Using Kolb to explore the use of the CHINS framework for effective breastfeeding positioning in nursing and midwifery curricula: an exploratory (inter)national survey of academics and students

Using Kolb to explore the use of the CHINS framework for effective breastfeeding positioning in nursing and midwifery curricula: an exploratory (inter)national survey of academics and students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using Kolb to explore the use of the CHINS framework for effective breastfeeding positioning in nursing and midwifery curricula: an exploratory (inter)national survey of academics and students Lynette Harland SHOTTON This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7575748/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Breastfeeding is a global public health priority with benefits for mothers and babies, yet UK rates remain among the lowest worldwide. Strengthening the workforce through effective education is essential. Positioning for effective breastfeeding is a core clinical skill, and the CHINS framework has become a widely adopted tool to support teaching and assessment. This study explores the impact of CHINS in university curricula from the perspectives of academics and students. Methods Two surveys were developed using Kolb’s experiential learning theory as a theoretical framework. Surveys included demographic, closed, and free-text questions to explore how CHINS is used in academic settings and its perceived value. Recruitment was via professional networks and social media. Quantitative data were analysed descriptively in SPSS, and qualitative responses thematically using Braun and Clarke’s six-stage framework, combining inductive and deductive approaches. Ethical approval was obtained from Northumbria University. Results A total of 39 participants responded (academics n = 21; students n = 18), mostly from the UK with three international responses. There was widespread adoption of CHINS in curricula, driven by recognition of breastfeeding as a priority and positioning as a fundamental skill. Academics reported embedding CHINS across teaching methods, including lectures, seminars, digital materials, and simulation. Reflection was encouraged through peer discussion and debriefs, which students valued. Both groups rated CHINS as highly effective for linking theory to practice and aiding recall of key principles. CHINS was frequently incorporated into summative assessments, which staff felt reassured them that students were prepared for professional roles. A key finding was that CHINS provided a framework for students to develop and consolidate skills even when placement exposure to breastfeeding was limited, mitigating variation in practice-based experience. Conclusion CHINS is widely adopted and valued in nursing and midwifery education as a simple, memorable, and effective pedagogical framework. Used alongside experiential learning approaches, it provides a structured scaffold for teaching and assessment, supporting the integration of theory and practice. Consistent inclusion across curricula may enhance student preparedness for clinical breastfeeding support. Breastfeeding education Positioning for breastfeeding CHINS framework Experiential learning exploratory research Figures Figure 1 Introduction and background Breastfeeding is a global public health priority and is known to provide protective health effects for mothers and babies. For babies, it reduces the risk of obesity, gastrointestinal, respiratory and ear infections, and hospital admissions, as well as impacting positively on emotional wellbeing and cognitive development [ 1 ]. For mothers, breastfeeding also has protective emotional and mental impacts as well as reducing the risk of some forms of cancer, and type 2 diabetes [ 2 ]. While most UK mothers initiate breastfeeding, rates drop rapidly, and the UK have some of the lowest rates of breastfeeding in the world [ 3 ]. The World Breastfeeding Trends Initiative [ 3 ] suggest that to address this, breastfeeding must become a strategic priority with emphasis on the training of health professionals and mandatory inclusion in pre-registration health training for health workers who care for mothers, babies and young children. Positioning is recognised as a core element of such training, and the CHINS framework (Table 1 ) has become a widely adopted tool to support teaching principles of positioning. Alongside this, there is sustained emphasis on the role of the UNICEF Baby Friendly Initiative, where they recommend mandatory accreditation in all healthcare and community settings. The UNICEF Baby Friendly Initiative was established in 1992 and launched in the UK in 1994 focusing initially on maternity services and later expanded to community services and universities in 2008 [ 4 ]. UNICEF BFI accreditation is widely acknowledged in policy documents [ 5 ] and is considered globally as one of the best, evidence-based approaches to improving breastfeeding. The university accreditation programme is aimed at departments responsible for pre-registration midwifery and health visitor / public health nurse education and aims to ensure that all new registrants in these fields are equipped with the knowledge and skills they need to support infant feeding and relationship building [ 4 ]. In the UK currently 40% of midwifery courses and 21% of health visiting courses are accredited [ 6 ] but, given the importance of breastfeeding, it suggested that all universities training the future breastfeeding workforce should be accredited or for inclusion of infant feeding as a mandatory element of the programme [ 3 ]. This paper concentrates on CHINS (Table 1 ), a pedagogical framework developed in 2010 [ 7 ] focussed on the principles of positioning babies for effective breastfeeding. Frameworks, such as CHINS, are widely used in healthcare practice and help individuals remember, retain and recall theory to structure and guide practice [ 8 ]. Each of the letters of CHINS relates to a word or phrase outlining a principle for effective positioning. When delivered as part of breastfeeding education and training, an explanation and rationale should be given for each of the principles to make sure that learners know how to support positioning for effective breastfeeding and why. Table 1 An overview of CHINS [ 7 ]. C lose: babies need to be close to their mothers so they can scoop enough breast into their mouths. Ensure both the mother's and baby's clothing and hands are not in the way. H ead free: when attaching to the breast, babies tilt their heads back. This allows the chin to lead as it comes to the breast. Even a finger on the back of the baby's head will restrict this important movement. I n line: the baby's head and body should be in alignment so they do not have to twist their neck, which would make feeding and swallowing difficult. N ose to nipple: with the mother's nipple resting below the baby's nose, they will begin to root. As the baby tilts its head back, the nipple will slip under its top lip upwards and backward to rest between the hard and soft palate. Nose to the nipple is the starting point for effective attachment. S ustainable: mothers need to be comfortable and relaxed and in a position that suits them best. CHINS was rapidly adopted in the breastfeeding workforce and has been included in UNICEF Baby Friendly Initiative (UNICEF BFI) training since 2010. A mixed methods evaluation [ 9 ] shows the widespread impact of CHINS across the UK and increasingly internationally, which was largely driven by its inclusion in UNICEF breastfeeding training. CHINS is found in a range of National Health Service resources, academic textbooks and on health focused webpages internationally. Key findings show that CHINS has helped to standardise how principles of positioning are taught and practised and that it helped to address inconsistencies and poor practice in this area, as well as playing an important role in building practical breastfeeding skills and confidence [ 9 ]. The evaluation included a sample of 115 participants, 24 of whom were from academic backgrounds. Their feedback provided evidence that CHINS was widely embedded in UK university curricula for breastfeeding education and underlined their responsibility in ensuring registrants had the requisite skills for practice. This is of particular importance in relation to breastfeeding, where many mothers give up breastfeeding before they would like to or have planned to, and one of the reasons cited is lack of professional support [ 10 ]. In the UK key breastfeeding professionals, namely midwives and health visitors, are required to complete Nursing and Midwifery Council approved pre-registration programmes, and as mentioned earlier, an increasing number of universities have or are working towards UNICEF accreditation. This ensures curricula include theoretical breastfeeding content and assessment of competence in practice settings. However, literature suggests there are varying levels of confidence in relation to how learners and new registrants feel about promoting and supporting breastfeeding and a potential theory to clinical practice gap [ 10 ]. This reflects wider concerns in the literature which highlights the crucial skills gap in new registrants and the need to consider how this is addressed in higher education, with increasing emphasis on curricula providing hands-on experiential learning through practical sessions and simulation [ 11 ]. Given the inclusion of CHINS in UNICEF training, and its recognised