Preferred Name

Elizabeth E. Nottingham

Creative Commons License

Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License.

Date of Graduation

Spring 2018

Document Type


Degree Name

Doctor of Philosophy (PhD)


Department of Communication Sciences and Disorders


Cynthia R. O'Donoghue

Carol C. Dudding

Rory DePaolis



Human milk is crucial for the healthy development of infants, particularly preterm infants. Practice patterns and resource allocations to support and promote optimal breastfeeding in this population of infants varies by facility. The purpose of this mixed methods study was to explore differences in practice patterns, describe nurses’ knowledge and perceptions about breastfeeding in the NICU, and identify factors contributing to the differences between hospitals.

Researchers used a sequential explanatory design to gather both quantitative and qualitative data. In the first quantitative phase, a Web-based questionnaire was developed and deployed via Qualtrics to all hospitals with a Neonatal-Perinatal Fellowship Training Program in the United States (N=98). Results from the survey informed phase II. Qualitative semi-structured one-on-one phone interviews were conducted with a sub-set of respondents from institutions that completed the questionnaire. Purposive sampling ensured representation from institutions employing a variety of practices. Interviews were recorded, transcribed, and coded using initial focused coding and constant comparative analysis to identify themes, following a grounded theory framework.

Differences in breastfeeding support are apparent in hospitals across the United States. Nurses in hospitals utilizing more breastfeeding support measures emphasized feeding directly at the breast in the NICU, use of interdisciplinary team decision making, and hospital support of breastfeeding (i.e., resources). Nurses in hospitals employing a moderate number of breastfeeding support measures reported emphasis on performance improvement measures, breastfeeding in the NICU, and support for mothers. Nurses from the hospitals reporting the least number of breastfeeding support measures more frequently reported nurse discomfort with breastfeeding, lack of team decision making for feeding, and staff lack of knowledge about breastfeeding.

Policy changes and implementation of best practice protocols require a deep understanding of the range of breastfeeding experiences that occur in NICUs across the United States. This study illuminates variations in practice patterns of level III and IV NICUs, and identifies different themes highlighted by nurses working in those hospitals. Hospitals may use this as a guide for implementation of improvement projects in a movement toward more evidence based practices.



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