Do nurses provide a safe sleep environment for infants in the hospital setting? An integrative review.

Linda Ikuta, MN, RN, CCNS, PHN, and Ksenia Zukowsky, PhD, APRN, NNP-BC ❍ Section Editors

Clinical Issues in Neonatal Care Do Nurses Provide a Safe Sleep Environment for Infants in the Hospital Setting? An Integrative Review

Carla Patton, RN, MSN, IBCLC; Denise Stiltner, RN, MSN, RNC-NIC; Kelly Barnhardt Wright, RN, MSN, RNC-OB; Donald D. Kautz, RN, PhD, CRRN, CNE, ACNS-BC

ABSTRACT Background: Sudden infant death syndrome (SIDS) may be the most preventable cause of death for infants 0 to 6 months of age. The American Academy of Pediatrics (AAP) first published safe sleep recommendations for parents and healthcare professionals in 1992. In 1994, new guidelines were published and they became known as the “Back to Sleep” campaign. After this, a noticeable decline occurred in infant deaths from SIDS. However, this number seems to have plateaued with no continuing significant improvements in infant deaths. Objectives: The objective of this review was to determine whether nurses provide a safe sleep environment for infants in the hospital setting. Research studies that dealt with nursing behaviors and nursing knowledge in the hospital setting were included in the review. Data Sources: A search was conducted of Google Scholar, CINAHL, PubMed, and Cochrane, using the key words “NICU,” “newborn,” “SIDS,” “safe sleep environment,” “nurse,” “education,” “supine sleep,” “prone sleep,” “safe sleep,” “special care nursery,” “hospital policy for safe sleep,” “research,” “premature,” “knowledge,” “practice,” “health care professionals,” and “parents.” Study Eligibility Criteria: The review included research reports on nursing knowledge and behaviors as well as parental knowledge obtained through education and role modeling of nursing staff. Only research studies were included to ensure that our analysis was based on rigorous research-based findings. Several international studies were included because they mirrored findings noted in the United States. All studies were published between 1999 and 2012. Participants: Healthcare professionals and parents were included in the studies. They were primarily self-report surveys, designed to determine what nurses, other healthcare professionals, and parents knew or had been taught about SIDS. Synthesis Method: Integrative review. Results: Thirteen of the 16 studies included in the review found that some nurses and some mothers continued to use nonsupine positioning. Four of the 16 studies discussed nursing knowledge and noncompliance with AAP safe sleep recommendations. Eleven of the 16 studies found that some nurses were recommending incorrect sleep positions to mothers. Five of the 16 studies noted that some nurses and mothers gave fear of aspiration as the reason they chose to use a nonsupine sleep position. Limitations: In the majority of the studies, the information was self-reported, which could impact the validity of the findings. Also, the studies used convenience sampling, which makes study findings difficult to generalize. Conclusions and Implications: The research indicates that there has been a plateau in safe sleeping practices in the hospital setting. Some infants continue to be placed in positions that increase the risk for SIDS. The research also shows that some nurses are not following the 2011 AAP recommendations for a safe sleep environment. Clearly, nurses need additional education on SIDS prevention and the safe sleep environment, and additional measures need to be adopted to ensure that all nurses and all families understand the research supporting the AAP recommendation that supine sleep is best. Further work is needed to promote evidence-based practice among healthcare professionals and families. Key Words: education, health care professionals, hospital policy for safe sleep, knowledge, newborn, NICU, nurse, parents, practice, premature, prone sleep, research, safe sleep, safe sleep environment, SIDS, special care nursery, supine sleep

udden infant death syndrome (SIDS) was first defined in 1969 by Dr Abraham Bergman as unexplained infant death.1 The Centers for Disease Control (CDC) defines SIDS as “the sudden

S

death of an infant under 1 year of age that cannot be explained after a thorough investigation is conducted, including a complete autopsy, examination of the death scene, and review of the clinical history.”2 SIDS

Author Affiliations: Catawba Valley Medical Center, Hickory, North Carolina (Mss Patton, Stiltner, and Wright); and University of North Carolina Greensboro Greensboro (Dr Kautz).

The authors declare no conflict of interest. Correspondence: Donald D. Kautz, RN, PhD, CRRN, CNE, ACNS-BC, Associate Professor of Nursing, UNC Greensboro, PO Box 26170, Greensboro, NC 27402 ([email protected]). Copyright © 2015 by the National Association of Neonatal Nurses

The authors gratefully acknowledge the vision, inspiration, and editorial assistance of Ms Elizabeth Tornquist, MA, FAAN, and the wonderful assistance of Mrs Dawn Wyrick with this article.

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DOI: 10.1097/ANC.0000000000000145

Advances in Neonatal Care • Vol. 15, No. 1 • pp. 8–22 Copyright © 2015 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.