disciplinary impact, this study, aims to understand why and how CHINS is included in educational curricula and its impact on experiential learning from the perspective of academics and learners. This is the first study to explore the impact of CHINS in higher education and primarily focuses on UK HEIs, where CHINS is more widely included but also includes a small number of international participants, reflecting the widening geographic inclusion of CHINS in education and training. Theoretical Framework This study is underpinned by experiential learning, which offers students the opportunity to apply domain specific knowledge and skills in a real-world context, integrating theoretical knowledge with practical experience [12]. While this is provided for student nurses and midwives in clinical practice placements, this study focuses specifically on those hands on / simulated learning experiences provided as part of their university campus-based learning, specifically using the memory aide CHINS. Kolb’s experiential learning theory [13] is one of the most influential experiential learning theories and is widely used in nursing where practical application and critical thinking are essential [14]. Kolb defines learning as a process whereby knowledge is produced by the transformation of experience. Kolb proposed a four-stage cyclical model (Figure 1) which includes concrete experience, reflective observation, abstract conceptualisations and active experimentation. The model offers a structured approach where each stage builds on the previous one creating a continuous loop that emphasises learning and improving [13]. Kolb considers learning to be a cyclical process rather than a linear progression and knowledge is therefore, derived from and tested out in the experiences of the learner and is constantly created and recreated [13]. The foundation of learning lies on concrete experience. Concrete experience involves direct interaction with learning experiences and in this case, with real world breastfeeding scenarios which would be associated with using CHINS. At this point in the cycle, the learner would be engaging with the task in hand, namely promoting and supporting breastfeeding and drawing on and collecting experiences that form the basis of further reflection [14]. Students would then move to the reflective observation stage, which involves analysing the experience and considering what went well and what could be improved. This stage would also encourage reflection on if and how each stage of CHINS was used and how this influenced feeding. In the abstract conceptualisation stage, learners would integrate their reflection with theoretical knowledge, which would help link theory to practice but also help students to understand why each element is important. In the active experimentation stage learners would apply new knowledge in varied situations. This could be via role play and clinical simulation or in clinical settings. Methods Study Design This study adopted an exploratory cross-sectional survey design to investigate how CHINS is incorporated in university curricula from the perspectives of academics and students. This design was chosen because little is currently known about use of CHINS specifically in university settings and the surveys allowed for collection of both quantitative descriptive data and qualitative insights via free text questions. Kolb’s experiential learning theory [13] informed both the development of the surveys and the approach to analysis. The surveys were designed to capture how participants engaged with CHINS across the four stages of Kolb’s learning cycle (concrete experience, reflective observation, abstract conceptualisation, and active experimentation). This theoretical lens also guided the thematic analysis of free-text responses. Setting and participants Two participant groups were targeted: 1. Academic staff involved in designing, delivering and assessing breastfeeding in university programmes with student midwives, health visitors or public health nurses. 2. Students currently enrolled on these programmes. The majority of responses were from academics and students in the United Kingdom, but a small number or international participants took part, reflecting the increasingly international adoption of CHINS. Recruitment Participants were recruited via a combination of direct emails through professional networks targeting midwifery and health visiting leads at UK universities. Digital fliers were also circulated via social media (X, Facebook, LinkedIn). Response rates could not be calculated due to the broad recruitment strategy but the final sample represents a range of UK institutions and 2 international institutions and a range of academic and student experience levels. Data Collection The two online surveys were developed via JISC surveys. JISC is the preferred institutional platform. The surveys were designed specifically for this study. The staff survey (supplementary file 1 ) comprised 34 items and the student survey (supplementary file 2 ) 33 items. Both included demographic questions to obtain background characteristics, role and geographic location. Closed responses and 1-10 rating scales were used to determine how CHINS was included in curricula and its perceived value, and effectiveness. Open text questions captured additional views and suggestions for improving the use of CHINS in academic curricula. Data collection took place between May and September 2025. Data Analysis Staff and student surveys were analysed separately using SPSS with means, standard deviations, ranges, frequencies and proportions calculated for key survey items. Missing responses were excluded from individual analyses, with sample sizes reported for each measure. The free-text responses were analysed thematically using Braun and Clarke’s [15] six-stage framework, combining both deductive and inductive approaches. The deductive element was guided by Kolb’s experiential learning theory, which provided the overarching structure for coding and organising themes. At the same time, an inductive approach ensured that no key issues raised by participants were overlooked, with themes allowed to emerge directly from the data. The process involved familiarisation with the data, generating and organising codes, and reviewing and refining themes, which were then mapped onto Kolb’s four stages (concrete experience, reflective observation, abstract conceptualisation, and active experimentation). This approach ensured that the analysis remained both theoretically informed and grounded in participants’ views and experiences. Ethical considerations Ethical approval was obtained from Northumbria University, Project No. 10208: Reference: Shotton 2025-10208-11380. The study adhered to the principles of the Declaration of Helsinki (2013 revision) . Participation in the survey was voluntary, and informed consent was obtained electronically from all participants prior to submission. Reflexivity This study was conducted by a single researcher who is also the developer of the CHINS memory aide and has expertise in breastfeeding education and curriculum development. The researcher has not been involved in decisions regarding the incorporation of CHINS into curricula or its use in practice, and the purpose of this study was not to promote the tool but to explore objectively why and how it is used and what impact it may have. While this dual role offered in-depth contextual knowledge, it also introduced the potential for bias in analysis and interpretation. To address this, Braun and Clarke’s [15] thematic framework was used to guide the analysis, and findings are presented with illustrative quotations to ensure transparency and grounding in the data. Results Participant characteristics and alignment with CHINS use A total of 39 participants took part: 21 academic staff and 18 students. Most of the participants were based in the United Kingdom (n=35), with representation from all four nations. Two students selected UK without specifying a nation. A small number were international respondents from Ireland and Australia (n=3). Of these, two were academic and one was a student. All participants identified as women (n=39) and most identified as White ethnicity (n=37) with two students identifying as minority ethnic backgrounds (one Indian and one Black/ African Caribbean). Academic staff backgrounds included midwifery (n=13), health visiting (n=6) and public health (n=2) and the majority had more than 3 years’ experience in their academic role (n=18), including seven with over ten years. Students included midwifery students (n=12) and health visiting students (n=6); two thirds were in their first year of study (n=12) but six were in years 2 or 3. CHINS use appeared consistent across staff groups regardless of professional background or length of role and across students in all years of study. A summary of participant characteristics is presented in Table 2. Inclusion of CHINS in curricula Inclusion of CHINS is summarised in Table 3. Almost all academic staff (20/21, 95%) reported including CHINS in their curricula. The single exception was an Australian public health academic who noted that while CHINS was not yet included, there were plans to incorporate it based on its longstanding use in UNICEF training. Similarly, almost all students (17/18, 94%) reported being taught CHINS as part of their programme. One student reported not being taught CHINS but did not provide further explanation. Perceptions of breastfeeding education and