Virtual Lactation Counseling Simulation Sessions for Diverse Lactation Minor Students: Using Grounded Theory to Classify Students’ Debriefing Questions

Sherri Garber Mendelson, PhD, RNC, CNS, IBCLC, FAWHONN ^1; Merav Efrat, Ed.D, MPH, CLC, IBCLC ^2; Myriam Forster, PhD, MPH^3; Cathy Kitinoja, BA-Soc^4,

1. Sherri Garber Mendelson, PhD, RNC, CNS, IBCLC, FAWHONNLactation Trainer, Department of Health Sciences, California State University Northridge, 25616 Cielo Court Valencia, CA 91355
2. Merav Efrat, Ed.D, MPH, CLC, IBCLCProfessor Department of Health Sciences, California State University Northridge, 18111 Nordhoff St. Northridge, CA 91330
3. Myriam Forster, PhD, MPHAssociate Professor, Department of Health Sciences, California State University Northridge, 18111 Nordhoff St. Northridge, CA 91330
4. Cathy Kitinoja, BA-SocHuman Lactation Administrative Assistant, Department of Health Sciences, California State University Northridge, 18111 Nordhoff St. Northridge, CA 91330

OPEN ACCESS

PUBLISHED:31 July 2025

CITATION:Mendelson, SG., Efrat, M., et al., 2025. Virtual Lactation Counseling Simulation Sessions for Diverse Lactation Minor Students: Using Grounded Theory to Classify Students’ Debriefing Questions. Medical Research Archives, [online] 13(7). https://doi.org/10.18103/mra.v13i7.6732

COPYRIGHT©This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI:https://doi.org/10.18103/mra.v13i7.6732

ISSN:2375-1924

ABSTRACT

Introduction: This study explored the value of simulations to improve programs that train and prepare lactation counselors from diverse communities. Breastfeeding rates are lower than desired. Increasing diverse rural lactation counselors is critical. Classification of student input will help strengthen future telehealth lactation counseling simulations for students’ understanding, and communication.

Methods: Multiple one-hour small virtual lactation counseling simulation sessions with diverse students included five patient questions and consultations by an International Board Certified Lactation Consultant (IBCLC) with debriefs. Qualitative design with Grounded Theory based on National League of Nursing (NLN) Jeffries Simulation Theory and Lewin’s Change Theory was used.

Results: Guiding students to communicate with new parents, demonstrating how to support parents’ autonomy, providing clear definitions of terms and intent, and understanding physiologic outcomes are critical elements of training students for future lactation practice.

Discussion: Not only were there students from diverse cultures, but also students within a wide age range, and wide life-experience range. Having small groups of students on the virtual simulation sessions allowed each student to be called on after each question to maximize their participation and answer or clarify any questions. It appears that as students became more familiar with the course content and with the simulation methodology, they were more comfortable participating in the session debriefs. Students often seemed surprised by the questions and the answers.

Conclusions: Results suggest virtual lactation counseling simulations as an addition to class instruction are a successful format for training students with the knowledge and skills needed to work as lactation counselors.

Keywords

Lactation counseling, simulation, telehealth, diverse communities, Grounded Theory, breastfeeding.

Background:

This study explores utilization and acceptability of virtual telehealth simulation sessions with student-instructor debriefing as a component of Certified Lactation Counselor (CLC) college courses to develop student’s lactation counseling and communication skills. The current program seeks to increase the number of diverse CLCs in the community among participating students of diverse ethnic backgrounds through lactation counseling courses that include lactation counseling simulation groups by an International Board-Certified Lactation Consultant (IBCLC). This manuscript describes how students reacted to lactation counseling simulations, responded to questions and their perceptions of the program to inform future lactation counseling simulations and develop best practices that will enhance students’ understanding and strengthen core capacities of the future lactation counselor workforce.

The need for CLCs is critical as evidence has demonstrated that breastfeeding has numerous positive health benefits for both mother and baby. Healthy People 2030 has set national objectives to increase the proportion of infants in the United States who are exclusively breastfed through six months of age and who continue to be breastfed through twelve months of age. Given that exclusive breastfeeding from birth through the postpartum hospital stay is more likely to result in breastfeeding continuation after discharge, breastfeeding assistance during the immediate hospital stay and after discharge is imperative to promote the Healthy People 2030 aim of increasing the number of infants exclusively breastfed for the first six months of life.

