On the Move,Unprotected: Enforcing the PUMP Act for Home Health Nurses

Abstract

Background:

Over the past decade, home health care has continued to expand and service a diverse group of patients. Home health agencies emphasize both accessible care to patients’ in addition to their commitment to their nursing staff. As home health nursing continues to grow, agencies need to make sure they maintain a nurturing work environment, especially for lactating nurses. In December 2022, The Providing Urgent Maternal Protection (PUMP) For Nursing Mothers Act was signed into law to protect the rights of breastfeeding nurses returning to work. The Providing Urgent Maternal Protection (PUMP) For Nursing Mothers Act mandates employers to implement workplace accommodations for breastfeeding mothers. However, home health care agencies struggle to initiate lactation support due to non-traditional work environments.

Aim:

Home health nurses are constantly on the go and tend to experience limited breaks due to working independently. Contrary to public belief, the flexibility that comes with this role also consists of last-minute schedule changes that can extend work hours. The environment these nurses are working in makes infant feeding decisions difficult to maintain. The return to work should be an easy transition for nurses and for this to happen, protocols must be put in place. This article serves as a call to action to health care agencies to create lactation policies for their nurses that are tailored towards their work environments to promote the health of nurses and their children.

Conclusion:

Without workplace accommodations, home health nurses are denied their right to protections that women are receiving in other careers. As home health nursing continues to grow, agencies need to make sure they maintain a nurturing work environment, especially for lactating nurses. Methods mentioned in this article can be used by home health care agencies to support their breastfeeding nurses.

Introduction

Home health care is one of the fastest-growing sectors in the United States healthcare system. A contributing factor to this increase is the growing elderly population. The percentage of Americans 65 and over is projected to be 20.3% in 2030 compared to 13.7% in 2012. ¹ Since the older population prefers home care, this shift predicts a demand in home health nurses to provide care to those with chronic conditions. ² As this workforce expands, so does the need to ensure that company policies support nurses. Unlike other specialties, home health nurses are traveling to patients’ home to provide skilled care. ² This non-traditional setting presents significant challenges regarding lactation support and highlights the need to introduce workplace protections.

With the introduction of the Affordable Care Act in 2010, breastfeeding rights became protected on a federal level. However, revisions under The Providing Urgent Maternal Protection (PUMP) For Nursing Mothers Act in 2022 allowed for more firm workplace requirements. The first step in addressing how home health nurses can be supported through their breastfeeding journey is distinguishing how these laws alter workplace expectations.

The Affordable Care Act

Signed into law in March 2010, The Affordable Care Act (ACA) is a health care reform law that greatly impacted health insurance coverage and public health. ³ Under Title IV, this act includes workplace accommodations for nursing mothers to prevent chronic disease by improving and creating healthier communities. ³ Employers with more than 50 employees must provide reasonable break time in private spaces other than a bathroom for lactating parents to pump. ³

 While the ACA mandated workplace accommodations, many women received little to no support from their employers. Five hundred and fifty mothers were surveyed and results show that 59% of women had adequate break time, 45% had private space, and 40% had both. ⁴ Additionally women offered both break time and private space were 2.3 times more likely to breastfeed at 6 months. ⁴ The Affordable Care Act laid the foundation for the protection of women in workplace while The Providing Urgent Maternal Protection (PUMP) For Nursing Mothers Act revised the mandated support employers should provide.

Providing Urgent Maternal Protection (PUMP) for Nursing Mothers Act

Signed into law on December 29, 2022, The Providing Urgent Maternal Protection (PUMP) For Nursing Mothers Act was created to expand workplace breastfeeding accommodations. ⁵ The PUMP For Nursing Mothers Act specified that pump break accommodations should be provided for the infants first year of life. ⁵ Pumping should still be conducted in a private space but if an employee was still working during their pump break, it is considered time worked and requires compensation. ⁵ With more specific policies, hospitals began to make efforts to support breastfeeding nurses.

Nurses Experiences Returning to Work

Returning to work after parental leave marks a significant and often complex transition for nurses as they navigate the dual responsibilities of parenthood and professional practice.