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Safe Sleep Environment

typically occurs before the infant is 6 months of age, with the greatest risk occurring between 4 and 6 months. An estimated 4000 infants die annually from sudden unexplained infant death. Sudden unexplained infant death is “a death in infants less than one year of age that occur suddenly and unexpectedly and are not immediately obvious prior to investigation” with SIDS causing at least half of these deaths.2 According to the CDC, in 2010 there were more than 2000 reported cases of SIDS.2 In 1974, the US Congress passed the SIDS Act, recognizing SIDS as a significant public health issue.1 In 1994, the national “Back to Sleep” campaign was initiated by the American Academy of Pediatrics (AAP) to promote public education on positioning babies supine for safe sleep.3 In 2005 and in November 2011, the AAP again recommended positioning babies supine for sleep and expanded the recommendation to improving the safety of the entire sleep environment of babies. The program was renamed “The Safe to Sleep Campaign.”4 (Please refer to www.nichd.nih.gov/sts/campaign/ moments/Pages/default.aspx for important moments in the history of safe sleep.) From 1983 to 1989, the CDC reported that in the United States the death rate from SIDS was 141 per 100,000 live-born infants.5 In 1994, after the initial AAP recommendations, SIDS declined from being the second leading cause of infant mortality to being third, with a rate of 103 deaths per 100,000 liveborn infants.5 However, the SIDS rate in the United States has remained relatively stable since 1998, at a rate of 52 deaths per 100,000 live-born infants.6 In 2010, there were almost 4 million births in the United States, approximately 12% of infants were born prematurely, and approximately 8% of these infants were born with a low birth weight.7 Infants who are born prematurely are at greater risk of dying from SIDS.7 It is imperative to establish a safe sleep environment in the hospital setting and in the home to reduce sleep-related deaths. The 2011 AAP “safe sleep environment” includes supine sleep on a mattress with fitted sheets, breastfeeding, no bed sharing (although room sharing with parents is encouraged), no soft objects in the crib, no loose bedding, use of a pacifier during sleep (immediately for bottle-fed babies, and after 4 weeks for breastfeeding babies), appropriate immunizations for the infant, and prevention of overheating. The infant should not be placed in devices such as swings or seats to sleep while at home or in the hospital. Furthermore, the infant should not be placed in any commercially available devices, including specialized mattresses, wedging devices, or positioning aids.8 The AAP also recommends that healthcare professionals who work with women, infants, and children act as role models and implement all the recom-

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mendations of the AAP8 as soon as an infant is stabilized. All healthcare professionals, especially nurses, should therefore receive appropriate education and training on a safe sleep environment, so they can serve as good role models. Nurseries and pediatric units should also have written policies to help nursing staff practice consistent evidence-based care and provide parents with accurate information on a safe sleep environment. However, nurses may be unaware of the recommendations set forth by the AAP, and nursing staff on neonatal intensive care units (NICUs) may disagree with and at times refuse to implement a safe sleep environment.9 Parents often feel the same way. They want to position their infants prone and seek tacit approval from nurses for not following the AAP recommendations. Parents are more apt to do what they see on a daily basis than what is told to them during a hurried discharge instruction session. When nursing staff are not supportive of the supine sleep campaign, parents copy the inappropriate behaviors practiced by professionals. This review of the research from 1999 to 2013 was conducted to determine whether nurses are providing a safe sleep environment for hospitalized term and preterm infants, as demonstrated by their knowledge and behaviors in the clinical setting. We included studies in the review that were conducted before and after the “Back to Sleep” AAP recommendations to determine whether the educational campaigns contributed to changes in nursing knowledge and behaviors.

METHODS The databases Google Scholar, CINAHL, PubMed, and Cochrane were searched for the years from 1999 to 2013 using the key words NICU, newborn, SIDS, safe sleep, safe sleep environment, nurse, education, supine sleep, prone sleep, special care nursery, hospital policy for safe sleep, research, premature, knowledge, practice, healthcare professionals, and parents. To be included in the review (Table 1), studies had to be primary research reports on nursing knowledge and nursing behavior in practice, or on parental knowledge obtained through education and role modeling of nursing staff. Quality improvement project reports, research focused on medical complications related to sleep positions, and studies on risk factors for SIDS were excluded (Table 2 for inclusion and exclusion criteria). International studies were included because they mirrored findings found in the United States; it is important to note that the 3 most recent studies, published in 2011 and 2012, were all conducted in foreign countries. Only studies published in English were included in the review. Careful review of the 47 studies, initially located in the

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Patton et al

TABLE 1. Studies Reviewed in Relation to Campaigns/Updatesa

tent only” file.) The 16 studies included term infants in various settings as well as preterm infants in the NICU. Sample sizes ranged from 94 to 5911 nurses and/or other healthcare workers. Samples of parents ranged from 100 to 671. In each of the studies, healthcare professionals and/or parents completed questionnaires or were interviewed about SIDS risk factors. Of the 16 studies, 12 used questionnaires or surveys10,13,14-18,20-22,24,25 to determine healthcare professionals’ knowledge of safe sleep positioning and SIDS. Four of the studies11,12,19,23 used personal or telephone interviews with parents of infants and/or healthcare professionals to assess knowledge or behaviors regarding safe sleep.

1994

“Back to Sleep” campaign

1999

Peeke

US

2001

Colson

US

2001

Delzell

US

2001

Hein

US

2002

Moon

US

2004

Bullock

US

2004

Stastny

US

2005

AAP—“Back to Sleep” update

2007

Rao

UK

2006

Aris

US

RESULTS

2006

Colson

US

2007

Burd

US

2010

Dattani

UK

2010

Grazel

US

2011

AAP—“Safe Infant Sleep Environment” campaign

In comparing the results of the studies, we focused on publication of the studies in relation to the campaigns and updates (Table 1), reviewing older studies first and then more recent studies. Of the 16 studies, 12 were conducted in the United States, 1 in the United Kingdom, 2 in Turkey, and 1 in Italy.