Strategies and interventions to help mothers start and maintain breastfeeding need to incorporate factors that have been shown to have positive results. For example, Chiurco, et al. examined the implementation of an inpatient, IBCLC certified breastfeeding support program that increased patient support and decreased sore and cracked nipples but was not able to improve exclusive breastfeeding rates at two weeks post birth. A study in Denmark assessed the effect of increased lactation counseling support for 2,065 mothers and found that in the intervention group fewer infants were readmitted to the hospital at 1 week in the intervention group and at 6 months following birth compared to the comparison group with support as usual. They also found that compared to the control group, significantly more infants in the intervention groups were exclusively breastfed, that mothers were breastfeeding more frequently and spent more hours skin to skin with their infants and that infants were less often treated for jaundice.

McFadden, et al. found in a systematic review of randomized control trials that breastfeeding counseling is effective at increasing any and exclusive breastfeeding rates. Use of telehealth to deliver breastfeeding counseling was explored as a potential benefit by Usher-Pines, et al. Otiv, et al. found that increasing lactation counseling during the post-birth hospital stay significantly decreased the incidence of sore nipples, and engorgement as well as significantly increasing the rate of exclusive breastfeeding at hospital discharge. Orchard & Nicholls explored the impact of social media on breastfeeding and found mixed results and indicated the content and viewpoint of the social media site may be an important determinant. To maximize parents’ understanding and implement programs that foster effective measures to improve the prevalence and length of breastfeeding among mothers, the United States (U.S.) needs to increase the availability of certified lactation counselors. Many factors are linked with optimal breastfeeding rates, including support from lactation counselors.

Currently the U.S. is experiencing an acute shortage of lactation professionals. Research documents a need for approximately 8.6 lactation professionals per 1,000 live births in the U.S. however, according to the Center for Disease Control’s Breastfeeding Report Card, the ratio of lactation counselors in California per 1,000 live births is merely 2.1, less than half the national average of 4.57, and far below the targeted ratio. One surrounding rural county demonstrated a shortage of lactation professionals that has resulted in significant disparities in breastfeeding rates among under-represented minorities. Aside from the severe shortage of lactation professionals in the nation, there is a growing need for lactation professionals in rural communities with access to timely and qualified lactation support is severely lacking in these areas. For example, the shortage of lactation professionals in one local rural community has resulted in significant disparities in breastfeeding rates among under-represented minorities.

One important way to increase breastfeeding rates is to provide appropriate training for lactation counselors. The clinical aspects of this training have typically been implemented in-person during hospital lactation visits, parent lactation classes and post-discharge lactation visits with individual students mentored by a certified lactation consultant. To increase access to training, this project provided lectures that can be delivered in classrooms or on-line. Telehealth training modalities, demonstrated to be effective for education, and health visits, are one method to implement education to a broad audience regardless of their proximity to a health clinic or hospital.

With multiple telehealth trainings demonstrating positive benefits, including lactation education and counseling, the current results can inform efforts to increase the understanding of future CLCs regarding questions mothers have about breastfeeding prior to giving birth and in the week after giving birth, as well as addressing any concerns that CLCs have about their experiential learning. Ultimately, this program seeks to determine if a lactation course that includes lactation telehealth simulations will increase the number of diverse CLCs in the community and increase the diversity of participating students to meet the needs of a diverse birthing population. Given the steady rise in breastfeeding initiation rates, the demand for lactation professionals is only expected to increase. As more mothers choose to attempt breastfeeding, and breastfeed their infants longer, they will need the education and support that lactation professionals of diverse backgrounds can provide. Rhodes, et al utilized the results from previous lactation studies on health equity in their study implementing a peer counselor program for lactation help delivered to diverse groups.

In addition to increasing the number of available lactation counselors in the U.S., there is a growing need to diversify the lactation workforce, highlighted by a recent report from the Academy of Lactation Policy and Practice that found minorities were severely underrepresented in the lactation profession. For example, while 18% of the U.S population identify as Latino/a, merely 8% of U.S. lactation professionals identify as Latino/a. The need for increased diversity in the nutrition science student body at the two-year and four-year college programs involved in this study as Latino/a are also underrepresented in the nutrition science programs at these Hispanic serving institutions. While Latino/a make up 74% of students at the large urban area school district (the main school district feeder to the four-year University), only 51% of the undergraduate student population in the nutrition program at the four-year University is Latino/a. Similar disparity exists at the two-year college, with Latino/a making up only 62% of students majoring in nutrition. Retention, transfer, and graduation rates of Latino/a students majoring in nutrition is also low at both institutions. At the two-year College, the fall-to-fall persistence rate of Latino/a nutrition students is 60.5%. Furthermore, while 47% of students entering the two-year College identify transfer to a 4-year university as their main goal, only 19% of students successfully transfer within eight years. As a result, only sixteen Latino/a nutrition students transferred from the two-year College to the four-year program in fall 2019. Once at the four-year University, undergraduate Latino/a nutrition students experience difficulties in graduating. In 2018-19, the one-year retention rate of Latino/a nutrition students was only 75% and the six-year graduation rate of Latino/a nutrition students was merely 35%.

