WORKPLACE LACTATION PROGRAM: A NURSING FRIENDLY INITIATIVE MICHELLE A.

ANGELETTI Florida Gulf Coast University ABSTRACT

The U.S. is experiencing a nursing shortage that is threatening its quality of healthcare. One contributing factor that has been identified is the level of dissatisfaction that nurses have with their working conditions. Health Services Organizations can use female and family friendly initiatives, such as workplace lactation programs to demonstrate that they are willing to support a female employees task of balancing familial and profession roles. By meeting the needs of breastfeeding mothers, organizations can have a positive impact on employees levels of satisfaction, which can positively impact recruitment efforts, productivity and retention.

Today, young women are opting not to enter the field of nursing, and this is creating a workforce shortage that threatens to have an enormous impact on the quality of the U.S. health care system. There is also a concern that hospitals will not be able to provide sufficient staffing to meet operational needs. There is much discussion over the cause of the shortage, but dissatisfaction is clearly a factor. By making the workplace more female friendly, Health Services Organizations (HSOs) may improve recruitment and retention of its female employees. A workplace lactation program is an initiative that provides needed support to female employees who would like to continue breastfeeding when they return to work after the birth of a child. Through workplace lactation programs, HSOs can improve organizational resource problems while supporting

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the breastfeeding mother in her task of balancing her professional life with the demands of motherhood and breastfeeding. WOMEN IN THE WORKFORCE Women are a large and growing segment of our workforce. Between 1970 and 2002, the participation of women in the labor force increased from 43% to 60% (U.S. Department of Labor, 2004b). Significantly, the largest increase in labor force participation occurred among those women most likely to breastfeed, those with infants and children under the age of 3 (U.S. Department of Labor, 2004b). Women have historically selected jobs in the areas of healthcare, and some segments of the healthcare workforce are overwhelmingly female. For example, registered nurses constitute the largest healthcare occupation which comprises 2.3 million jobs (U.S. Department of Labor, 2004a), and 93% of registered nurses, 95% of licensed practical nurses and 90% of nursing aides are female (U.S. Department of Labor, 2004b). Looming on the horizon is a workforce shortage that threatens to have enormous impact on the quality of our health care system. While the need for nurses is expected to increase dramatically as the baby boom generation ages, the number of women who traditionally form the core of the nursing workforce is expected to remain unchanged (Berliner & Ginzberg, 2002; GAO, 2001). There are multiple factors involved in the development of the nursing shortage, including a decrease in the number of young women opting to pursue a career in nursing, and problems with recruitment and retention of the current workforce (Berliner & Ginzberg, 2002). One factor identified as a major contributor to the nursing shortage because it directly impacts recruitment, retention and the

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movement of young women into nursing is job dissatisfaction (Berliner & Ginzberg, 2002; GAO, 2001). While the percent of employees within an industry who are dissatisfied with their jobs averages between 10% and 15%, more than 40% of nurses in the U.S. report being dissatisfied with their jobs (Aiken et al, 2001; Berliner & Ginzberg, 2002). Interestingly, job dissatisfaction is not only related to wages, which have kept pace with inflation, but to nurses feelings of recognition by the administration, and the belief that hospital administrators listen and respond to their concerns (GAO, 2001). The dissatisfaction that nurses have with the profession is so great that it is leading currently employed nurses to dissuade younger women from entering the profession. Administrators will need to address the issues affecting the level of nurse satisfaction if they are going to recruit young women into the field of nursing and retain the current employees. HSOs can attempt to reduce worker dissatisfaction by implementing policies and programs that are female friendly, such as a workplace lactation program. There is a movement to recognize the employees need to balance work and family through implementation of work life programs. Unfortunately, many employers have neglected to recognize the breastfeeding needs of mothers returning to the workforce. Businesses may be reluctant to support breastfeeding in the workplace because of false ideas regarding the loss of work time spent expressing milk and the costs associated with space and equipment. Additionally, because of the sexualization of breasts in our society, administrators and managers may not feel comfortable discussing breastfeeding and lactation. Yet, lactation programs are simple to implement, cost-effective and offer numerous benefits to both the employer and employee. By assisting women in balancing their professional and familial responsibilities, HSOs can demonstrate to