clinical context Academics consistently emphasised the importance of teaching breastfeeding and positioning skills, noting that ineffective positioning is a leading cause of breastfeeding problems and early cessation. Several described positioning as a “core clinical skill” that underpinned all breastfeeding support and welcomed CHINS as a structured and memorable way to teach these principles. One staff member commented that “if students don’t understand positioning, they cannot effectively support women to continue breastfeeding,” while another noted that CHINS “gives us a consistent language for teaching what really matters in practice.” At the same time, both academics and students drew attention to the challenges of gaining sufficient practice-based experience. The relatively low prevalence of breastfeeding in some UK settings meant that opportunities to observe and support mothers varied considerably between placements. One academic observed that students “may go through an entire placement seeing very few women breastfeeding,” while a student explained, “on my ward I hardly saw any breastfeeding at all, so CHINS was something I could hold onto.” Another student described CHINS as “a guide that helped me check positioning in skills sessions when I couldn’t see it much on the ward.” These findings suggest that CHINS serves not only as a pedagogical framework for classroom and simulation teaching but also as a means of mitigating the variability of placement experiences, supporting students to consolidate core skills even where clinical exposure is limited. Teaching, assessment and experiences of CHINS mapped to Kolb’s experiential learning cycle. Table 4 provides a summary of academic and student survey responses mapped to the four key stages of Kolb’s Experiential Learning Theory [13]. Concrete experience CHINS was mostly introduced through lectures, seminars and online learning materials, but learning was reinforced with practical sessions and other activities including role play, demonstration and simulation. These activities were considered particularly importantly as they not only gave students the chance to apply CHINS directly to clinical scenarios and to engage with the framework in a realistic but supportive environment but also provided the opportunity to develop key skills when opportunities in placement to observe breastfeeding were limited. In this way, CHINS was an important reference point during concrete learning experiences. Reflective observation Staff described using CHINS within structured reflection, peer discussion, and feedback activities, often linked to formative assessments. Students also identified CHINS as a useful guide when reflecting on both classroom and practice experiences. Most (94%) agreed that it provided a clear, step-by-step framework that helped them to assess effective positioning and recognise suboptimal techniques. One student explained it gave them a guide to “think back to when positioning worked well and when it didn’t”. Free-text comments highlighted the value of peer discussion and group work in supporting reflection and shared understanding. Abstract conceptualisation Staff rated CHINS as highly effective for supporting students to grasp theoretical principles and link them to practice. Students also rated CHINS as helpful for remembering positioning principles, describing it as simple and easy to recall. Quantitative ratings were uniformly high across both groups, citing CHINS as a useful conceptual framework for bridging theory and practice. Active experimentation Staff reported embedding CHINS in formative and summative assessments, including role play, observation, written work, and OSCEs, and rated it highly for standardising teaching and practice. Several noted that formal assessment of CHINS reassured them that students would be better equipped for their professional roles in supporting breastfeeding and modelling good practice. Students confirmed that CHINS was included in assessments, and almost all reported applying it during placements. For many, it helped build confidence, particularly where opportunities to support breastfeeding mothers in practice were limited. While most students rated CHINS highly, there were occasional low ratings (minimum scores of 1-2 on some measures), which may reflected individual learning preferences or specific experiences. Indeed, in one free-text response, one student reported finding CHINS unhelpful, highlighting the need to ensure that teaching approaches remain inclusive of different learning preferences. Discussion The findings of this study highlight two main points. First, experiential learning is central to nursing and midwifery education, with teaching and assessment activities structured to integrate theory and practice. Second, CHINS is an effective and well used pedagogical framework for supporting students’ knowledge and skills in positioning for effective breastfeeding. Experiential learning is widely recognised to support student development, promote deeper schematic learning and reflexivity, and help build advanced clinical management and decision-making skills [ 16 ]. It was therefore encouraging that all the academics in this study reported embedding a range of experiential learning opportunities within their curricula. While experiential models are well established, relatively little research has examined how specific tools align with Kolb’s cycle. The present study suggests a synergy between Kolb’s theory and CHINS, where CHINS provides a structured framework for remembering positioning principles, and associated teaching and learning activities enable progression through Kolb’s [ 13 ] experiential learning stages. In this sense, CHINS complements Kolb by acting as a practical scaffold when embedded within experiential teaching. This is consistent with wider research on the use of mnemonics in healthcare education, which shows they improve retention, recall and application of theoretical principles [ 8 ]. Importantly, the endorsement of CHINS by experienced staff, many with over ten years of academic experience, reinforces its credibility and suggests that its value is recognised across different levels of expertise. The strong academic endorsement reflects alignment with professional standards and the UNICEF Baby Friendly Initiative, ensuring students are prepared to deliver consistent, evidence-based breastfeeding support in practice. As outlined earlier, the student sample was weighted towards those in their first year of study, which may have amplified the emphasis on CHINS as a scaffold where clinical placement exposure was limited. However, consistent use and value of CHINS were reported across all years, suggesting that it is accessible early in training while retaining relevance as students’ progress. The variability in student perspectives is also important. While most rated CHINS highly, one student reported finding it unhelpful. This suggests that CHINS may not suit all learning preferences, and that relying solely on a single pedagogical framework may be limiting. This echoes wider educational literature emphasising the need for mnemonics such as CHINS to be embedded within interactive and reflective learning activities to promote deeper understanding, and the importance of maintaining a range of pedagogical strategies within curricula to ensure essential skills, such as those required to support breastfeeding, are developed [ 17 ]. Importantly, in this case the student was able to identify that CHINS did not work for them, while their curriculum still offered alternative approaches to support their learning. The use of CHINS was widely attributed to its endorsement within UNICEF Baby Friendly training and its widespread adoption across the NHS, which gave staff confidence in embedding it within curricula. However, both staff and students also offered an independent appraisal of its pedagogical value. Respondents consistently highlighted that CHINS was not only externally endorsed but also practically useful, memorable, and effective in supporting learning. This suggests that its continued inclusion in curricula is sustained not only by external guidance but also by the positive experiences of those who teach and learn with it. Implications for education and practice These findings suggest that CHINS offers educators a practical, standardised framework that can be applied across teaching and assessment. When integrated into experiential learning activities, CHINS provides a shared reference point that strengthens learning for both staff and students. Importantly, several staff highlighted that formal assessment of CHINS reassured them that students would be better equipped for their professional roles in supporting breastfeeding, underlining the importance of embedding CHINS not only in teaching but also in structured assessment. For students, CHINS enhanced confidence and skill development, bridging theory with practice and supporting knowledge transfer to clinical contexts. Curricula may therefore benefit from ensuring that CHINS is consistently embedded in formative and summative assessments, reinforcing its role in preparing students for practice and meeting professional regulatory requirements [18;19]. Strengths and limitations This study is the first to investigate how CHINS is used within university curricula. Strengths include the inclusion of both staff and student perspectives and analysis structured with reference to Kolb’s experiential learning theory. Limitations include the