Pumping is a multi-step process that includes thinks like transporting equipment, milk expression, sanitation of equipment, and milk storage. ⁶ The turbulent workplace leaves nurses rushing through these steps and adjusting pump times to accommodate their workload. ⁶ To relive anxiety mothers felt by asking their colleagues for relief to pump, some women implemented pre-planned pump breaks. ⁶

Additionally, healthcare workers have found inconsistencies in lactation spaces. One nurse expressed frustration with having to decrease her pump session since the pumping room was 5 minutes away from her unit. ⁶ Low availability and accessibility resulted in the use of cars, bathrooms, vacant exam rooms, and closets for lactation.^6,7 Though hospitals intended to support nurses, these spaces increased frustration as breastfeeding began to delay patient care.^6,7 With the right feedback and revision of protocols, nurses will feel more motivated to continue breastfeeding. ⁸

The Effect of Hospital Policies

Research done at The Children’s Hospital of Pennsylvania (CHOP) gives insight on their revisions made to increase breastfeeding rates amongst staff. ⁸ In addition to an employee lactation policy, their lactation support program offers prenatal education, support in obtaining a breast pump, and over 30 breast pump rooms equipped with hospital grade pumps. ⁸ The evaluation of 545 employees allowed CHOP to compare staff data to the CDC’s. ⁸ Employees “returned to work either full or part time had significantly higher breastfeeding rates compared to national CDC data (94.5% vs 76.9%; P < .0001). At 6 months, significantly more CHOP employees were breastfeeding (78.6% vs 47.2%; P < .0001), and at 12 months, 32.4% of CHOP employees were still breastfeeding as compared to CDC data of 25.5% (P = .0003)” ⁸ (p. 690). This further supports suggestions made by healthcare workers to improve equipment and design preferences to accommodations which include both equipment comprehensive programs will improve breastfeeding continuation. ⁹ The accessibility to resources to help sustain adequate milk supply and education changes this trajectory.

Education is an essential part of policy initiation. Breastfeeding is an acquired experience that causes unawareness in healthcare workers who don’t have personal experience. ⁶ To combat this, the Baby Friendly Initiative was implemented to promote breastfeeding education amongst hospital staff. ¹⁰ This hospital accreditation requires staff to obtain breastfeeding education and hands on lactation training regardless of any prior education.^10,11 By improving health literacy amongst staff members, exclusive breastfeeding rates increase. ¹¹ A health care facility provided 3 months of breastfeeding education to their nursing staff and exclusive breastfeeding rates increased from 38.5% to 53.5%. ¹¹ While the Baby Friendly Initiative was implemented for hospital use, their resources are easily accessible online. ¹⁰ As the home health sector rapidly expands, companies should consider these educational resources. With increasing health literary, home health care agencies can create a foundation to implementing strong policies that are specific to their nurse’s needs. ¹¹

The Home Health Nurse

Home health nurses work independently to provide patient specific medical care in homes with efforts to lower the reoccurrence of hospitalized individuals who are homebound. ¹² Home health nursing is divided into visiting and private duty nursing. Visiting nurses are assigned to patients daily and responsible for calling them to schedule visit times. ¹² While visiting nurses appreciate the flexibility of this role, last minute cancelations and schedule changes can alter works hours and create inconsistencies in pay. ¹² On the other hand, private duty nurses work shifts in homes to provide long term care that is more individualized. ¹³

As the demand for nurses increase, staff retention remains an issue.^12,13 Some reasons for this include lack of compensation, work environments, and complex medical needs.^12,13 Nurses working on an intensive care unit can possibly see their pay cut in half if they worked in home care as well as less benefits. ¹³ Factors effecting schedules high patient acuity which creates longer work days and if patients are admitted reduces both work day and pay.^12,13 As home health nurses think about their infant feeding decisions, these stressors become fear. Nurses are now doubting their abilities to breast feed without even trying solely because work responsibilities. Helping others should not make a nurse feel like they can’t breast feed. Instead, nurses should be aware that while breastfeeding can be challenging that they will have a supportive work environment.

Challenges for Home Health Nurses that Breastfeed

While there is limited research done on the experiences of home health nurses returning to work from breastfeeding in the United States, the PUMP For Nursing Mothers Act does not exclude home health employers. The job structure of both visiting and private duty nursing causes difficulty with taking breaks.^12,13 If a break is needed to pump, a delay or missed break impacts milk supply. ¹⁴ “Without emptying the breasts, the levels of feedback inhibitor of lactation increase, and the parent's milk supply would decrease. For a pumping parent to maintain their milk supply, regular milk removal is essential to maintain breast milk supply” ¹⁴  (p. 949). The absence of policies in home care leaves nurses to turn to blogs to express their frustration. Nurses shared having to turn down jobs, choosing not to breastfeed, reducing patient visits, and even having to stop breastfeeding upon returning to work. The experiences and emotional responses shared in blogs from nurses across the United States further emphasize the need for policies in home health agencies. ¹⁵ Creating realistic solutions for implementing the PUMP For Nursing Mothers Act in home care settings is essential for legal compliance, well-being, and retention of a vital workforce.

