool is used for documenting a breastfeeding assessment. • Nurses’ self-assessed knowledge related to breastfeeding. • Nurses’ average self-reported awareness levels of community referral sources for breastfeeding support. • Percentage of mothers reporting a prenatal breastfeeding assessment conducted by a nurse. • Percentage of mothers reporting a postnatal breastfeeding assessment conducted by a nurse. Outcome • To evaluate the impact of implementing the recommendations. • Policies and procedures related to promoting breastfeeding are consistent with the guideline. • Percentage of breastfed infants given a supplement while in hospital. • Evidence of documentation in health record related to: • Prenatal assessment; • Postnatal assessment; • Family education; and • Community referral. • Percentage of primiparas initiating breastfeeding while in hospital. • Percentage of multiparas initiating breastfeeding while in hospital. • Percentage of mothers (primips and multips) exclusively breastfeeding at 8 weeks (2 months) postpartum. • Percentage of mothers accessing referral sources in the community. Structure • To evaluate the supports in the organization that allow for nurses to appropriately promote breastfeeding. • Availability of patient education resources that are consistent with best practice guideline recommendations. • Review of guideline recommendations by organizational committee(s) responsible for policies or procedures and/or for BabyFriendly™ Hospital Initiative (BFHI) accreditation. • Percentage of full-time, part-time and casual nurses attending education sessions on breastfeeding. • Average number of hours of education on breastfeeding since guideline implementation. • Provision of adequate financial and human resources. Implementation This best practice guideline was pilot tested in a hospital and public health unit in Sudbury, Ontario. The lessons learned and results of the pilot implementation may be unique to these organizations, and it is acknowledged that their experience may not be appropriate to generalize to other settings. However, there were many strategies that the pilot sites found helpful during implementation, and those who are interested in implementing this guideline may wish to consider these tips. A summary of these strategies follows: Identify an individual to lead the project who is able to provide dedicated time to implementation. If the implementation initiative crosses more than one site, each site should consider identifying such a resource nurse. This nurse will provide support, clinical expertise and leadership to the implementation, and should have strong interpersonal, facilitation and