relatively small sample (n = 39), which limits generalisability. Most participants were UK-based and White women, reflecting the demographics of the workforce but limiting diversity. The study was also conducted by a single researcher who developed CHINS; although reflexivity measures were adopted, this dual role may have influenced analysis and interpretation. Finally, the cross-sectional design means that the study cannot assess the impact of CHINS on clinical outcomes directly. Future research Further research is needed to explore the impact of CHINS in larger, more diverse and international samples. Longitudinal studies could assess how CHINS influences competence and confidence over time, including OSCE performance and clinical outcomes. Future work should also explore why a minority of students may find CHINS unhelpful, and whether adaptations or complementary approaches could enhance inclusivity across different learning styles. Conclusion CHINS is adopted and valued within nursing and midwifery education as a simple, memorable, and effective pedagogical framework. Used alongside Kolb’s experiential learning theory, it provides a structured scaffold for teaching and assessment, supporting the integration of theory and practice. The endorsement of CHINS by experienced academics adds weight to its credibility and its relevance was evident across different levels of expertise. Consistent inclusion across curricula may support student learning and preparedness for providing breastfeeding support, contributing to improved consistency in practice. Declarations Ethics approval and consent to participate Ethical approval was obtained from Northumbria University, Project No. 10208: Reference: Shotton 2025-10208-11380. Participation in the survey was voluntary, and informed consent was obtained electronically from all participants prior to submission. The study adhered to the principles of the Declaration of Helsinki and followed Northumbria University’s research ethics policies. Consent for publication Not applicable. Availability of data and materials The datasets generated and analysed during the current study are not publicly available but are available from the corresponding author on reasonable request. Competing interests The author is the developer of the CHINS framework. The author was not involved in decisions regarding its adoption in curricula or practice. The study aimed solely to explore how and why CHINS is used in education and its impact on learning. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions LS conceived and designed the study, collected and analysed the data, and drafted the manuscript. Acknowledgements The author would like to thank the academic staff and students who generously gave their time to participate in the survey. References World Health Organization. Breastfeeding [Internet], Geneva WHO. 2023 [cited 2023 Oct 30]. 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Standards of proficiency for specialist community public health nurses [Internet]. London: NMC. 2022 [cited 2025 Sep 9]. Available from: https://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-of-proficiency-for-specialist-community-public-health-nurses.pdf Nursing and Midwifery Council. Standards for pre-registration midwifery programmes [Internet]. London: NMC. 2024 [cited 2025 Sep 9]. Available from: https://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-for-pre-registration-midwifery-programmes.pdf Additional Declarations No competing interests reported. Supplementary Files Supplementaryfile1StudentSurvey.pdf Supplementaryfile2AcademicSurvey.pdf Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Oct, 2025 Reviewers agreed at journal 21 Oct, 2025 Reviewers invited by journal 09 Oct, 2025 Editor assigned by journal 07 Oct, 2025 Editor invited by journal 19 Sep, 2025 Submission checks completed at journal 18 Sep, 2025 First submitted to journal 18 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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1","display":"","copyAsset":false,"role":"figure","size":33487,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe four stages of Kolb’s Experiential Learning Cycle\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7575748/v1/8f48fdf0d7c92e4ef451b22c.png"},{"id":94205003,"identity":"9eb76de8-ab05-4aa2-a93c-7ac3db661296","added_by":"auto","created_at":"2025-10-23 14:29:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":858008,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7575748/v1/3dad6856-ee16-421f-b274-839aac7718cb.pdf"},{"id":94203196,"identity":"e6b585e0-d694-4b96-9a6a-7da49256329f","added_by":"auto","created_at":"2025-10-23 14:13:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":380219,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1StudentSurvey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7575748/v1/8ff93fb57792616d9f4e224e.pdf"},{"id":94203202,"identity":"dc070ba6-8c86-40e7-840c-a4df4a6bb93d","added_by":"auto","created_at":"2025-10-23 14:13:44","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":357649,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile2AcademicSurvey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7575748/v1/9f291327da96c48ef897e791.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using Kolb to explore the use of the CHINS framework for effective breastfeeding positioning in nursing and midwifery curricula: an exploratory (inter)national survey of academics and students","fulltext":[{"header":"Introduction and background","content":"\u003cp\u003eBreastfeeding is a global public health priority and is known to provide protective health effects for mothers and babies. For babies, it reduces the risk of obesity, gastrointestinal, respiratory and ear infections, and hospital admissions, as well as impacting positively on emotional wellbeing and cognitive development [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For mothers, breastfeeding also has protective emotional and mental impacts as well as reducing the risk of some forms of cancer, and type 2 diabetes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While most UK mothers initiate breastfeeding, rates drop rapidly, and the UK have some of the lowest rates of breastfeeding in the world [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The World Breastfeeding Trends Initiative [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] suggest that to address this, breastfeeding must become a strategic priority with emphasis on the training of health professionals and mandatory inclusion in pre-registration health training for health workers who care for mothers, babies and young children. Positioning is recognised as a core element of such training, and the CHINS framework (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) has become a widely adopted tool to support teaching principles of positioning. Alongside this, there is sustained emphasis on the role of the UNICEF Baby Friendly Initiative, where they recommend mandatory accreditation in all healthcare and community settings.\u003c/p\u003e\u003cp\u003eThe UNICEF Baby Friendly Initiative was established in 1992 and launched in the UK in 1994 focusing initially on maternity services and later expanded to community services and universities in 2008 [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. UNICEF BFI accreditation is widely acknowledged in policy documents [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and is considered globally as one of the best, evidence-based approaches to improving breastfeeding. The university accreditation programme is aimed at departments responsible for pre-registration midwifery and health visitor / public health nurse education and aims to ensure that all new registrants in these fields are equipped with the knowledge and skills they need to support infant feeding and relationship building [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In the UK currently 40% of midwifery courses and 21% of health visiting courses are accredited [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] but, given the importance of breastfeeding, it suggested that all universities training the future breastfeeding workforce should be accredited or for inclusion of infant feeding as a mandatory element of the programme [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis paper concentrates on CHINS (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), a pedagogical framework developed in 2010 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] focussed on the principles of positioning babies for effective breastfeeding. Frameworks, such as CHINS, are widely used in healthcare practice and help individuals remember, retain and recall theory to structure and guide practice [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Each of the letters of CHINS relates to a word or phrase outlining a principle for effective positioning. When delivered as part of breastfeeding education and training, an explanation and rationale should be given for each of the principles to make sure that learners know how to support positioning for effective breastfeeding and why.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAn overview of CHINS [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eC\u003c/span\u003elose: babies need to be close to their mothers so they can scoop enough breast into their mouths. Ensure both the mother's and baby's clothing and hands are not in the way.