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Assessing health worker performance in assisting a mother to learn the skills of hand expression of breast milk

By Genevieve Becker


Breastfeeding is important in the health of children and their mothers, and expressed milk is particularly important when the infant is ill or unable to breastfeed. Mothers may not receive effective assistance to learn skills of milk expression. This study was undertaken to examine if a mother-centred framework could be used to develop a method to assess a lactation consultant student’s performance in assisting a mother in learning skills for hand expression.\ud As there was no apparent research on techniques of hand expression, a three-round Delphi exercise was conducted with experts from three continents, in conjunction with a review of educational materials and observation of mothers expressing. This resulted in a composite list of knowledge and skills that a mother needed. A review of educational methods indicated that adult learning and self-efficacy techniques could be used effectively for assisting the mother’s learning. These techniques were in line with expected professional practice of student lactation consultants.\ud The skills of expression were blended with the skills of assisting learning to develop an instrument to facilitate assessment by observation in a real workplace encounter. Gathering the views of the mother, of the student assisting, and of an examiner, facilitates feedback to the student as well as an assessment score. The instrument and assessment process underwent a validation process involving panels composed of students, mothers and examiners and educators. The evidence from this validation indicated that the instrument was representative and relevant to the expected behaviours of assisting the mother, that it was useable by the three groups, and that it was likely to pick up a poorly performing student. The three panels’ views indicated that all items should meet a minimum level to pass, that the views of the mother, the student and the examiner should all have value, and that a visual analogue scale provided an acceptable means to mark the performance. A passing standard was determined that can be used for pilot testing of the instrument and process, and for testing of reliability.\ud The instruments and assessment process are brought to readiness for pilot testing with students to determine their performance as well as the feasibility of multi-source assessment that is mother-centred and values the views of the mother. It potentially provides a means of effectively assessing one area of clinical practice and could be extended to assess other areas

Publisher: School of Medicine (Leeds)
Year: 2008
OAI identifier:

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  5. (1990). A critical review of visual analogue scales in the measurement of clinical phenomena.
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  7. A K (2006b) Randomized controlled trial to determine effects of prenatal breastfeeding workshop on maternal breastfeeding selfefficacy and breastfeeding duration.
  8. (2002). A new foundation for methodological triangulation.
  9. (2002). A performance assessment module for experienced general practitioners.
  10. (1998). A perspective on clinical evaluation in nursing education.
  11. (2006). A plea for new psychometric models in educational assessment.
  12. (2007). A psychometric toolbox for testing validity and reliability.
  13. (2000). A qualitative study of women's views about how health professionals communicate about infant feeding.
  14. (1998). A self-help program to increase breastfeeding among low-income women.
  15. (2000). A systematic review to evaluate the effectiveness of interventions to promote the initiation of breastfeeding.
  16. (2005). A work-centered approach for setting passing scores on performance-based assessments.
  17. (2000). Action research to improve the pre-registration midwifery curriculum. Part 3: can fitness for practice be guaranteed? The challenges of designing and implementing an effective assessment in practice scheme.
  18. (1992). Acute prolactin and oxytocin response and milk yield to infant suckling and artificial methods of expression in lactating women.
  19. (1997). Addressing epistemologic and practical issues in multimethod research: a procedure for conceptual triangulation.
  20. (2006). Addressing the learning deficit in breastfeeding: strategies for change.
  21. (2007). Adopting and adapting the mini-CEX as an undergraduate assessment and learning tool.
  22. (2006). Aligning assessment with long-term learning.
  23. (1998). AMEE Guide No. 13: real patients, simulated patients and simulators in clinical examinations.
  24. (1999). AMEE Guide No. 14: Outcome-based education: Part 3 -Assessment in outcome-based education.
  25. (2000). AMEE Guide No. 18: Standard setting in student assessment.
  26. (2004). American Academy of Pediatrics, Policy Statement: Breastfeeding and the use of human milk.
  27. (2000). An accessible analytical approach for investigating what happens between the rounds of a Delphi study.
  28. (1992). An Argument-Based Approach to Validity.
  29. (2000). An evaluation of skills acquisition on the WHO/UNICEF Breastfeeding Management Course using the pre-validated Breastfeeding Support Skills Tool (BeSST).
  30. (1993). An evaluation of the breastfeeding content of selected medical textbooks,
  31. (2005). An evaluation of the breastfeeding support skills of midwives and voluntary breastfeeding supporters using the Breastfeeding Support Skills Tool (BeSST).