2011

Yikikan

Turkey

2012

Efe

Turkey

2012

Luca

Italy

Abbreviation: AAP, American Academy of Pediatrics. aThis table illustrates when the studies included in this review were published in relation to the sleep campaigns/updates. International studies were included in this review to compare the United States with other countries. Note that we found no studies conducted in the United States since the 2011 “Safe Infant Sleep Environment” campaign.

search, indicated that only 16 met the inclusion criteria for the review10-25 (Figure). The 16 studies focused on various aspects of the AAP safe infant sleep recommendations for reducing SIDS and examined hospital staff's and/or parents’ knowledge of SIDS and practice of AAP infant sleep recommendations. (A matrix developed to assist in analyzing these studies is included as Table 3 as a “digital con-

Use of Nonsupine Positioning Although supine is the position recommended by the AAP, 13 of the studies16-19,22-24 found that some nurses and some mothers continued to use nonsupine positioning. Their rationales included a lack of confidence in AAP recommendations, infant comfort, fear of aspiration, and advice from family members.10-19,22-24 These 13 studies were published from 1999 to 2012 and thus spanned the 2005 update and 2011 campaigns, and they were conducted in the United States and abroad. Nursing Knowledge and Compliance With Safe Sleep Recommendations Four of the 16 studies10,12,15,16 discussed nursing knowledge and compliance with the AAP safe sleep recommendations. Peeke and colleagues10 (published in 1999), who studied 103 maternal child nurses and 206 infants in 2 institutions, found that although

TABLE 2. Inclusion/Exclusion Criteria for Studies to Be Included in This Review Inclusion Criteria (Primary Research Reports)

Exclusion Criteria

Nursing knowledge

Non-English research reports

Nursing behavior in practice

Quality improvement reports

Parental knowledge obtained through education

Research focused on medical complications related to sleep positions

Role modeling of nursing staff

Research on risk factors for SIDS

Studies conducted in the United States or foreign countries Abbreviation: SIDS, sudden infant death syndrome.

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FIGURE

Flowchart of study selection.

97% of nurses were aware of the AAP recommendations, only 67% agreed with these recommendations. Only 29% of nurses positioned infants supine for sleep. Thus, 4 years after the “Back to Sleep” campaign, nurses were still reluctant to adopt the AAP recommendations and make practice changes. Delzell and colleagues12 assessed nursing practice and nursing policy in relation to infant sleeping positions in 1992 and 1999. Their 1992 survey found that 92% of nurses were aware of the AAP recommendations; however, 58% disagreed. Seven years after the original AAP recommendations, the 1999 study found that 100% of nurses were aware of the AAP recommendations but 25% continued to disagree. Five years later, Bullock et al15 (published in 2004) surveyed 528 maternal child nurses in 58 Missouri hospitals. They found that although 96% of the nurses surveyed were aware of the AAP recommendations, 45% believed that the infant would be at greater risk for aspiration in the supine position. Stastny et al16 (also published in 2004) surveyed 96 staff members, including licensed vocational nurses, registered nurses, bachelor's of science in nursing recipients, master's of science in nursing recipients, and certified nursing assistants, as well as

579 mothers of newborns from 8 hospitals in California. They found that only 72% of the healthcare professionals surveyed correctly identified the supine position as the position to lower SIDS risk.

Fear of Aspiration In 5 of the 16 studies,13-16,19 some nurses and some mothers noted fear of aspiration as the reason they chose to use a nonsupine position for sleep. In the study by Hein and Pettit13 (published in 2001), which included 94 charge nurses who cared for term infants in various obstetric departments, the investigators discovered that 51.4% of nurses believed that the side-lying position would prevent aspiration. In 2004, 12 years after the “Back to Sleep” campaign was initiated, Bullock et al15 found that 45% of nurses were under the false assumption that infants would be at risk for aspiration if placed in the supine position. Another study in 2004, by Stastny et al,16 found that 91% of the nurses surveyed avoided the supine position because of fear of infant aspiration. The “Back to Sleep” update was launched in 2005, yet Colson et al,19 who published their study in 2006, after the campaign, found that 50% of mothers believed that their infant would choke if placed supine.


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To determine changes in newborn nursery policies and practices regarding infant sleeping positions between 1992 and 1999

Delzell et al,12 US

To determine why nurses continue to use and endorse the side-lying position rather than supine sleep

To examine the association between the perceptions of innercity parents regarding teaching and modeling by hospital staff of infant sleep positioning during the postpartum period, and their choice of sleeping position for their infants after discharge

Colson et al,11 US

Hein and Pettit,13 US

To examine whether maternal/ N = 103 maternal child nurses child nurses accept the AAP in 2 institutions recommendations on sleep n = 206 infants observed for position and to observe pracsleep position in 2 institutice regarding positioning and tions bedding Descriptive survey and observational assessment of nursing practice

Peeke et al,10 US

Why nurses positioned on side to sleep?