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eH\u003c/span\u003eead free: when attaching to the breast, babies tilt their heads back. This allows the chin to lead as it comes to the breast. Even a finger on the back of the baby's head will restrict this important movement.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eI\u003c/span\u003en line: the baby's head and body should be in alignment so they do not have to twist their neck, which would make feeding and swallowing difficult.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eN\u003c/span\u003eose to nipple: with the mother's nipple resting below the baby's nose, they will begin to root. As the baby tilts its head back, the nipple will slip under its top lip upwards and backward to rest between the hard and soft palate. Nose to the nipple is the starting point for effective attachment.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eS\u003c/span\u003eustainable: mothers need to be comfortable and relaxed and in a position that suits them best.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eCHINS was rapidly adopted in the breastfeeding workforce and has been included in UNICEF Baby Friendly Initiative (UNICEF BFI) training since 2010. A mixed methods evaluation [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] shows the widespread impact of CHINS across the UK and increasingly internationally, which was largely driven by its inclusion in UNICEF breastfeeding training. CHINS is found in a range of National Health Service resources, academic textbooks and on health focused webpages internationally. Key findings show that CHINS has helped to standardise how principles of positioning are taught and practised and that it helped to address inconsistencies and poor practice in this area, as well as playing an important role in building practical breastfeeding skills and confidence [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The evaluation included a sample of 115 participants, 24 of whom were from academic backgrounds. Their feedback provided evidence that CHINS was widely embedded in UK university curricula for breastfeeding education and underlined their responsibility in ensuring registrants had the requisite skills for practice. This is of particular importance in relation to breastfeeding, where many mothers give up breastfeeding before they would like to or have planned to, and one of the reasons cited is lack of professional support [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the UK key breastfeeding professionals, namely midwives and health visitors, are required to complete Nursing and Midwifery Council approved pre-registration programmes, and as mentioned earlier, an increasing number of universities have or are working towards UNICEF accreditation. This ensures curricula include theoretical breastfeeding content and assessment of competence in practice settings. However, literature suggests there are varying levels of confidence in relation to how learners and new registrants feel about promoting and supporting breastfeeding and a potential theory to clinical practice gap [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This reflects wider concerns in the literature which highlights the crucial skills gap in new registrants and the need to consider how this is addressed in higher education, with increasing emphasis on curricula providing hands-on experiential learning through practical sessions and simulation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eGiven the inclusion of CHINS in UNICEF training, and its recognised disciplinary impact, this study, aims to understand why and how CHINS is included in educational curricula and its impact on experiential learning from the perspective of academics and learners. This is the first study to explore the impact of CHINS in higher education and primarily focuses on UK HEIs, where CHINS is more widely included but also includes a small number of international participants, reflecting the widening geographic inclusion of CHINS in education and training.\u003c/p\u003e"},{"header":"Theoretical Framework","content":"\u003cp\u003eThis study is underpinned by experiential learning, which offers students the opportunity to apply domain specific knowledge and skills in a real-world context, integrating theoretical knowledge with practical experience [12]. While this is provided for student nurses and midwives in clinical practice placements, this study focuses specifically on those hands on / simulated learning experiences provided as part of their university campus-based learning, specifically using the memory aide CHINS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKolb\u0026rsquo;s experiential learning theory [13] is one of the most influential experiential learning theories and is widely used in nursing where practical application and critical thinking are essential [14]. Kolb defines learning as a process whereby knowledge is produced by the transformation of experience. Kolb proposed a four-stage cyclical model (Figure 1) which includes concrete experience, reflective observation, abstract conceptualisations and active experimentation. The model offers a structured approach where each stage builds on the previous one creating a continuous loop that emphasises learning and improving [13].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKolb considers learning to be a cyclical process rather than a linear progression and knowledge is therefore, derived from and tested out in the experiences of the learner and is constantly created and recreated [13]. The foundation of learning lies on concrete experience. Concrete experience involves direct interaction with learning experiences and in this case, with real world breastfeeding scenarios which would be associated with using CHINS. At this point in the cycle, the learner would be engaging with the task in hand, namely promoting and supporting breastfeeding and drawing on and collecting experiences that form the basis of further reflection [14]. Students would then move to the reflective observation stage, which involves analysing the experience and considering what went well and what could be improved. This stage would also encourage reflection on if and how each stage of CHINS was used and how this influenced feeding. In the abstract conceptualisation stage, learners would integrate their reflection with theoretical knowledge, which would help link theory to practice but also help students to understand why each element is important. In the active experimentation stage learners would apply new knowledge in varied situations. This could be via role play and clinical simulation or in clinical settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study adopted an exploratory cross-sectional survey design to investigate how CHINS is incorporated in university curricula from the perspectives of academics and students. This design was chosen because little is currently known about use of CHINS specifically in university settings and the surveys allowed for collection of both quantitative descriptive data and qualitative insights via free text questions.\u003c/p\u003e\n\u003cp\u003eKolb’s experiential learning theory [13] informed both the development of the surveys and the approach to analysis. The surveys were designed to capture how participants engaged with CHINS across the four stages of Kolb’s learning cycle (concrete experience, reflective observation, abstract conceptualisation, and active experimentation). This theoretical lens also guided the thematic analysis of free-text responses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting and participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo participant groups were targeted:\u003c/p\u003e\n\u003cp\u003e1.\u0026nbsp; \u0026nbsp;\u0026nbsp;Academic staff involved in designing, delivering and assessing breastfeeding in university programmes with student midwives, health visitors or public health nurses.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp; \u0026nbsp;\u0026nbsp;Students currently enrolled on these programmes.\u003c/p\u003e\n\u003cp\u003eThe majority of responses were from academics and students in the United Kingdom, but a small number or international participants took part, reflecting the increasingly international adoption of CHINS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were recruited via a combination of direct emails through professional networks targeting midwifery and health visiting leads at UK universities. Digital fliers were also circulated via social media (X, Facebook, LinkedIn). Response rates could not be calculated due to the broad recruitment strategy but the final sample represents a range of UK institutions and 2 international institutions and a range of academic and student experience levels.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe two online surveys were developed via JISC surveys. \u0026nbsp;JISC is the preferred institutional platform. The surveys were designed specifically for this study. The staff survey \u003cstrong\u003e(supplementary file 1 )\u003c/strong\u003e comprised 34 items and the student survey \u003cstrong\u003e(supplementary file 2\u003c/strong\u003e) 33 items. Both included demographic questions to obtain background characteristics, role and geographic location. Closed responses and 1-10 rating scales were used to determine how CHINS was included in curricula and its perceived value, and effectiveness. Open text questions captured additional views and suggestions for improving the use of CHINS in academic curricula. Data collection took place between May and September 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStaff and student surveys were analysed separately using SPSS with means, standard deviations, ranges, frequencies and proportions calculated for key survey items. Missing responses were excluded from individual analyses, with sample sizes reported for each measure.