  32. (2006). An investigation of the field trip model as a method for teaching breastfeeding to pediatric residents.
  33. (2001). Antenatal expression of colostrum.
  34. (2004). Assessing competence in communication and interpersonal skills: the Kalamazoo II report.
  35. (2002). Assessing competence to practise in nursing: a review of the literature.
  36. (2006). Assessing fitness to practise and managing work-based placement.
  37. (1998). Assessing medical student effectiveness from the psychiatric patient's perspective: The Medical Student Interviewing Performance Questionnaire.
  38. (2005). Assessing professional competence: from methods to programmes.
  39. (1987). Assessing students: How shall we know them?
  40. (2007). Assessing students’ communication skills: validation of a global rating.
  41. (2002). Assessing third-year medical students' breast cancer screening skills.
  42. (1994). Assessment of clinical practice and the role of the nurse teacher.
  43. (1997). Assessment of clinical skills in midwifery: some ethical and practical problems.
  44. (2000). Assessment of social work students: standpoint and strong objectivity.
  45. (1994). Assessment of student performance: a framework for improving practice.
  46. (2005). Assessment tools for foundation programmes--a practical guide.
  47. (1999). Assessment, Learning Theories and Testing Systems.
  48. (1990). Assisting the employed breastfeeding mother.
  49. (1993). Audiovisual education and breastfeeding practices: a preliminary report.
  50. (2005). Author's reply to Pell.
  51. (1999). Baby friendly: where has it got to?
  52. (2007). Baby-friendly Hospital Initiative. Nutrition Unit, World Health Organization,
  53. (1980). Basics of breastfeeding. Part II: the anatomy and psychophysiology of lactation.
  54. (2002). BFHI Country Reports. Coordinators Network Workshop.
  55. (2005). Breast pump adverse events: reports to the Food and Drug Administration.
  56. (2006). Breastfeeding a preterm infant and the objectification of breastmilk.
  57. (1999). Breastfeeding and medical education.
  58. (2007). Breastfeeding Best Start study: training midwives in a 'hands off' positioning and attachment intervention.
  59. (1993). Breastfeeding counselling: a training course, Geneva, World Health Organization/UNICEF.
  60. (2006). Breastfeeding duration in mothers who express breast milk: a cohort study
  61. (2004). Breastfeeding for longer - what works? London, Health Development Agency.
  62. (2000). Breastfeeding in medical handbooks and teaching materials in the Netherlands, Amsterdam, Zorg voor Borstvoeding,
  63. (2007). Breastfeeding information in nursing textbooks needs improvement.
  64. (2004). Breastfeeding information in pediatric textbooks needs improvement.
  65. (2004). Breastfeeding knowledge and practice of pediatric nurse practitioners.
  66. (1992). Breastfeeding knowledge of hospital staff in rural maternity units in Ireland.
  67. (2008). Breastfeeding practice in the UK: midwives' perspectives.
  68. (1996). Breastfeeding self-efficacy: the effects of a breastfeeding promotion nursing intervention, PhD, College of Nursing, University of Rhode Island,
  69. (2003). Breastfeeding support from partners and grandmothers: perceptions of Swedish women.
  70. (1994). Breastmilk expression, storage and feeding, a literature review,
  71. (2008). Building capacity for service user and carer involvement in social work education.
  72. (2004). Changing education, changing assessment, changing research?
  73. (2002). Clinical competence assessment in nursing: a systematic review of the literature.
  74. (2004). Clinical skills in junior medical officers: a comparison of self-reported confidence and observed competence.
  75. (2000). Clinical support can make the difference in exclusive breastfeeding success among working women.
  76. (2003). Cognitive, social and environmental sources of bias in clinical performance ratings. Teaching and Learning in
  77. (2003). Common problems of clinical performance examination in breastfeeding instruction for nursing baccalaureate students.
  78. (1998). Comparing the psychometric properties of checklists and global rating scales for assessing performance on an OSCEformat examination.
  79. (2002). Comparison of faculty, peer, self, and nurse assessment of obstetrics and gynecology residents.
  80. (1994). Comparison of patient questionnaire, medical record, and audio tape in assessment of health promotion in general practice consultations.