Nursing knowledge and Practice

1999—100% nurses aware of AAP, 0% use prone, 0% advise prone, 75% say position used is position taught to parents, 25% disagree with AAP

1999—92% of nurses know AAP recommendations, 32% prone or side, 58% disagree with AAP, 68% say position used is position taught to parents

Nursing knowledge and practice

Position observed in nursery: 37% supine, 50% side, and 10% side/supine; parents who were educated and observed supine chose supine at home

Parents perception of position education received: 55% supine, 17% side, and 23% side/ supine

Position reported by parents 2 wks of age: 42% supine, 43% side, and 26% prone some of the time

97% nurses knew AAP recommendations, only 67% agreed; only 29% infants in supine position for sleep, 55% side-lying, 16% prone


51.4%—prevent aspiration Survey with open-ended ques- 34.2%—federal brochure states it is a safe tions and circle all that alternative apply

N = 94 charge nurses in obstetric departments who care for term infants

10-item telephone survey on nursing

N = 75 newborn nurseries (1999) completed by charge nurses

N = 79 newborn nurseries (1992) completed by charge nurses

Face-to-face interviews in English and Spanish

n = 100 parents (50%) were African American

Purpose

Design/Setting, Participants, Characteristics/Demographics, Measurement Results

Author, Country

TABLE 3. Characteristics of Included Studies

(continues)

Impacts nursing knowledge and practice

Impacts nursing knowledge and nursing practice

Impacts nursing practice and parental knowledge/ practice

Impacts nursing knowledge and nursing practice

Implications for Practice

12 Patton et al

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Purpose

To determine the prevalence and determinants of prone sleeping among infants in the District of Columbia, and to ascertain what information is being provided to parents by healthcare professionals

To examine nurses’ knowledge, attitude, practice, and in positioning healthy newborns for sleep in the hospital setting

To assess newborn placement practices of the mother and nursery staff and their interrelationship in the hospital setting in 8 Orange County, California, hospitals

Author, Country

Moon and Omron,14 US

Bullock et al,15 US

Stastny et al,16 US

80% stated the hospital policy approved sidelying as an acceptable position

Only 53% knew hospital policy for sleep position

75% of nurses used side-lying or mixture of side and back position (6% were aware of AAP recommendations); 45% worry about aspiration


Reasons compared were SIDS prevention, concern about vomiting, sleeps better, advice, and other

Study compared reasons parents put infants supine, side, or other for sleep

Parents’ placement, position of infants the night before survey: 34.1 % supine, 50.8% side, and 15.1% prone

Results

Mothers: 36% reported use of supine infant placement choice varied by advice and placement modeling by staff; highest proportion of supine infant placement was when both were received

34% reported advising exclusive supine position to mothers

Nursing knowledge and practice N = 96 newborn staff (LVN, RN, BSN, MSN, and CNA) Staff: from 8 hospitals in California 72% supine position as the placement that lown = 579 mothers of newborns ers SIDS risk from 8 hospitals in California 30% reported most often use supine position Anonymous 1-page question91% cited fear of aspiration the reason to avoid naire supine

A 24-item questionnaire using the attitude, knowledge, and practice instrument developed by the authors

N = 528 maternal child nurses in 58 Missouri hospitals

60-question survey regarding infant care practices, information received from healthcare professionals and demographic information

Large percentages were African American

n = 126 parent–infant pairs

Design/Setting, Participants, Characteristics/Demographics, Measurement

TABLE 3. Characteristics of Included Studies, Continued

(continues)



Impacts nursing knowledge and parental knowledge and practice


Safe Sleep Environment 13

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To repeat survey 5 yrs after pre- N = 182 NICU units (current vious study to determine neostudy) natal practitioners’ current N = 181 (2001-2002 study recommendations regarding survey) the sleeping position for prematurely born infants ready to be discharged from neonatal units, and whether these had changed from those recorded in the prior study

To explore and describe NICU nurses’ knowledge and practice in the NICU and to determine the content of parent instruction that healthcare workers know about SIDS regarding infant sleep position at discharge

Rao et al, UK

Aris et al,18 US N = 252, phase I, testing the instrument N = 157 neonatal nurses in the level II and level III nurseries Phase II, final phase N = 95 nurses in level II and level III NICUs Convenience sample A 10-item questionnaire Phase I (fill in the blank, yes/ no answers, mark all that apply) Phase II 18-item questionnaire (yes/no answers, circle all that apply, fill in the blank)

Purpose

17

Author, Country




(continues)

Nursing knowledge and practice current findings: Impacts nursing knowledge and nursing Phase I and II combined analysis: practice Best sleep position Preterm infant Neonatal nurses’ choice of best sleep position— 65% prone, 12% prone or side-lying NICU 35% all positions 22% prone Term infant—NICU 40% supine 30% side or supine Discharge teaching: 52% advised parents to exclusively place infants supine, 38% reported teaching parents that either side-lying or supine positioning was suitable 51% recommended supine position only after hospital discharge

Impacts nursing knowlNursing practice current findings: edge and practice 83% recommended supine sleeping position, 1-2 wks before discharge Nonsupine sleeping recommended longer for: Chronic oxygen dependency 23% Recommended for conditions including upper airway problems or reflux 62% After discharge: Active discouragement of prone sleeping 39% Recommended side sleeping 17% Written policy for staff 33%, for parents 90% 2001-2002 findings Recommended supine sleeping position, recommended 1-2 wks before discharge 43% Nonsupine sleeping recommended longer for: Chronic oxygen dependency 22% Recommended for conditions including upper airway problems/reflux 40% After discharge: Active discouragement of prone sleeping 58% Recommended side sleeping 29% Written policy for staff 23%, for parents 70%