This project provided a pathway to increase the number of qualified diverse nutrition students trained and credentialed in the lactation field as CLCs. By educating an increased number of diverse nutrition graduates trained as lactation counselors, the University intends to help address this acute shortage of lactation professionals. In this project, the diverse nutrition students would be positioned, upon graduation, to provide families needed support to provide their infants with optimal nutrition via breastmilk. This study supports the University’s leadership in providing lactation education for underserved populations looking to become CLCs. The experiential learning curriculum component of this project was designed to enable students to demonstrate proficiency in the skills and competencies required to sit for the certified lactation counselor exam. Importantly, the experiential learning component was offered in a fully virtual environment, thereby allowing students to shadow and receive mentorship from a lactation professional as they develop vital leadership and lactation counselor skills and competencies from a remote location, offering students a cost-effective and time-efficient option to complete a minor in human lactation, while simultaneously completing their bachelor’s degree in nutrition.

This project developed hands-on experiential learning opportunities for students that extended beyond the classroom and provided students with a context in which to solve complex problems in a real-world setting guided by change and simulation theoretical frameworks. Telehealth is a service delivery model for provision of health care services, health information and health education remotely. Telehealth is an innovative way to extend health care across populations to improve access to high-quality and efficient health care with a focus on empowering patients to manage their own illness. Telehealth provides access to health assessment, diagnosis, interventions, consultation, supervision and information across a distance.

A Pilot Study of Home-Based Videoconferencing for Breastfeeding Support was done by Rojjanasrirat, W; et al. Methods included 4 videoconferencing sessions for lactation support with 10 new mothers over age eighteen, speaking English, using high speed internet. Success of the program was measured by comparing LATCH score, composed of assessment of Latch, Audible swallowing, Type of nipple, Comfort and Hold, for assessment with in-person validation during two sessions. Use of a doll by the IBCLC to demonstrate latch and positioning was included. Outcomes of LATCH score agreement during the 1st visit were 40-100% and 80-100% in the 2nd visit. All patients strongly indicated they were comfortable talking about breastfeeding needs via videoconferencing although four out of ten participants could not use their existing computers, and two telehealth visits had to be rescheduled due to poor quality of pictures and sound. Studies on telehealth for lactation have largely been focused on the post discharge needs of breastfeeding couplets. One suggestion to maximize benefits of lactation assistance is for a hands-off approach thus allowing the mother to independently learn to position and help her baby to latch, leading to improved breastfeeding self-efficacy following the consultation. Lactation telehealth may be a vehicle to promote this hands-off approach. The LACTOR study by Ahmed, A., et al. explored the development and assessment of an interactive web-based breastfeeding monitoring system. Although integrating telehealth in lactation education is still in the early phases, some data support overall outcomes for patient breastfeeding success, improved mother/baby health, cost effectiveness, patient satisfaction and provider satisfaction, and use in education simulations for lactation students.

Change theories are beneficial for planning interventions, monitoring and evaluating, engaging stakeholders, and for anticipation of how a process will function within evidence-based policy and practice. The utilization of Lewin’s Change Theory is especially helpful when implementing a new program. Lewin recognized the importance of planning ahead when new ideas are introduced, rather than waiting for unintentional or accidental processes to occur. Lewin’s Change Theory describes three levels of change: unfreezing, changing, and refreezing. To get buy-in from the staff, the benefits of the change must be made clear; this is the unfreezing stage. Once the need for the change is identified, the staff will undergo the change stage. During this stage the staff realize “life will not be the same.” This stage may involve pilot runs in which the staff are provided with additional training and resources to implement the change. The final stage, refreezing, is the point at which reinforcements for the new procedures will increase the likelihood of sustaining them. It is helpful if leaders reinforce the new processes and reward adopters of the new processes; for those who develop new programs, it is important to retain support by stakeholders and champions of the cause in advance of the rollout to increase the likelihood of practice uptake and sustainability. Overall, literature identifies leadership, effective communication and teamwork as the most critical elements for change to be accepted and adopted.