  81. (2005). Competency based assessment of speech pathology students' performance in the workplace, PhD, School of Communication Sciences and Disorders,
  82. (2000). Competency checklist for midwives... teaching mothers to attach their babies for breastfeeding.
  83. (2007). Competency-based postgraduate training: can we bridge the gap between theory and clinical practice?
  84. (1998). Consensus development methods and their use in clinical guideline development.
  85. (2007). Construct validity: a universal validity system or just another test evaluation procedure?
  86. (2005). Consultant's corner. Manual expression of breast milk.
  87. (2006). Consulting the oracle: ten lessons from using the Delphi technique in nursing research.
  88. (2001). Contamination of breast milk obtained by manual expression and breast pumps in mothers of low birth weight infants.
  89. (1995). Content validity in psychological assessment: a functional approach to concepts and methods.
  90. (1995). Creating reality or contributing to confusion? An exploratory study of client participation in student learning.
  91. (2005). Current perspectives in assessment: the assessment of performance at work.
  92. (1986). Determination and quantification of content validity.
  93. (2006). Developing a prenatal breastfeeding workshop to support maternal breastfeeding self-efficacy
  94. (1994). Developing professional knowledge and competence,
  95. (1999). Development and psychometric testing of the Breastfeeding Self-Efficacy Scale.
  96. (2004). Development of the student placement evaluation form: a tool for assessing student fieldwork performance.
  97. (2005). Early identification of 'at-risk' students by the parents of paediatric patients.
  98. (2005). Editorial -- Inverting the Pyramid.
  99. (2004). Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory.
  100. (1987). Effects of education on breastfeeding success.
  101. (2007). Electric breast pump use increases maternal milk volume in African nurseries.
  102. (1996). Evaluation of a patient teaching skills course disseminated through staff developers.
  103. (1994). Evaluation of an information booklet on breastfeeding duration: a clinical trial.
  104. (2007). Evidence on the long-term effects of breastfeeding: systematic review and meta-analyses Geneva, Department of Child and Adolescent Health and Development, World Health Organization.
  105. (2000). Examining and recording clinical performance: a critique and some recommendations.
  106. (2001). Expanding the enablement framework and testing an evaluative instrument for diabetes patient education.
  107. (2004). Feedback and the Mini Clinical Evaluation Exercise.
  108. (2004). Flawed self-assessment: implications for health, education and the workplace.
  109. (2001). From Novice to Expert: excellence and power in clinical nursing practice,
  110. (2004). From the field: a maternal-child health nursing competence validation model.
  111. (1996). Gazing into the oracle: the Delphi method and its application to social policy and public health,
  112. (2007). Getting it right: Australian primiparas' views about breastfeeding: A quasi-experimental study.
  113. (2002). Global Strategy on Infant and Young Child Feeding, Geneva, World Health Organization.
  114. (2000). Grading student clinical practice performance: the Australian perspective.
  115. (2003). Health education: a case for resuscitation.
  116. (2003). Health measurement scales-a practical guide to their development and use,
  117. (2004). Health promotion by social cognitive means.
  118. (1990). Helping adults learn.
  119. (2004). HIV transmission through breastfeeding: a review of available evidence,
  120. (2005). Human milk pumping rates of mothers of singletons and mothers of multiples.
  121. (1993). Identifying critical issues and problems in technology education using a modified-Delphi technique.
  122. (2006). Identifying predictors of breastfeeding self-efficacy in the immediate postpartum period.
  123. (2001). Impact of breast pumping on lactogenesis stage II After Cesarean delivery: a randomized clinical trial.
  124. (2000). Improving residents' breastfeeding assessment skills: a problem-based workshop.
  125. (2004). Improving the interviewing and self-assessment skills of medical students: Is it time to readopt videotaping as an educational tool?
  126. (2007). Incorporating patients' assessments into objective structured clinical examinations.
  127. (1989). Increasing breast milk production for premature infants with a relaxation/imagery audiotape.
  128. (2007). Involving service users in educational assessment.
  129. (2001). Is the Delphi technique a qualitative method?
  130. (2002). Is there inter-rater reliability of the perceptions of competency in teaching health related skills between the clinical skills assessor, the student health worker and the client/patient? , MEd, unpublished,
  131. (2006). Making it our own ball game: learning and assessment in social work education.
  132. (2005). Marking criteria for assessing practice-based portfolios at masters' level.
  133. (1989). Meaning and values in test validation: the science and ethics of assessment.