\u003c/p\u003e\n\u003cp\u003eThe free-text responses were analysed thematically using Braun and Clarke’s [15] six-stage framework, combining both deductive and inductive approaches. The deductive element was guided by Kolb’s experiential learning theory, which provided the overarching structure for coding and organising themes. At the same time, an inductive approach ensured that no key issues raised by participants were overlooked, with themes allowed to emerge directly from the data. The process involved familiarisation with the data, generating and organising codes, and reviewing and refining themes, which were then mapped onto Kolb’s four stages (concrete experience, reflective observation, abstract conceptualisation, and active experimentation). This approach ensured that the analysis remained both theoretically informed and grounded in participants’ views and experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from Northumbria University, Project No. 10208: Reference: Shotton 2025-10208-11380. The study adhered to the principles of the \u003cstrong\u003eDeclaration of Helsinki (2013 revision)\u003c/strong\u003e. Participation in the survey was voluntary, and informed consent was obtained electronically from all participants prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflexivity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted by a single researcher who is also the developer of the CHINS memory aide and has expertise in breastfeeding education and curriculum development. The researcher has not been involved in decisions regarding the incorporation of CHINS into curricula or its use in practice, and the purpose of this study was not to promote the tool but to explore objectively why and how it is used and what impact it may have.\u003c/p\u003e\n\u003cp\u003eWhile this dual role offered in-depth contextual knowledge, it also introduced the potential for bias in analysis and interpretation. To address this, Braun and Clarke’s [15] thematic framework was used to guide the analysis, and findings are presented with illustrative quotations to ensure transparency and grounding in the data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant characteristics and alignment with CHINS \u0026nbsp; use\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 39 participants took part: 21 academic staff and 18 students. Most of the participants were based in the United Kingdom (n=35), with representation from all four nations. Two students selected UK without specifying a nation. A small number were international respondents from Ireland and Australia (n=3). Of these, two were academic and one was a student. All participants identified as women (n=39) and most identified as White ethnicity (n=37) with two students identifying as minority ethnic backgrounds (one Indian and one Black/ African Caribbean).\u003c/p\u003e\n\u003cp\u003eAcademic staff backgrounds included midwifery (n=13), health visiting (n=6) and public health (n=2) and the majority had more than 3 years\u0026rsquo; experience in their academic role (n=18), including seven with over ten years. Students included midwifery students (n=12) and health visiting students (n=6); two thirds were in their first year of study (n=12) but six were in years 2 or 3. CHINS use appeared consistent across staff groups regardless of professional background or length of role and across students in all years of study.\u003c/p\u003e\n\u003cp\u003eA summary of participant characteristics is presented in \u003cstrong\u003eTable 2.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion of CHINS in curricula\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInclusion of CHINS is summarised in \u003cstrong\u003eTable 3.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlmost all academic staff (20/21, 95%) reported including CHINS in their curricula. The single exception was an Australian public health academic who noted that while CHINS was not yet included, there were plans to incorporate it based on its longstanding use in UNICEF training. Similarly, almost all students (17/18, 94%) reported being taught CHINS as part of their programme. One student reported not being taught CHINS but did not provide further explanation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceptions of breastfeeding education and clinical context\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcademics consistently emphasised the importance of teaching breastfeeding and positioning skills, noting that ineffective positioning is a leading cause of breastfeeding problems and early cessation. Several described positioning as a \u0026ldquo;core clinical skill\u0026rdquo; that underpinned all breastfeeding support and welcomed CHINS as a structured and memorable way to teach these principles. One staff member commented that \u0026ldquo;if students don\u0026rsquo;t understand positioning, they cannot effectively support women to continue breastfeeding,\u0026rdquo; while another noted that CHINS \u0026ldquo;gives us a consistent language for teaching what really matters in practice.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eAt the same time, both academics and students drew attention to the challenges of gaining sufficient practice-based experience. The relatively low prevalence of breastfeeding in some UK settings meant that opportunities to observe and support mothers varied considerably between placements. One academic observed that students \u0026ldquo;may go through an entire placement seeing very few women breastfeeding,\u0026rdquo; while a student explained, \u0026ldquo;on my ward I hardly saw any breastfeeding at all, so CHINS was something I could hold onto.\u0026rdquo; Another student described CHINS as \u0026ldquo;a guide that helped me check positioning in skills sessions when I couldn\u0026rsquo;t see it much on the ward.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThese findings suggest that CHINS serves not only as a pedagogical framework for classroom and simulation teaching but also as a means of mitigating the variability of placement experiences, supporting students to consolidate core skills even where clinical exposure is limited.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeaching, assessment and experiences of CHINS mapped to Kolb\u0026rsquo;s experiential learning cycle.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 4 provides a summary of academic and student survey responses mapped to the four key stages of Kolb\u0026rsquo;s Experiential Learning Theory [13].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConcrete experience\u003cbr\u003e\u003c/strong\u003eCHINS was mostly introduced through lectures, seminars and online learning materials, but learning was reinforced with practical sessions and other activities including role play, demonstration and simulation. These activities were considered particularly importantly as they not only gave students the chance to apply CHINS directly to clinical scenarios and to engage with the framework in a realistic but supportive environment but also provided the opportunity to develop key skills when opportunities in placement to observe breastfeeding were limited. In this way, CHINS was an important reference point during concrete learning experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReflective observation\u003cbr\u003e\u003c/strong\u003eStaff described using CHINS within structured reflection, peer discussion, and feedback activities, often linked to formative assessments. Students also identified CHINS as a useful guide when reflecting on both classroom and practice experiences. Most (94%) agreed that it provided a clear, step-by-step framework that helped them to assess effective positioning and recognise suboptimal techniques. One student explained it gave them a guide to \u0026ldquo;think back to when positioning worked well and when it didn\u0026rsquo;t\u0026rdquo;. Free-text comments highlighted the value of peer discussion and group work in supporting reflection and shared understanding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAbstract conceptualisation\u003cbr\u003e\u003c/strong\u003eStaff rated CHINS as highly effective for supporting students to grasp theoretical principles and link them to practice. Students also rated CHINS as helpful for remembering positioning principles, describing it as simple and easy to recall. Quantitative ratings were uniformly high across both groups, citing CHINS as a useful conceptual framework for bridging theory and practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eActive experimentation\u003cbr\u003e\u003c/strong\u003eStaff reported embedding CHINS in formative and summative assessments, including role play, observation, written work, and OSCEs, and rated it highly for standardising teaching and practice. Several noted that formal assessment of CHINS reassured them that students would be better equipped for their professional roles in supporting breastfeeding and modelling good practice. Students confirmed that CHINS was included in assessments, and almost all reported applying it during placements. For many, it helped build confidence, particularly where opportunities to support breastfeeding mothers in practice were limited. While most students rated CHINS highly, there were occasional low ratings (minimum scores of 1-2 on some measures), which may reflected individual learning preferences or specific experiences. Indeed, in one free-text response, one student reported finding CHINS unhelpful, highlighting the need to ensure that teaching approaches remain inclusive of different learning preferences.