Results

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To quantify the degree to which specific barriers such as advice, infant comfort, safety, and knowledge about reducing the risk of SIDS were associated with the choice of infant sleeping positions in a larger group of primarily black, low-income mothers

To determine whether educaN = 341 parents tion by nurses to parents Hospital setting 252 whites increased parents’ knowledge Home 89 Native Americans of SIDS risk factors Pre and posttest

To determine whether a national N = 195 NICUs campaign “Time to Get Back 2006—the first survey to Sleep” influenced recom2008—the second survey mendations made by NICUs regarding sleep position for premature born babies before and after discharge

Colson et al,19 US

Burd et al,20 US

Dattani et al,21 UK

Next interviews were conducted with the participants

Focus group done initially to identify any barriers to back to sleep recommendations

n = 671 mothers from 4 WIC program centers

Purpose

Author, Country



A greater number of NICUs provided written information to parents on sleep positioning

No significant difference in the number of NICUs that recommend supine sleeping at least 1-2 wks before discharge

Nursing knowledge

The study did not address if these changes resulted in behavior changes

Nursing education Examined changes in knowledge but did not assess whether these changes in behaviors on positioning, environment of newborns, etc

43% believe sleep positions are related to SIDS

29% infants sleep with adult will prevent SIDS

50% choking if supine

Safety/knowledge:

36% believe prone position more comfortable

Comfort:

60% mothers reported trust in doctors/nurses

60% saw infants supine in hospital

42% told by nurses to place infants supine

58% of nurses advised supine position

72% given advice from nurses

Advice:

59% use supine position for sleep

Mothers:

Results

(continues)

Impacts if new nursing knowledge affected nursing practice

Examined changes in knowledge of parents but did not assess changes in behaviors; nursing implications for parents

Impact seen on nursing knowledge





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Purpose

To examine and describe NICU nurses’ knowledge of SIDS risk-reduction measures, modeling of safe infant sleep interventions before discharge, and inclusion of SIDS risk reduction in parent education

To determine knowledge/attitudes of parents and healthcare providers of the risk factors for SIDS

Author, Country

Grazel et al,22 US

Yikilkan et al,23 Turkey

Descriptive, cross-sectional study

A 10-item questionnaire

n = 150 mother telephone interviews (ages 17-42 yrs)

N = 174 healthcare professionals including midwives, nurses, and doctors

Prospective survey design

A 14-item questionnaire (select all that apply, mark the frequency)

Convenience sample

N = 430 (NICU nurses in both level II and level III nurseries)



Nursing knowledge mother: 39% aware of SIDS 62% of these were aware by media 82% stated had never been advised on sleeping position by health care providers. Health care professionals: 73% chose side, 17% chose supine, 10% chose prone, 72% of reported they recommended a sleep position; of this 72%, 78% recommend side, 7% recommend prone, 15% supine

Nursing knowledge and education 85% recognize risk-reduction strategies When do you place infants supine for sleep? 50% when the infant is open crib Actual position used for infants ready for discharge: Preterm: 57% supine only Term: 67% supine Do NICU nurses model safe sleep strategies in the hospital? 45.5% use positioning aids in the crib for term infants; 10% place stuffed toys in the crib of term infants; 60% cover the head of the crib Are NICU nurses educating parents about SIDS? Nurses always delivered SIDS education: 48% overheating, 53% smoking, 84% tummy time, 60% sleep area, 57% bedding

Results

(continues)

Assessed parental knowledge of SIDS risk factors


Impacts nursing knowledge, practice, and parental knowledge


16 Patton et al



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To determine nurses’ and pedia- N = 904 nurses tricians’ knowledge regarding N = 252 pediatricians safe sleep position and safe Single 15-question survey sleep environment (5 questions on demographics, 10 questions on knowledge of a safe sleep environment and positioning of infants)

To determine healthcare providers’ knowledge about SIDS

Efe et al,24 Turkey

Luca and Boccuzzo,25 Italy

Nursing knowledge Pediatricians are best trained, then obstetricians; next are nurses who work with newborns; healthcare workers’ role is “crucial” as they are the link between evidence-based practice and parental education on SIDS prevention It is extremely essential to provide proper training for healthcare workers who provide direct care to infants; these are the individuals who are educating parents on infant care

Pediatricians: 46.4% recommend side during the day, 44% side at night, 70.6% side after feeds

Nurses: 63.6% nurses recommend side during the day, 74.1% side at night, 82.2% side after feeds

Nursing knowledge

Results




Abbreviations: AAP, American Academy of Pediatrics; BSN, bachelor's of science in nursing; CNA, certified nursing assistant; LVN, licensed vocational nurse; MSN, master's of science in nursing; N, number of health care professionals or sites; n, other study participants; NICU, neonatal intensive care unit; RN, registered nurse; SIDS, sudden infant death syndrome; WIC, women infants and children.