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female employees that they are concerned about their needs. Lactation programs demonstrate to employees that the organization is willing to assist the mother in balancing her roles as both a mother and a wage-earner. If employers do not support breastfeeding, women generally have two options; they must decide between breastfeeding and returning to work. Working in the health care field, nurses are generally aware of the numerous health benefits related to breastfeeding. Those women with a high desire to breastfeed may elect to resign and remain at home with their children. When women do not return to work after the birth of a child, the organization has the expense of recruiting and training a new employee. Fortunately, workplace lactation programs can create a supportive environment that encourages women to return to work after the birth of their children. One study found that 94.2% of women who worked for companies with lactation programs returned to work after having a child. Additionally, these women returned to work after the birth of their second, third and fourth child (Ortiz, McGilligan & Kelly, 2004). Those women who do decide to return to work in an unsupportive environment may feel that it would be too difficult to maneuver working and breastfeeding, so they may never initiate breastfeeding or may wean their children when they return to work. Studies indicate that returning to work is a major obstacle in breastfeeding continuation. It has been found that as a result of both the attitudinal and structural barriers in the workplace, women discontinue breastfeeding during the month prior to returning to work (Lindberg, 1996). Specific aspects of the work environment that have been reported to be obstacles to breastfeeding include restricted schedules and breaks and insufficient privacy (Taveras, Capra and Braveman et al, 2003). Unfortunately, these are organizational factors over which a worker generally has little control, and may cause

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frustration in a woman attempting to continue breastfeeding her child while working. THE BENEFITS OF HUMAN MILK Human milk is species specific and meets the nutritional and immunological requirements of infants and children. It is nutritious, convenient, cost-effective and contains protective ingredients that enhance the immature immune systems of infants. Human milk contains antibacterial and anti-inflammatory properties and acts as a booster for the infants immature immune system. The consumption of human milk has been linked to decreased rates of diarrheal disease (Bhandari, et al., 2003), respiratory infections (Lopez-Alarcon, Villalpando & Fajardo, 1997), asthma (Bachrach, Schwarz & Bachrach, 2003; Oddy, Peat & deKlerk, 2002 ), ear infections (Dewey, Heinig & Nommsen-Rivers, 1995; Duncan, et al., 1993), urinary tract infections (Marild, Hansson, Jodal, Odon & Svedberg, 2004), childhood leukemia and lymphoma (Bener, Denic & Galadari, 2001), diabetes (Taylor, Kacmar, Nothnagle & Lawrence, 2005), obesity (Grummer-Strawn & Mei, 2004; Harder, Bergmann, Kallischnigg & Plagemann, 2005), and sudden infant death syndrome (Chen & Rogan, 2004). It has also been associated with increased cognitive development (Anderson, Johnstone & Remley, 1999; Jain, Concato & Leventhal, 2002; Mortensen, Michaelsen, Sanders & Reinisch, 2002; Reynolds, 2001). Human milk is the biological norm for infant feeding, from which all other feeding methods should be measured (AAP, 1997). Infant formulas do not contain the immunological protection from disease, are much more difficult to digest, and may cause an increase in allergies. Overall, children who are breastfed have fewer and less