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study highlight two main points. First, experiential learning is central to nursing and midwifery education, with teaching and assessment activities structured to integrate theory and practice. Second, CHINS is an effective and well used pedagogical framework for supporting students\u0026rsquo; knowledge and skills in positioning for effective breastfeeding.\u003c/p\u003e\u003cp\u003eExperiential learning is widely recognised to support student development, promote deeper schematic learning and reflexivity, and help build advanced clinical management and decision-making skills [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. It was therefore encouraging that all the academics in this study reported embedding a range of experiential learning opportunities within their curricula. While experiential models are well established, relatively little research has examined how specific tools align with Kolb\u0026rsquo;s cycle. The present study suggests a synergy between Kolb\u0026rsquo;s theory and CHINS, where CHINS provides a structured framework for remembering positioning principles, and associated teaching and learning activities enable progression through Kolb\u0026rsquo;s [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] experiential learning stages. In this sense, CHINS complements Kolb by acting as a practical scaffold when embedded within experiential teaching. This is consistent with wider research on the use of mnemonics in healthcare education, which shows they improve retention, recall and application of theoretical principles [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Importantly, the endorsement of CHINS by experienced staff, many with over ten years of academic experience, reinforces its credibility and suggests that its value is recognised across different levels of expertise. The strong academic endorsement reflects alignment with professional standards and the UNICEF Baby Friendly Initiative, ensuring students are prepared to deliver consistent, evidence-based breastfeeding support in practice.\u003c/p\u003e\u003cp\u003eAs outlined earlier, the student sample was weighted towards those in their first year of study, which may have amplified the emphasis on CHINS as a scaffold where clinical placement exposure was limited. However, consistent use and value of CHINS were reported across all years, suggesting that it is accessible early in training while retaining relevance as students\u0026rsquo; progress. The variability in student perspectives is also important. While most rated CHINS highly, one student reported finding it unhelpful. This suggests that CHINS may not suit all learning preferences, and that relying solely on a single pedagogical framework may be limiting. This echoes wider educational literature emphasising the need for mnemonics such as CHINS to be embedded within interactive and reflective learning activities to promote deeper understanding, and the importance of maintaining a range of pedagogical strategies within curricula to ensure essential skills, such as those required to support breastfeeding, are developed [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Importantly, in this case the student was able to identify that CHINS did not work for them, while their curriculum still offered alternative approaches to support their learning.\u003c/p\u003e\u003cp\u003eThe use of CHINS was widely attributed to its endorsement within UNICEF Baby Friendly training and its widespread adoption across the NHS, which gave staff confidence in embedding it within curricula. However, both staff and students also offered an independent appraisal of its pedagogical value. Respondents consistently highlighted that CHINS was not only externally endorsed but also practically useful, memorable, and effective in supporting learning. This suggests that its continued inclusion in curricula is sustained not only by external guidance but also by the positive experiences of those who teach and learn with it.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eImplications for education and practice\u003c/h2\u003e\u003cp\u003eThese findings suggest that CHINS offers educators a practical, standardised framework that can be applied across teaching and assessment. When integrated into experiential learning activities, CHINS provides a shared reference point that strengthens learning for both staff and students. Importantly, several staff highlighted that formal assessment of CHINS reassured them that students would be better equipped for their professional roles in supporting breastfeeding, underlining the importance of embedding CHINS not only in teaching but also in structured assessment. For students, CHINS enhanced confidence and skill development, bridging theory with practice and supporting knowledge transfer to clinical contexts. Curricula may therefore benefit from ensuring that CHINS is consistently embedded in formative and summative assessments, reinforcing its role in preparing students for practice and meeting professional regulatory requirements [18;19].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThis study is the first to investigate how CHINS is used within university curricula. Strengths include the inclusion of both staff and student perspectives and analysis structured with reference to Kolb\u0026rsquo;s experiential learning theory. Limitations include the relatively small sample (n\u0026thinsp;=\u0026thinsp;39), which limits generalisability. Most participants were UK-based and White women, reflecting the demographics of the workforce but limiting diversity. The study was also conducted by a single researcher who developed CHINS; although reflexivity measures were adopted, this dual role may have influenced analysis and interpretation. Finally, the cross-sectional design means that the study cannot assess the impact of CHINS on clinical outcomes directly.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eFuture research\u003c/h2\u003e\u003cp\u003eFurther research is needed to explore the impact of CHINS in larger, more diverse and international samples. Longitudinal studies could assess how CHINS influences competence and confidence over time, including OSCE performance and clinical outcomes. Future work should also explore why a minority of students may find CHINS unhelpful, and whether adaptations or complementary approaches could enhance inclusivity across different learning styles.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCHINS is adopted and valued within nursing and midwifery education as a simple, memorable, and effective pedagogical framework. Used alongside Kolb\u0026rsquo;s experiential learning theory, it provides a structured scaffold for teaching and assessment, supporting the integration of theory and practice. The endorsement of CHINS by experienced academics adds weight to its credibility and its relevance was evident across different levels of expertise. Consistent inclusion across curricula may support student learning and preparedness for providing breastfeeding support, contributing to improved consistency in practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003cbr\u003e\u003c/strong\u003eEthical approval was obtained from Northumbria University, Project No. 10208: Reference: Shotton 2025-10208-11380. Participation in the survey was voluntary, and informed consent was obtained electronically from all participants prior to submission. The study adhered to the principles of the Declaration of Helsinki and followed Northumbria University\u0026rsquo;s research ethics policies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003cbr\u003e\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003cbr\u003e\u003c/strong\u003eThe datasets generated and analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003cbr\u003e\u003c/strong\u003eThe author is the developer of the CHINS framework. The author was not involved in decisions regarding its adoption in curricula or practice. The study aimed solely to explore how and why CHINS is used in education and its impact on learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003cbr\u003e\u003c/strong\u003eLS conceived and designed the study, collected and analysed the data, and drafted the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003cbr\u003e\u003c/strong\u003eThe author would like to thank the academic staff and students who generously gave their time to participate in the survey.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Breastfeeding [Internet], Geneva WHO. 2023 [cited 2023 Oct 30]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/health-topics/breastfeeding\u003c/span\u003e\u003cspan address=\"https://www.who.int/health-topics/breastfeeding\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoyal College of Paediatrics and Child Health. Breastfeeding in the UK: position statement [Internet]. London: RCPCH. 