  134. (2002). Measurement of clinical performance of nurses: a literature review.
  135. (1999). Measuring outcomes from the patients' perspective.
  136. (2005). Measuring patient-centered communication in Patient-Physician consultations: Theoretical and practical issues.
  137. (2001). Medical student interviewing skills and motherreported satisfaction and recall.
  138. (1994). Meeting the learning needs of post-myocardial infarction patients. Nurse Education Today,
  139. (2004). Monitoring the development of clinical skills during training in a clinical placement.
  140. (2003). Multisource feedback: a method of assessing surgical practice.
  141. (2006). Not just social work academics: the involvement of others in the assessment of social work students.
  142. (2004). Nurse Competence Scale: development and psychometric testing.
  143. (2003). Nurse practioner practice and deployment: electronic mail Delphi study.
  144. (2000). Nurses' attitude, subjective norms, and behavioral intentions toward support of breastfeeding mothers.
  145. (2007). Optimising the provision of human milk for preterm infants.
  146. (2002). Optimising the reproducibility of a performance-based assessment test in midwifery education.
  147. (1986). Ottawa Charter for Health Promotion, Geneva, World Health Organization.
  148. (2005). Partnership in education: the involvement of service users in one midwifery programme in New Zealand.
  149. (1989). Patient counseling for osteoporosis prevention.
  150. (2001). Patient education: principles and practice,
  151. (1999). Patient satisfaction with nursing care: a measurement conundrum.
  152. (1988). Patient teaching or patient counselling?
  153. (1986). Patient teaching standards for the professional nurse.
  154. (2000). Patient-oriented learning: a review of the role of the patient in the education of medical students.
  155. (2004). Patient, faculty, and self-assessment of radiology resident performance: A 360-degree method of measuring professionalism and interpersonal/communication skills.
  156. (2002). Patients' global ratings of student competence. Unreliable contamination or gold standard?
  157. (2006). Patients' views of nurses' competence.
  158. (2004). Performance assessment in medical education: where we've been and where we're going.
  159. (2003). Predictors of a child's ability to use a visual analogue scale.
  160. (2003). Psychometric characteristics of the Breastfeeding Self-Efficacy Scale: data from an Australian sample.
  161. (2003). Rater discrimination using the visual analog scale of the Physical Therapist Clinical Performance Instrument.
  162. (1992). Registered dietitians' teaching and adherence promotion skills during routine patient education.
  163. (2000). Research guidelines for the Delphi survey technique.
  164. (2002). Reveille for Radicals! The paramount purpose of health education?
  165. (2004). Satisfying the patient, but failing the test.
  166. (1953). Science and human behaviour,
  167. (1997). Selection and use of content experts for instrument development.
  168. (2003). Selection processes in a Delphi study about key qualifications in senior secondary vocational education.
  169. (2001). Self- and peer assessment in a first-year communication and interviewing course.
  170. (1977). Self-efficacy: toward a unifying theory of behavioral change.
  171. (2008). Service user involvement in the assessment of a practice competency in mental health nursing - Stakeholders' views and recommendations.
  172. (2003). Setting defensible performance standards on OSCEs and standardized patient examinations.
  173. (2000). Setting performance standards on complex educational assessments.
  174. (2002). Shifting paradigms: from Flexner to competencies.
  175. (2001). Should parents assess the interpersonal skills of doctors who treat their children? A literature review.
  176. (1996). Simulations for the assessment of counselling skills.
  177. (2006). Standard setting for clinical competence at graduation from medical school: a comparison of passing scores across five medical schools
  178. (2007). Student self-assessment and its impact on learning - A pilot study.
  179. (2000). Successful breastfeeding as a result of a health education programme for mothers.
  180. (1999). Supporting breastfeeding of babies in neonatal units.
  181. (2000). Sustainable assessment: rethinking assessment for the learning society.
  182. (2004). Teaching and breast self-examination: an insufficiency of instruction.
  183. (2004). Teaching mothers to express and store breast milk.
  184. (2005). The Adult Learner, London,
  185. (1990). The assessment of clinical skills, competence, performance.
  186. (1981). The collection and storage of human milk, 22, London, Committee on Medical Aspects of Food Policy,
  187. (2006). The content validity index: Are you sure you know what's being reported? Critique and recommendations.
  188. (1997). The Delphi method?
  189. (2002). The development and testing of APTA clinical performance instruments.