N = 5911 questionnaires completed by healthcare professionals (pediatrician, obstetrician, nurse, healthcare assistant, and physician) from 11 regions in Italy

Purpose

Author, Country






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Nurses’ Recommendations—Incorrect Sleep Positioning In 12 of the 16 studies,10-13,15-18,22-25 some nurses were recommending incorrect sleep positions to mothers. The publication dates of these studies ranged from 1999 to 2012. Of these 12 studies, 8 were conducted in the United States, and 4 in foreign countries. The studies did not show any consistent pattern over time. In Delzell et al's12 survey in 1992, 32% of newborn nurseries were positioning infants prone or side-lying. Colson et al11 (published in 2001) found that parental perceptions of the education received during infant hospitalization varied: 55% of parents said they were told to place infants in the supine position for sleep, 8% in a side-lying position, and 23% in either position. Parental observations also revealed inconsistencies in practice by healthcare professionals: 50% used the side-lying position, 37% the supine position, and 10% a combination of positions. Yet, a prior study published in 1999 by Peeke and colleagues10 found no prone positioning being used in the newborn nursery, though 35% of nurses disagreed with the recommendation of the supine position. Clearly, these studies show that some nurses continue to be hesitant to fully adopt the recommendations, and the number of nurses complying with the recommendations varies from 1 year to another, and in both the United States and other countries. Effects of Nursing Practice on Parental Behaviors Nursing practice affects parental behaviors, as evidenced by a study conducted by Stastny et al16 (published in 2004), which found that only 36% of mothers used the supine sleeping position on the basis of healthcare professional role modeling and recommendations. The study by Colson et al19 (published in 2006) found that 59% of mothers were positioning infants supine; 60% of these mothers had observed supine placement of their infants while hospitalized. These studies suggest that nurses modeling and recommending correct sleeping position can be important for the appropriate parent positioning choice. Deficits in Nursing Knowledge About Safe Sleep Recommendations Eleven of the studies10,12,14-17,19,22-25 reported a deficit in nurses’ knowledge of the AAP recommendations on a safe sleep environment. The authors of 2 of the 11 studies18,23 concluded that some nurses lacked knowledge of both appropriate safe sleep positions and general risk factors for SIDS. Seven of the 11 studies10,15,16,18,22-24 concluded that some nurses need education on topics such as SIDS prevention, appropriate positioning, policies, and AAP recommendations. For example, the study by Delzell et al12 (pub-

lished in 2001) noted that educational interventions should focus on nurses’ predisposition to place infants in nonsupine sleeping positions, because appropriate positioning is essential for promoting safe sleep. According to Moon and Omron14 (published in 2002), nurses also need to be educated on culturally specific barriers to supine positioning to meet the needs of all parents. They need to be taught in culturally appropriate ways,16 noted Stastney et al (published 2004). Rao et al17 included 182 NICUs in a 2007 study and compared these with 181 NICUs in a 2001 to 2002 study; they concluded that evidencebased guidelines need to be used to educate nurses about the AAP safe sleep recommendations. On the basis of findings published in 2010, Grazel et al22 suggested that if nurses received proper education, the number of deaths from SIDS would decrease.

Inconsistencies in Nursing Practice in Implementing Safe Sleep Ten of the 16 studies10,12,13,15-18,22-24 revealed that many nurses are aware of the AAP recommendations; however, their practice does not always reflect this knowledge. For example, Peeke et al10 (published in 1999) found that 97% of nurses knew AAP recommendations but only 67% of the nurses agreed with them, and only 29% of the infants in their study were positioned supine by nursing staff for sleep. Nurses in the hospital setting did not use the supine sleeping position solely for either term or preterm infants. Peeke et al10 observed that most of the nurses were using the side-lying position. Three of these 10 studies,10,23,24 one conducted in the United States and published in 1999, the other 2 conducted in foreign countries and published in 2012, noted that other sleeping positions nurses commonly used in place of the supine position, which include prone, lateral, side-lying, or a combination of sleeping positions. In another example, Aris et al18 (published in 2006) discovered that 95% of nurses working in the hospital setting used various sleeping positions for infants that did not include supine. Various rationales for using a nonsupine sleeping position were discovered; this included fear of aspiration,15 a general disagreement with the AAP recommendations,10 and a concern about the supine position on the part of some nursing staff.12 However, as early as 2001, Hein and Petit13 concluded that the rationale nurses provided for using the side-lying position could not justify its continued use. Parental Education Provided by Nurses Of the 16 studies included in the review, 5 studies11,12,14,19,20 looked at whether education of parents by nurses increased parental knowledge of SIDS risk factors. Colson and colleagues11 (published 2001) examined the associations between 100 inner city parents’ perceptions of teaching and modeling of www.advancesinneonatalcare.org