Using Lewin’s Change Theory to develop a telehealth program of simulations for students will provide a template to plan, implement and evaluate the plan to change. This theory can map out the paths of each actor in the process to achieve the desired outcome. The hospitals who implemented Lewin’s Change Theory practices had a higher rate of buy-in from staff. When hospitals capitalized on the refreezing stage by providing additional Information Technology experts to be available to help staff in real time it was a much smoother and successful transition to telehealth services. Avenues such as funding to provide additional information technology nurses and staff will create reinforcements for the new process, which will increase the likelihood of success.

The National League of Nursing (NLN) Jefferies Simulation Theory is also incorporated into the current study as it is referenced to establish, evaluate, and/or modify simulated participant education programs by inclusion of a simulation experience with dynamic interaction between facilitators and participants via pre-briefing, simulation progression, cues, and debriefing. This study offers experiential learning in human lactation for diverse minors in human lactation students through an innovative virtual mechanism. It provides lactation counseling prenatal and postnatal simulation sessions with student and instructor debriefs for experiential learning for CLC students from rural areas. Utilization and acceptability of virtual telehealth simulation counseling sessions with student-instructor debriefing to develop student’s lactation counseling and communication skills. Thematic analysis using grounded theory will help determine gaps in the simulation to clarify and expand upon for future learning experiences by generating new theories directly from the data, which can be useful for developing new frameworks or models. Grounded theory is adaptable to qualitative data and allows theory generation that is grounded in real-world data that will be relevant to ongoing education development of CLCs.

The study hypothesized that the simulation sessions would increase understanding that CLC students have during their experiential learning regarding breastfeeding questions that the mother might ask and how those questions might be answered by an IBCLC for strengthening future areas to concentrate on in the experiential learning.

Methods:

DESIGN:

This was a quasi-experimental experiential virtual learning intervention within a lactation counselor training program targeted towards a diverse population. The sample consisted of students taking either one or both of two lactation minor courses (see Table 1).

SETTING AND RELEVANT CONTEXT:

Following Institutional Review Board (IRB) approval from the University (11-17-2023), an IBCLC presented 107 one-hour, virtual simulated prenatal and first week at home postnatal simulation breastfeeding consultations with small groups of 4-6 CLC students as part of each lactation minor class. The socio-cultural context of the study was to include diverse students to increase the availability of CLCs and in turn increase breastfeeding rates among these groups. The study places value on increasing well-trained CLCs in these economically underserved areas with the understanding that increased breastfeeding rates also improve health which has important economic implications.

SAMPLE:

The target population for this study was college students from diverse backgrounds. The sample were college students pursuing a minor in lactation from a specific 2-year college, or a specific 4-year university. The inclusion criteria were students enrolled in at least one of two lactation education courses. Exclusion criteria were students not enrolled in either of the two lactation courses or not enrolled as students in participating academic locations. Students with vision or hearing disability were not excluded as the virtual simulation sessions could include verbal discussions (visual disabilities) and verbal text inclusion (hearing disabilities).

Students were recruited to register for the courses that included the study virtual simulation sessions in the same way that all courses were advertised on the school websites.

During the three-year program there were 71 prenatal simulation sessions with a total of 388 student attendees, and 36 postnatal sessions with a total of 162 student attendees. Therefore, there were 107 total simulation sessions offered with 550 student attendees.

The sample size for this study, N=550, is adequate to avoid the effect of attrition in limiting validity of the findings.

DATA COLLECTION:

Data collection, through recordings of each lactation simulation session began during Fall Semester, 2023 and continued through Spring Semester, 2024. All participating students were asked to sign a consent to allow videotaping of the sessions they would be attending. Students could opt out of being visually present during the videotaping. A University Zoom platform was used and recordings were saved on the platform and then transcripts of the simulations were kept on a password protected computer. The transcripts will be destroyed twelve months after the final simulation session.

The IBCLC assumed the role of lactation counselor and of the expectant or breastfeeding parent. Five cases were included in each session with a debrief between the IBCLC and the students after each question (questions are listed in Table 3).

