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LACTNET Home

LACTNET Home

LACTNET  August 2004, Week 3

LACTNET August 2004, Week 3

Subject:

the physician is in charge, but the nurse interprets

From:

Arly Helm <[log in to unmask]>

Reply-To:

Lactation Information and Discussion <[log in to unmask]>

Date:

Sun, 15 Aug 2004 09:54:28 -0700

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (72 lines)

In a survey I conducted in Utah, 25% of the nurses felt formula was so
important to a baby's well-being that they would give formula even if the
physician or mother specifically said not to. 

By experience I learned that there are some staff members who feel so sorry
for the breastfed babies (who seem to get fed so little compared to
formula-fed babies) that they will take any opportunity to feed them, truly
feeling that they are looking out for the babies' welfare better than the
misguided mothers and doctors who want the baby to be exclusively breastfed.
They can be strengthened in this belief if there is one physician who
vocalizes the same beliefs, though he be only one physician of many.  And if
there are other physicians who "go along with" mothers' desires to
exclusively breastfeed but don't get excited if the babies are given
supplementary formula, this weakens the argument for the importance of
exclusive breastfeeding, which again influences the nurses in their
decision-making.  If afterwards, she hears, "Well, OK, of course you had to
feed the baby," this makes it more likely that she will choose to supplement
an "exclusively breastfed" baby in the future.  Surely the nurse receives a
lot of mixed messages with regard to feeding.  Exclusive breastfeeding is
still seen as the exception in many facilities, permitted only in special
circumstances and jettisoned as soon as the road gets bumpy.

Another loophole is that babies are to be breastfed unless there is a
medical indication otherwise, and medical indications include going a
certain number of hours without eating (4, 6, or...) and hypoglycemia
(numbers may be set higher at some facilities than others); as well as more
subjective criteria related to how the baby and mom look.  In a common
scenario, with a baby crying in the nursery, the nurse may use her judgment
to decide that the mother's need for rest precludes feeding, even if the
mother (and her doctor) has asked that the baby be brought to her.  

There are other pressures leading to supplementation. In hospitals where
nurseries are a fair distance from the postpartum unit, or where the
territory is divided between postpartum (mothers') nurses and nursery
(babies') nurses, it may be physically or socially easier for the nursery
nurse to give a bottle than to take the baby out for a feed. Social
pressures within the hospital culture (as elsewhere) are powerful.

Staffing is another issue.  I often had nurses tell me that they had too
many babies in the nursery to be taking one out to the floor, and what did I
want them to do?  Let the baby scream? I do think there is something quite
wrong with giving nurses a bunch of babies they can't feed and making them
feel as if they can't give them back to the person who can feed them.
Clearly warehousing babies and limiting staff leads to unwanted and
unnecessary supplementation. 

And then there is the training issue. In one California hospital I observed,
they had excellent policies and protocols regarding supplementation, but the
nurse manager seemed to be the only staff member familiar with them.  Status
quo kept the system functioning as it had been before the new protocols were
written.

The physician is in charge, and writes the orders, but it is the nurse who
interprets and carries out the orders all day and all night long. The nurse
has to sort through all the messages, possibilities, and barriers, and make
decisions in the moment as to what to do.  We would all benefit if nurses
had a single clear message, and a way to follow through.

Arly Helm, MS, IBCLC

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December 2001, Week 5
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December 2001, Week 3
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December 2000, Week 5
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December 2000, Week 1
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January 1996, Week 1
December 1995, Week 5
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