  190. (1999). The development and validation of the Breastfeeding Support Skills Tool (BeSST). Clinical Effectiveness in
  191. (2001). The development of a competency-based clinical performance examination model in maternity nursing for BSN graduates [Chinese].
  192. (1946). The early failure of breastfeeding: a clinical study of its causes and prevention.
  193. (2005). The effectiveness of public health interventions to promote the duration of breastfeeding. Systematic review, London, National Institute for Health and Clinical Excellence.
  194. (2008). The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice:
  195. (1988). The emotional experience of breast expression.
  196. (2002). The experience of qualified nurses in assessing student nurses' clinical skills.
  197. (2003). The first breastfeed: a content analysis of midwifery textbooks.
  198. (2004). The five-stage model of adult skill acquisition.
  199. (1999). The framework, concepts and methods of the Competency Outcomes and Performance Assessment (COPA) Model.
  200. (2007). The impact of prematurity and neonatal illness on the decision to breast-feed.
  201. (2000). The implementation of the HOT program at the Royal Women's Hospital.
  202. (2003). The involvement of service users in the assessment of diploma in social work students on practice placements.
  203. (2003). The Mini-CEX: a method for assessing clinical skills.
  204. (2005). The Practice of Nursing Research: Conduct, Critique and Utilization,
  205. (2001). The practice of patient education,
  206. (2002). The relationship between competence and performance: implications for assessing practice performance.
  207. (2004). The relationship between measures of patient satisfaction and enablement and professional assessments of consultation competence.
  208. (2000). The reliability of measuring nursing clinical performance using a competency based assessment tool: a pilot study.
  209. (2005). The role of a computerised case-based testing procedure in practice performance assessment.
  210. (1980). The selection and training of examiners for clinical examinations.
  211. (2004). The uses of photography in clinical nursing practice and research: a literature review.
  212. (2002). The validity and reliability of methods to assess the competence to practise of pre-registration nursing and midwifery students.
  213. (1993). Therapeutic touch and milk let-down in mothers of non-nursing preterm infants, PhD, School of Education, Health, Nursing and Arts Professions,
  214. (2008). Towards an alternative to Benner's theory of expert intuition in nursing: A discussion paper.
  215. (1999). Towards expert knowledge? A comparison between a constructivist and a traditional learning environment in the university.
  216. (2005). Trainees perspectives on the assessment and selfassessment of surgical skills.
  217. (2007). Training needs survey of midwives, health visitors and voluntary-sector breastfeeding support staff in England.
  218. (2006). Transfer of communication skills training from workshop to workplace: The impact of clinical supervision.
  219. (2003). Translation and validation of the Breastfeeding Self-Efficacy Scale into Spanish: data from a Puerto Rican population.
  220. (2006). Trends in the expression of breastmilk.
  221. (2005). Use and misuse of Likert scales.
  222. (1994). Use of performance-based assessment to evaluate the impact of a skill-oriented continuing education program.
  223. (1994). Use of standardized patients in clinical assessments: recent developments and measurement findings.
  224. (2007). User and carer involvement in the training and education of health professionals: A review of the literature.
  225. (2006). User opinions and expectations of multi-source feedback in the Foundation Programme. Multi-source feedback in medical education. London, ASME -Association for the Study of Medical Education.
  226. (2002). Using a visual analogue scale to estimate aspects of ethos in four secondary schools.
  227. (2005). Using an action research approach to involving service users in the assessment of professional competence.
  228. (2000). Using the Delphi and nominal group technique in health services research,
  229. (2004). Using the Dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education.
  230. (1996). Using triangulation in nursing research.
  231. (1994). Validating the Performance Standards Associated with Passing Scores.
  232. (2007). Validation of the clinical internship evaluation tool
  233. (1995). Validity and reliability of assessment tools.
  234. (2007). Validity by design.
  235. (1995). Validity issues in clinical assessment.
  236. (1988). Volume 6: Hand Expression,
  237. (2008). What is feedback in clinical education?
  238. (2002). When enough is enough: a conceptual basis for fair and defensible practice performance assessment.
  239. (2004). Which data source in clinical performance assessment? A pilot study comparing self-recording with patient records and observation.
  240. (1993). Women's experiences with combining breast-feeding and employment.
  241. (2007). Workplace-based assessment in clinical training, Edinburgh, Association for the Study of Medical Education (ASME).

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