2022 [cited 2023 Oct 11]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.rcpch.ac.uk/resources/breastfeeding-uk-position-statement\u003c/span\u003e\u003cspan address=\"https://www.rcpch.ac.uk/resources/breastfeeding-uk-position-statement\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWorld Breastfeeding Trends Initiative. Breastfeeding trends: UK report 2024 [Internet]. London: WBTI. 2024 [cited 2025 Jul 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://ukbreastfeeding.org/wbtiuk2024/\u003c/span\u003e\u003cspan address=\"https://ukbreastfeeding.org/wbtiuk2024/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNICEF UK. History of Baby Friendly [Internet]. London: UNICEF; [date unknown] [cited 2025 Jul 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org.uk/babyfriendly/about/history/\u003c/span\u003e\u003cspan address=\"https://www.unicef.org.uk/babyfriendly/about/history/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNHS England. The NHS long term plan [Internet]. London: NHS. 2019 [cited 2025 Sep 9]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.england.nhs.uk/2019/01/long-term-plan/\u003c/span\u003e\u003cspan address=\"https://www.england.nhs.uk/2019/01/long-term-plan/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUNICEF UK. Accreditation statistics and awards table [Internet]. London: UNICEF. 2024 [cited 2025 Jul 15]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.unicef.org.uk/babyfriendly/about/accreditation-statistics-and-awards-table-2/\u003c/span\u003e\u003cspan address=\"https://www.unicef.org.uk/babyfriendly/about/accreditation-statistics-and-awards-table-2/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarland L, Remember. CHIN Community Pract. 2011;84(1):18.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMaheshwari SK, Kaur P. Mnemonics and nursing. Int J Nurs Sci Pract Res. 2019;5(2):1\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShotton L, Collins T, Cordier R, Chikwava F, Steen M. A mixed methods evaluation of the breastfeeding memory aide CHINS. Matern Child Nutr. 2024;20(4):e13704. doi: 10. 1111/mcn.13704.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpencer RL, Stephenson J, Thomas C. One of those things the student is left to do: student midwives\u0026rsquo; experience of infant feeding education. Nurse Educ Pract. 2022;63:103416. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nepr.2022.103416\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2022.103416\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaddeland K, Sletteb\u0026oslash; \u0026Aring;, Fossum M. Enablers of the successful implementation of simulation exercises: a qualitative study among nurse teachers in undergraduate nursing education. BMC Nurs. 2021;20:234. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-021-00756-3\u003c/span\u003e\u003cspan address=\"10.1186/s12912-021-00756-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDuchatelet D, Cornelissen F, Volman M. Features of experiential learning environments in relation to generic learning outcomes in higher education. J Exp Educ. 2024;47(3):400\u0026ndash;23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/10538259231211537\u003c/span\u003e\u003cspan address=\"10.1177/10538259231211537\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKolb DA. Experiential learning: experience as the source of learning and development. Englewood Cliffs (NJ): Prentice Hall; 1984.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNursing Science. Kolb\u0026rsquo;s experiential learning cycle [Internet]. Nursing Science; 2024 [cited 2025 Jul 18]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://nursing-science.com/about/index/kolb's-experiential-learning-cycle\u003c/span\u003e\u003cspan address=\"https://nursing-science.com/about/index/kolb's-experiential-learning-cycle\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeen A. From theory to practice [Internet]. Br J Midwifery. 2021 [cited 2025 Sep 8]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.britishjournalofmidwifery.com/content/birthwrite/from-theory-to-practice/\u003c/span\u003e\u003cspan address=\"https://www.britishjournalofmidwifery.com/content/birthwrite/from-theory-to-practice/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMousavi SK, Javadzadeh A, Hasankhani H, Parizad ZA. Relationship between learning styles and clinical competency in nursing. BMC Med Educ. 2024;24:469. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12909-024-05432-z\u003c/span\u003e\u003cspan address=\"10.1186/s12909-024-05432-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNursing and Midwifery Council. Standards of proficiency for specialist community public health nurses [Internet]. London: NMC. 2022 [cited 2025 Sep 9]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-of-proficiency-for-specialist-community-public-health-nurses.pdf\u003c/span\u003e\u003cspan address=\"https://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-of-proficiency-for-specialist-community-public-health-nurses.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNursing and Midwifery Council. Standards for pre-registration midwifery programmes [Internet]. London: NMC. 2024 [cited 2025 Sep 9]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-for-pre-registration-midwifery-programmes.pdf\u003c/span\u003e\u003cspan address=\"https://www.nmc.org.uk/globalassets/sitedocuments/standards/2024/standards-for-pre-registration-midwifery-programmes.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Breastfeeding education, Positioning for breastfeeding, CHINS framework, Experiential learning, exploratory research","lastPublishedDoi":"10.21203/rs.3.rs-7575748/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7575748/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eBreastfeeding is a global public health priority with benefits for mothers and babies, yet UK rates remain among the lowest worldwide. Strengthening the workforce through effective education is essential. Positioning for effective breastfeeding is a core clinical skill, and the CHINS framework has become a widely adopted tool to support teaching and assessment. This study explores the impact of CHINS in university curricula from the perspectives of academics and students.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eTwo surveys were developed using Kolb\u0026rsquo;s experiential learning theory as a theoretical framework. Surveys included demographic, closed, and free-text questions to explore how CHINS is used in academic settings and its perceived value. Recruitment was via professional networks and social media. Quantitative data were analysed descriptively in SPSS, and qualitative responses thematically using Braun and Clarke\u0026rsquo;s six-stage framework, combining inductive and deductive approaches. Ethical approval was obtained from Northumbria University.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 39 participants responded (academics n\u0026thinsp;=\u0026thinsp;21; students n\u0026thinsp;=\u0026thinsp;18), mostly from the UK with three international responses. There was widespread adoption of CHINS in curricula, driven by recognition of breastfeeding as a priority and positioning as a fundamental skill. Academics reported embedding CHINS across teaching methods, including lectures, seminars, digital materials, and simulation. Reflection was encouraged through peer discussion and debriefs, which students valued. Both groups rated CHINS as highly effective for linking theory to practice and aiding recall of key principles. CHINS was frequently incorporated into summative assessments, which staff felt reassured them that students were prepared for professional roles. A key finding was that CHINS provided a framework for students to develop and consolidate skills even when placement exposure to breastfeeding was limited, mitigating variation in practice-based experience.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eCHINS is widely adopted and valued in nursing and midwifery education as a simple, memorable, and effective pedagogical framework. Used alongside experiential learning approaches, it provides a structured scaffold for teaching and assessment, supporting the integration of theory and practice. Consistent inclusion across curricula may enhance student preparedness for clinical breastfeeding support.\u003c/p\u003e","manuscriptTitle":"Using Kolb to explore the use of the CHINS framework for effective breastfeeding positioning in nursing and midwifery curricula: an exploratory (inter)national survey of academics and students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 14:13:37","doi":"10.21203/rs.3.rs-7575748/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-10-30T20:34:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"127787606720815274311328273141773732437","date":"2025-10-21T21:10:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-09T11:20:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-08T03:02:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-19T08:21:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-18T12:58:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-09-18T11:21:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5717921f-07ef-4df9-8bd9-22052f5033f3","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-23T14:13:37+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-23 14:13:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7575748","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7575748","identity":"rs-7575748","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}