Early Planning

One crucial aspect influencing milk production after returning to work is the level of assistance provided by the workplace. Discussions between management and staff regarding lactation accommodations are crucial before the conclusion of parental leave. Research shows after an average parental leave, 41.7% of mothers encounter at least 1 negative experience and inconsistent pumping resulted in 71.3% of mothers being unable to maintain their milk supply. ¹⁶ Encouraging and promoting working women to breastfeed will help decrease turnover of staff and improve job productivity. ¹⁶ In regulation with federal laws, employers must provide support to employees within the infants first year. ⁵

A supportive conversation between pregnant nurses and employers should be initiated to discuss their breastfeeding goals. Then, preliminary agreement can be created that entails what accommodations are needed to provide a successful breastfeeding experience. Things to consider include break times for pumping, estimated durations of pumping session, designated lactation space, breastmilk storage, and equipment maintenance. Once the nurse is on parental leave, health care agencies should make sure that they have achieved all workplace accommodations promised to nursing staff and prepare to solidify the agreement with signatures. Early planning serves as both preparation and promotion to an already established comprehensive lactation program.

Lactation Office Spaces and Supplies

Health care agency offices are a great place to start by transforming a vacant room into a private lactation space. This can be used by a private duty nurse who is going to the office, a visiting nurse who sees patients in the area, or any staff member working there. A study including 97 healthcare workers ranked the relevant items needed in a lactation room for it to be effective. Women ranked these items the highest: “hospital-grade pumps (62%), sink (59%), a comfortable chair (46%), a dedicated refrigerator (42%)” ⁹ (p. 610).

While the FDA does not recognize hospital grade as a way to define pump effectiveness, it is a common word used to market multi user breast pumps. ¹⁷ The Medela Symphony is the first computer chipped breast pump that uses dual pump technology to create a stimulation similar to infant sucking. ¹⁸ This pump has clinically proven to increase and maintain mothers milk supply. ¹⁹ This research based pump became popular in hospitals setting for both patients and staff. ¹⁸ Out of 151 women working in a healthcare setting, 90% of them reduces pump breaks to twice or 3 time a day and 72% of them used a hospital-grade pump at least once. ⁹

The Medela Symphony is a great addition to an agency office lactation space. While in the field, nurses may benefit from a more portable FDA approved multi user pump.

When traveling, the CDC recommends using a manual or battery-operated breast pump. If not, a car adapter can be used to charge electrical pumps as well. ²⁰ Purchasing car adapters are an effective way to offer hospital grade pumps to home health nurses while working in the community. Following pumping, milk should be stored in a cooler bag to prevent expiration because room temperature milk expires after 4 hours. ²¹ Milk supply is individualized due to the differentiations in mammary glands and milk duct growth. ²² “When women have lower milk storage capacity, their infants need to feed more frequently to obtain their necessary milk volumes for the day.” ²² If nurses desire long term breastfeeding, milk supply needs to be maintained because delays in nipple stimulation risks decreasing supply, leading to frequent pumping and nipple stimulation. ²² If supplies is purchased, the use of logs will allow managers can track supply inventory and sterilization.

While health care agencies might not see any benefit in purchasing these items, promoting long term breastfeeding is beneficial. Breast milk contains nutrients needed to maintain adequate health for both mothers and infants. ²³ “Costs for hospitalization from lower-respiratory infections among 1,000 never-breastfed babies range from $26,585 to $30,750 more than for 1,000 infants exclusively breastfed” ²⁴ (p. 1). Nurses that use formula will have cause companies to have increased health claims and frequent call. ²⁴ Investing in renovations and equipment can help with staff retention and even attract nurses that are looking for a company that offers lactation support. The purchase of supplies can be used in a variety of locations.