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infant sleep position during the postpartum period and their choice of sleeping position for their infant. The authors found that although parents were educated on supine positioning for infant sleep, reported observing the infant supine while in the nursery, only 37% of parents chose other positions. Moon et al14 (published 2002) reported on the information parents received from healthcare professionals before discharge. Another study by Colson and colleagues19 (published in 2006) examined the barriers to safe sleep positioning of 671 mothers from 4 Women Infants and Children programs. These barriers included advice by others, infant comfort, safety, and lack of knowledge of SIDS riskreducing factors, and they were associated with parents’ choice of infant sleeping positions. Burd and colleagues20 (published in 2007) surveyed 430 NICU nurses in level I and level II nurseries to determine whether education by nurses to parents increased parents’ knowledge of SIDS risk factors. The study did not examine whether the changes in education resulted in changes in behaviors. These studies suggest that some nurses are not properly educating parents about supine sleep or the risk factors for SIDS. In 2006, Aris et al18 discovered that only half of the nurses were providing discharge teaching on supine sleep. In a study published in 2007, 2 years after the 2005 “Back to Sleep” update, Rao et al17 found that prone positions were actually encouraged if the infant had respiratory complications. Also, 4 studies12,13,17,22 found inconsistencies between when nurses practiced and what they taught to parents. These inconsistencies may confuse parents and affect parental decisions on the appropriate sleeping position. Eighteen years after the AAP instituted the “Back to Sleep” campaign, a quality improvement study by Gelfer et al27 (published in 2013) in a large tertiary NICU found during random crib audits that only 39% of infants were positioned supine, only 5% had a firm sleep surface, and only 45% had no soft objects in the crib. They noted that “medical personnel are critical role models for parents, and the way they position infants in the hospital strongly influences parental practices at home27” (p. e1265). Clearly, regardless of the various safe sleep positioning campaigns, further work is needed to ensure all nursing staff consistently use safe sleep practices for babies and their families. The frequent observations that some nurses do not model the correct positioning of babies may contribute to poor parental education on a safe sleep environment.

LIMITATIONS There were limitations in all 16 studies reviewed (Table 1). For instance, 11 of the 16 studies10-20 were

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completed before 2010, and thus some of the information is older though still pertinent. The studies all used convenience samples who completed surveys, questionnaires, face-to-face interviews, or telephone interviews. According to Aris et al18, convenience sampling makes it hard to generalize the findings. Finally, a major limitation of the studies was the selfreporting of information, by a charge or head nurse, parents, or nursing staff. Self-reporting may not have reflected true practice; it is interesting, however, that healthcare professionals self-reported the use of sidelying and prone positioning of infants. Parents might have reported what they thought the interviewer wanted to hear rather than what was actually being done at home. Also, if a family prefers a specific infant sleeping position, they may report this as being taught to them even though it may not have been. Despite these limitations, this review shows that a lack of knowledge and compliance with safe sleep recommendations seems to be a universal problem.

DISCUSSION The decisions nurses make in regard to safe sleep practices can influence parental behavior at home. In the studies reviewed here (Table 3), some mothers were not even aware of SIDS22 and the risk factors associated with it.20 When nurses lack knowledge and their practice is inconsistent, parents may find themselves confused about what is considered best practice. If parents observe inconsistencies between practice and teaching, then they are going to use the positions they actually observe the nurses perform. The authors of this review have seen side-lying sleeping positions and prone sleeping positions, cribs with big fluffy blankets, toys placed in the crib by parents, and cribs being covered with a blanket in the NICU. Parents of these tiny patients could easily be confused between actual nursing practice and the education provided at the time of discharge. Stressing the importance of supine sleep needs to start in the hospital setting and be demonstrated by evidence-based nursing practice. Nonsupine positioning, if medically indicated, should be explained and justified to the parents by the infant's healthcare providers.

Nursing Implications In 11 of the 16 studies reviewed here,10-13,15-17,21-25 many nurses in the United States, the United Kingdom, Turkey, and Italy understood safe sleep recommendations, but they did not practice them. This leads to ineffective parental education and places infants at greater risk for SIDS. Disregard of the AAP recommendations does not seem malicious. Improper positioning is because of inadequate education on the physiological effects of positioning and fear that the infant will aspirate during sleep. Education on SIDS and a safe sleep


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environment for newborns should be mandated to improve nurses’ knowledge and behaviors and decrease inaccurate parental education regarding SIDS and safe sleep. The “Family Teaching Toolbox: The Parent's Guide to a Safe Sleep Environment,”26 by Ibarra and Goodstein, was published by the National Association of Neonatal Nurses in Advances in Neonatal Care in 2011 as a reproducible tool for educating families of high-risk infants. This handout includes the top 10 ways to promote a safe sleep environment and decrease the risk of SIDS. The tool includes the following points: (a) place the baby supine for sleep, (b) use firm mattress, no loose sheets, (c) no soft bedding, pillows, toys, and so on, (d) have a separate but close sleep environment and breastfeed your baby, (e) never smoke around baby, (f) use a pacifier for sleep (if breastfeeding, use after the first month), (g) do not overheat the baby, (h) use no products that claim to reduce SIDS, (i) home monitors do not reduce SIDS, and (j) provide “Tummy Time” with supervision only.26 The guide was developed for parents, but it is also an excellent tool for nurses. Educating nurses will make better role models for parents as nurses practice safe sleep positioning of infants during hospitalization. Many conditions must be taken into consideration when discussing the proper positioning of preterm infants. They may require promotion of neurodevelopment and maintenance of physiological stability by placement in various sleeping positions. This causes the nursing staff and therapists working in the NICU to struggle with providing the AAP “safe sleep environment.” Use of positioning aids in the NICU helps facilitate developmental care; therefore, it is crucial that staff communicate with parents

