I can certainly commiserate with Mary and Nikki regarding recalcitrant nursing staff and the idea of skin to skin or making any changes for that matter. I remember one hospital where I was providing a 3 day in-service to staff as they pursued Baby Friendly. I heard all of the excuses about how there was no time for skin to skin, that it was just making more work for nurses, that is was more nonsense from bleeding heart lactation consultants who had nothing better to do than make mothers feel guilty, etc. What an eye opener that class was! I had a great set of evidence-based PowerPoint slides with all of the citations about S2S and how breastfeeding outcomes were enhanced, but decided that it probably was not a good time to discuss these until we got past what I perceived as anger in many of these nurses. We talked about why they felt this way and as we talked I quickly forwarded the slides to a bunch I had with photos of warm furry animal mothers and babies snuggling, nursing, and gazing into each others eyes. I figured I needed to establish an oxytocin enhancing environment in that room! I showed one slide of a baby hippo who had lost his mother snuggled next to a great big 100 year old tortoise and asked when do mammals not like to snuggle? I talked about how touch is so important to all mammalian species--remember Harry Harlow and his experiments on baby monkeys? I had them talk about how touching and snuggling with your honeybun was so satisfying and how good that felt. I asked if newborn infants didn't need and deserve that first hug as a welcome to the world rather than being bound up like a mummy and carted off with strangers. I moved on to slides of mothers and newborn babies gazing into each others eyes to see if I could defuse the room before it exploded.We then looked at each excuse to see if there was a way to change how things were being done to accommodate skin to skin. We had nurses from labor and delivery as well as the nursery and lo and behold they started talking to each other saying how each could do this or that.

We talked of how skin to skin would actually reduce the workload on nurses, how they could sit down (wow!) and chart, teach, assess, etc, making a "flowsheet" of tasks that could be accomplished all the while mother and baby remained skin to skin. What I finally suggested was that nurses form small task forces of 2 to 5 nurses and work on each of the issues they had brought forward as excuses why skin to skin could not be done. This way they would all be invested in the process and the outcome. One nurse stubbornly sat in the back of the room glaring daggers at me and writing some pretty horrible comments on her evaluation sheet. But at the end of the 3 days she was still in the room and had even contributed to some of the discussion. I recommended to the nurse manager that perhaps that particular nurse could be tasked with mentoring and overseeing some of the breastfeeding skills acquisition that we worked on, i.e., checking off that staff could accurately teach and assess positioning, latch, swallowing, etc. At least it gave her something to do other than complain.

Change is never easy. Mary, perhaps you could look at your hospital's mPINC score to see if nurses would be interested in improving it. Check to see if your hospital will be choosing the Joint Commission's Perinatal Core Measure set as a quality improvement project. My best recommendation is to approach your Quality Improvement Department and ask that skin to skin be designated as a QI project. This will involve a multi-disciplinary task force that will include representation from all those opposed to change, making them owners of the process and the outcome.

Marsha Walker, RN, IBCLC
Weston, MA










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