Pumping in the Car

The PUMP For Nursing Mothers Act emphasizes that staff should not be limited to pumping in the bathroom. ⁵ While people may think that the car is not a private place, there are ways to make your car a private setting. If nurses decide to pump in their car, employers can provide their nurses with a breast milk cooler, car adapter, and breast pump. In addition, a privacy screen can be provided or recommended by employers as an option to make pumping more discrete. Providing proper sanitizers can be considered as well. If supplies are provided, they will be returned to the employer after the nurse is done breastfeeding.

To ensure that the milk is being transported correctly, Employers and nurses should follow CDC education guidelines for the proper transportation and storage of milk. Breast milk can be stored for up to 24 hours in an insulated cooler bag and upon returning home milk should be stored in a fridge or freezer. ²⁰ In order to maintain hand hygiene, if no soap and water is available before expressing milk, an alcohol-based hand sanitizer with at least 60% alcohol can be used. ²⁰

Pumping in the car can be done by a visiting nurse in between patients. Pumping goals can be maintained by including breaks in between patients. Times when patients are being visited by nurses are usually not something communicated with office staff, but this can be outlined in an agreement with the employer when discussing feeding options. Private duty nurses may decide to pump in their car while traveling to work, but it can be difficult during their shift. They are typically alone with their patient requiring proper coverage. Lactating nurses can’t assume that trained caregivers will take on this responsibility but, the use of a clinical manager can be an option.

Case Managers Relieving Nurses from Work

Case managers are registered nurses that work to provide smooth transitions through health setting and reduce gaps in care by coordinating care within the multidisciplinary team. ²⁵ In home health, managers work to increase patient satisfaction while ensuring the correct resources and education is being provided to combat complex health care needs. ²⁵ They create close relationships with patients and families due to can easily reach doctors regarding any patient concerns or updates in status.

With this level of skill, clinical managers are often dividing their day between the field and the office, becoming well verse in their patient’s needs. Field duties may allow clinical managers to give lactating nurses an adequate pump break. By allowing the clinical manager to relieve a nurse from their patient, private pumping won’t impact care. This can be initiated during early planning and finalized postpartum by giving the manager a pump schedule. Though this may not be feasible for all pumping sessions, it can still allow women to get adequate pump time. While I was not able to find research on this being initiated in healthcare, it creates a safe alternative, especially for those taking care of high acuity patients. Health care agencies should consider ways to support private duty nurses so they can feel reassured that their lactation needs aren’t overlooked.

Designated Pump Spaces in the Community

While some nurses may not mind pumping in the cars, public areas provide additional space. There has been an increase in the number of public spaces that provide lactation rooms. There are state variations in whether places like museums, libraries, and airports have incorporated accessible areas for the public.

Companies like Mamava contribute to lactation spaces across the United States. ²⁶ Mamava installs private lactation pods that can be used for breastfeeding or pumping. ²⁶ The app can conveniently locate spaces and tell you the current occupancy status. In addition, users can add lactation spaces that they find to the app to spread awareness. ²⁶

While there is no research on Mamava, an app called MoomMae was studied in Thailand to determine its effect on breastfeeding. ²⁷ MoomMae not only provided parents with locations of lactation sites, but it also allowed them to record their pump and feed times as well. ²⁷ Twenty women were surveyed and “almost all participants (20/21, 95%) exclusively breastfed up to 6 months. The remainder reported to breastfeed 98% of the time: giving formula milk a few times when her child was underweight”²⁷ (p. 6).

Globally, women struggle to pump publicly due to societal biases. This intimate experience between mother and baby is publicly considered too exposing, leaving women embarrassed. Mothers in Thailand are hoping that MoomMae creates a cultural shift around opinions of breastfeeding in public places. ²⁷ Promoting apps like Mamava can help nurses find local breastfeeding spaces. ²⁶ Health care agencies can also create lists with verified locations specific to zip codes they service. For accuracy, these lists should be checked regularly, and any revisions should be communicated to prevent pumping delays.

Conclusion

To improve breastfeeding outcomes for nurses employed in home health care, managers need to be innovative and creative to ensure they are compliant with the PUMP Act. Working in a mobile environment should not preclude the federal law from being adhered to. The initiation of supportive conversation amongst nurses and management is the first step to allowing a nurturing home health nurses to become breastfeeding mothers. This manuscript serves as a call to action and provides practical solutions with hopes that using some of these in health care will allow for future research to be conducted in this space.