Reflexivity is an important aspect of qualitative research. According to Lazard and McCoy the reflective process is based on the question, “what is the research process, and how am I influencing it?” Reflexivity requires the qualitative researcher to actively consider any personal bias that might affect the study outcomes at each stage of the study process and is a critical aspect of successful and meaningful qualitative research. As all simulation sessions were recorded, essential data was not left out. As the IBCLC who conducted the simulation sessions could have influenced the student responses, she intentionally left the debrief time open after each question, calling on each student in turn and asking if they had any questions or thoughts about the consultation. During data analysis the IBCLC was aware of the important role of reflexivity and explored personal bias in the thematic derivations of the student debrief comments and questions.

DATA ANALYSIS:

The demographic characteristics of the study sample were analyzed using descriptive statistics. Qualitative analysis using Grounded Theory methodology was used to summarize the contents of session recording transcripts into thematic groups and sub-groups by the first author. Grounded theory is a systematic qualitative methodology, developed by Glaser and Strauss, that collects empirical data to create a theory that is grounded within the results. This was completed systematically through four steps (see Table 3). Step one was data planning. This involved determination of the simulation questions and answers. Step two was data collection through simulation session recording. Step three was data analysis. Analysis consisted of three sub-stages. The first was open coding with reading through the recorded transcripts multiple times and breaking down the qualitative data into excerpts with summaries of concepts or themes. The next sub-stage of analysis, axial coding, consisted of reading through the data to make defined summaries to develop emerging theories. Finally, the third sub-stage was selective coding using the summaries of the previous stages to identify strong core concepts. Trustworthiness of the data analysis was increased by the large number of both prenatal and postnatal simulation sessions. To determine student satisfaction with the experiential learning provided through the lactation simulation sessions, descriptive quantitative analysis was used.

Results:

Students attended at least one session. Those registered for both courses took both a prenatal and postnatal lactation counseling simulation session. Each session was one hour long via Zoom and included five questions that might be asked prenatally or postnatally prior to or immediately post breastfeeding (See Table 2). Aspects that were always included were assessment of the plan for feeding the baby and the concept that the lactation consultant is there to help the mother meet her feeding goals and provide education as needed. As part of this, the lactation counseling simulations provided encouragement for the mother to advocate for herself and her baby to meet her feeding plans. This included appropriate wording from the CLC to the mother, for example: how do you plan to feed your baby, as opposed to how do you plan to breastfeed. We attempted to provide a positive approach with support for self-advocacy within aspects of family involvement and what that might look like.

Students with prior breastfeeding experience seem to ask the most questions. Comments concerned the concept of patient autonomy and included: “I wish someone had asked me what my plan for feeding my baby was.” Another frequent comment was that laying out options for the mother to determine what would work for her gives her a say in the process. All student participants that responded to the concluding survey agreed or strongly agreed that simulations were extremely helpful in enhancing their lactation learning.

Discussion:

Not only were there students from diverse cultures, but also students within a wide age range, and wide life-experience range. Having small groups of students on the virtual lactation counseling simulation sessions allowed each student to be called on after each question to maximize their participation and answer or clarify any questions. Early sessions at the beginning of the class tended to have fewer questions or comments suggesting that as students became more familiar with the course content and with the simulation methodology, they were more comfortable participating in the session debriefs. Students often seemed surprised by the questions and the answers. One comment made on multiple sessions (both prenatal and postnatal) was, “I wish I had known that when I had my baby.”

Limitations:

The results of this study are limited by participants from a single geographic area. An additional limitation is that students within this study had access to adequate internet access and conductivity which might not be available in all geographic areas.

Conclusions

Future programs for students pursuing a minor in lactation should consider using virtual lactation counseling simulations. Results suggest virtual lactation counseling simulations as an addition to classroom instruction are a successful format for training future CLCs from diverse backgrounds. Guiding students to communicate with new parents in non-judgmental ways, demonstrating how to support parents’ autonomy, providing clear definitions of terms and intent, and understanding physiological outcomes is a critical element of training students for future lactation practice to meet future needs, particularly among diverse families. Learning about lactation issues and what might be happening for the nursing parent and baby, as well as potential solution pathways and how to communicate with the lactating parent and other family members, places the student participants in a position to become effective CLCs. Equally important is that the lactation counseling simulations will bolster their ability to support family, friends and community members in their breastfeeding journey, ideally within their own diverse populations. Consideration should be given to the debriefing portion of the lactation counseling simulation session asking for input from those that have experience with breastfeeding and those that do not. Additionally, during the debrief, the themes can be introduced to lead the students to ask questions and provide comments to maximize participation and increase learning regarding lactation issues.

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