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severe illnesses than their non-breastfed companions (Davis, 2001; Dewey, Heinig & Nommsen-Rivers, 1995). The American Academy of Pediatrics (AAP) and UNICEF policy statements on breastfeeding emphasize the importance of human milk, and recommend that infants be exclusively fed human milk for the first six months of life (AAP, 2005; UNICEF, 2002). There is no need to provide supplemental food of any kind, including water, nonhuman milk, juices, fruits, infant cereals or any other foods until around six months of age, when supplemental foods begin to be gradually introduced to the infant. The AAP recommends that the feeding of human milk should continue through the childs first year, and for as long as it is desirable by the mother and child (AAP, 2005) and UNICEF recommends that breastfeeding should continue through the childs second year and beyond (UNICEF, 2002). It has been recognized that there is a dose-response effect to the intake of human milk. Specifically, the more human milk a child receives in dose and duration, the greater the health benefits (Raisler, Alexander & OCampo, 1999). Although much attention has been given to the health benefits of human milk for the child, breastfeeding also improves maternal health (Labbok, 2001). In the immediate post-partum period, breastfeeding stimulates oxytocin which leads to a more rapid uterine involution and reduces post-partum bleeding (Chua, Aralkumaran, Lim, Selamat & Ratnam, 1994)). Breastfeeding enhances postpregnancy weight loss, and lactational amenorrhea leads to increased child spacing (Kennedy, Labbok & Van Look, 1996). Studies also indicate that breastfeeding reduces the risk of ovarian cancer (Rosenblatt & Thomas, 1993), premenopausal breast cancer (Jernstrm et al., 2004), and osteoporosis (Paton et al., 2003). Organizationally, there are significant cost savings to having healthy employees with healthy families. When

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parents have a child who is sick, they may be under increased stress that could lead to distraction and decreased productivity. When a child in a daycare setting becomes ill, in most cases, the mother must leave work to care for the child. Children can also pass infectious diseases to their parents who may then pass the disease to other workers or patients within the organization. As a direct result of increased illness among workers and their families, organizations will have increased costs to cover absent workers and increased health care utilize costs for services and medications for treatment of the illnesses (UCLA, 2000). One study that reviewed the outcomes of a corporate lactation program found that women who continued to breastfeed after returning to work had significantly fewer absences than employees who formula fed their children. They had fewer absences related to the illness of their children, and had shorter absences when their children were ill (Cohen, Mrtek & Mrtek, 1995). Another study of a workplace lactation program at a large organization found that reduced absenteeism by breastfeeding mothers saved the organization approximately $60 thousand annually (UCLA, 2000). A WORKPLACE LACTATION PROGRAM Through a workplace lactation program, organizations can establish the policies and organizational structures that support a working mothers breastfeeding initiative. Corporate lactation programs can be a successful tool in increasing the duration of breastfeeding in working mothers (Cohen & Mrtek, 1994) by allowing a working mother to provide her own milk to her child while they are apart. In most cases, the mother will express her milk with a breast pump while she is at work and continue to breastfeed her child when they are together.

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The production of breast milk is on a supplydemand basis (Wilde, Prentice & Peaker, 1995). Simply, the child indicates its demand by suckling. Through physical stimulus and hormonal reactions in the mother, the breast responds by producing a supply of milk. The more the child suckles and removes milk from the breast, the more milk is produced. If the child decreases its level of suckling or milk remains in the breast after a breastfeeding session, the breast responds by producing less milk. The working mother can use a breastpump to simulate suckling and express milk from her breasts. The ejected milk can be stored in plastic containers or bottles and fed to a child at a later time. If a breastfeeding mother does not have the opportunity to express her milk at regular intervals while at work, she may experience painful engorgement that can lead to embarrassing leakage, plugged milk ducts, infection or mastitis. If she does not have the opportunity to express regularly, her milk supply will decrease and she wont be able to meet the nutritional demands of her child. In order to express her milk at work, an employee needs to be provided with an appropriate space. A workplace lactation program should include the designation of a private, secure room where a woman can express her milk. It is very important that the woman is in a secure and relaxed environment because if a woman is not relaxed, she will not be able to stimulate the milk ejection reflex and will not be able to express the milk from her breasts (Udea, Yokoyama, Irahara & Aono, 1994). To make the room more relaxing, it can have soft music and bulletin boards for photos of the womans child. This room should have a table to hold the breastpump, a comfortable chair, electricity to operate the breastpump and a secure lock. Because the woman will need to wash her hands before expressing her milk and wash her equipment afterwards, there needs to be access to a sink.

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Although women can successfully use a variety of pumps at work, either a hospital-grade electric pump or an individual use double electric pump is recommended for women working outside the home for more than 20 hours a week (Biagioli, 2003). Hospital-grade electric pumps are larger, more efficient and more expensive than the double electric pump. An organization may want to purchase or rent one of these pumps as part of its workplace lactation program. Because the mechanical features are sealed, this pump can be reused by different individuals. Generally, each woman is provided with an individual package of reusable tubing and breast shields. The second type of recommended pump is the individual use double electric pump. This type of pump is generally the size of a briefcase and can be carried to work daily, and then the pump and milk transported home in the evening. The case may contain a cold storage container with ice packs to store milk until it can be refrigerated. While the hospital-grade electric pumps can have multiple users, many of the individual use electric pumps are not recommended for multiple users because milk can back up into the mechanical areas, and any viral or bacterial agents in a users milk could be introduced into the milk of another user. It would be important to follow the manufacturers instructions for use and maintenance of these machines. Workplace lactation programs also include flexible breaks, flexible work hours, part-time work, or phase-back programs that allow women to return to work gradually (Barber-Madden, Petschek & Pakter, 1987). It has been found that women who are employed part-time have higher breastfeeding initiation rates and maintain breastfeeding longer than women who are employed full-time (Lindberg, 1996). Once a woman returns to work, it is recommended that she take several breaks throughout the day, at regular intervals to express her milk. If she is working part-time, it is recommended that she take 1-2 breaks to express her

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milk. If she is working full-time, it is recommended that she take a 20 to 30 minute break in the morning and afternoon, along with her lunch break so that she can express her milk three times per day (Florida Healthy Mothers, Healthy Babies, 1994). Generally, when returning from maternity leave, a mother will need more break time to express her milk and this will decrease gradually with time. When an infant is very young, its dependence on breastmilk will be the greatest and its mother will need to express a larger volume of milk. However, as the child grows and other supplemental foods are introduced, the amount of milk that the mother will need to express will decrease (Lindberg, 1996). If the expressed milk is going to be fed to the child at a later time, it needs to be stored appropriately. Human milk contains anti-bacterial properties that help it maintain its freshness (Ogundele, 2000). Some lactation programs have secured refrigerators available for women to store their milk. If a refrigerator is not available, a woman can use a cold storage container with ice packs to keep her milk fresh. In addition to a lactation room, pumps, cold storage and a flexible schedule, a workplace lactation program can provide information and support. Information can be provided to all employees about the benefits of breastfeeding, the organizational policy on breastfeeding, and the workplace lactation program. Specialized information about breastfeeding can be provided to the female employee who is pregnant, immediately after delivery and when she is ready to return to work. Additionally, organizations can use the assistance of professional lactation consultants to provide individual counseling and support groups. Breastfeeding support groups have been found to provide guidance and emotional support. They have also been used successfully to identify and correct organizational obstacles to breastfeeding

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success (Chezem & Friesen, 1999). If is not feasible for the organization to run support groups on location, they can provide information about community based breastfeeding support groups. CONCLUSION The nursing shortage that is looming on the horizon is threatening to impact the quality of healthcare delivery in the U.S. It is evident that nurses, who are predominantly female, are greatly dissatisfied with the profession and feel as though administrators are not acknowledging their needs. HSOs can use female and family friendly initiatives, such as workplace lactation programs to demonstrate that they are willing to support a female employees task of balancing familial and profession roles. Showing support for workers by meeting the needs of breastfeeding mothers can have a positive impact on employee morale. Organizational benefits include decreased costs associated with employee illness and absenteeism. Additionally, implementing programs that demonstrate support for breastfeeding mothers may lead to increased levels of employee satisfaction, which can positively impact recruitment efforts, productivity and retention. Additionally, employee satisfaction can lead to a positive corporate image and serve as a powerful recruitment tool in todays tight health care labor market.

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