about the purpose of these positioning aids and the need at some point during the infant's hospitalization to transition “back to sleep.” According to the AAP,8 all infants in the NICU should be placed in the supine sleep position when the infants are medically stable and nearing discharge from the NICU. The question is, when is the appropriate time to transition infants born at an early gestation or medically unstable at birth to a supine sleep position and still maintain adequate developmental care? Quality improvement programs have been implemented to aid in the establishment of an environment that encourages safe sleep for infants in the hospital setting. The results of 2 quality improvement projects published in 2013 can assist both the newborn nursery and the NICU with SIDS prevention techniques and strategies. The University of Texas Medical School and the NICU and Quality Improvement/Leadership Academy of Memorial Hermann Hospital in Houston, Texas, developed a safe sleep protocol to address the increased risk of SIDS of premature and low-birth-weight infants, who have a higher rate of SIDS than term infants.27 The first step in the development of the quality model was development of a policy on safe sleep education of the staff on the policy. The NICU nurses were then required to complete an SIDS Risk Reduction Program developed by the National Institute of Child Health and Human Development. Meetings were held with staff members after they completed the program, during which they were encouraged to voice their fears or concerns; this allowed open discussion and further education. Afterward, all NICU nurses were required to have a safe sleep role-modeling skills assessment. A crib card was developed using AAP recommendations

Summary of Recommendations for Practice and Research What we know

• Many cases of sudden infant death syndrome (SIDS) are preventable through consistent provision of safe sleep practices • Through 3 national campaigns, the American Academy of Pediatrics (AAP) has made a significant impact on the occurrence of SIDS, but that impact has plateaued • Nurse awareness of these campaigns and their implementation of routine practices and interventions to support safe sleep appears to be lacking

What needs to be studied

• Best methods for providing information and supporting nurses in implementing safe sleep practices in the neonatal intensive care unit (NICU) • Exploration of strategies for changing nursing attitudes and beliefs about provision of safe sleep strategies • Exploration of safe sleep strategies to best support families during the transition to home after neonatal intensive care

What we can do today

• Continue to educate and support nurses in the provision of safe sleep in the NICU environment • Examine NICU policies and ensure they are congruent with recommended safe sleep practices • Explore strategies to ensure parents receive consistent information about safe sleep from all healthcare providers www.advancesinneonatalcare.org


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and placed in all open cribs as a reminder to staff and parents of safe sleep positioning. Parents were given the opportunity to watch an SIDS prevention DVD developed by the First Candle Foundation, and then given a verbal review and written instructions regarding safe sleep at the time of discharge. Finally, a postdischarge telephone call was made to parents a few days after discharge, and sleep positioning was again discussed. During this project, the rate of supine positioning increased from 39% to 83%.27 Another SIDS Prevention Model28 developed at Saint Joseph's Hospital Health Center in Syracuse, New York, began with development of an organizational policy on the basis of AAP safe sleep recommendations. The neonate nurse practitioners then developed a 60-minute educational program and required all neonatal intensive care nurses to complete it. The education included the AAP recommendations from 2011 on SIDS risk reduction in the NICU, which encourage nurses to position the infant in the supine position before the infant is discharged to model correct behavior for parents. A laminated crib card called “Steps to Home” was designed for family members. This card includes 5 steps: (a) supine for sleep, (b) do not bundle the baby, (c) have tummy time with supervision only, (d) teach all care givers back to sleep only, and (e) homes should be tobacco free. A discharge instruction sheet was developed, and the NICU nurses reviewed the handout with parents before discharge. The NICU also invested in “Sleep Sacks”: long gowns, sewn shut at the bottom with open sleeves so the infant's arms are exposed, which eliminate the need for loose blankets in the bed and reduce the risk of overheating from swaddling. After 6 months of the quality improvement program, 98% of NICU infants were sleeping supine in open cribs, 93% were in sleep sacks, and 88% had visible crib cards in the open cribs.28 Clearly, some nurses still do not “believe” or understand that positioning infants on their side or prone puts the infants at risk for SIDS, despite the educational campaigns and updates by the AAP in 1994, 2005, and 2011. How can we help nurses believe that it does? How can we best help nurses break out of the pattern of positioning infants on the side or prone? What is the best way for one nurse to approach another when that nurse is not following the AAP guidelines? Why do some hospitals not have a “safe sleep policy?” Clearly, more research is needed to understand these issues. We also need research with families. How can we best overcome resistance from grandmothers and others who believe infants need to lie prone and also need toys, blankets, and pillows in the bed? Should all cribs be required to have the sign, “Bare is best,” with warnings about SIDS? Colson and colleagues have been conducting studies of infant sleep positioning for many years. At a conference in May 2014,29 their survey of 1030

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mothers enrolled in the “Study of Attitudes and Factors Affecting Infant Care” from January 2011 to February 2013 found that approximately 70% reported “usual supine sleeping.” These findings are consistent with findings from Colson and colleagues’ “National Infant Sleep Position Study” conducted from 1993 to 201030 that some infants continue to be placed at risk for SIDS because some parents are not following the AAP recommendations. These studies provide support for why the SIDS rate in the United States has remained relatively stable since 1998, at a rate of 52 deaths per 100 000 live-born infants,6 despite the 2005 and 2011 campaigns. Our integrative review clearly shows that some healthcare professionals are still not following these recommendations, and there is a need to improve healthcare professionals’ knowledge and behaviors to ensure a safe sleep environment. The American Nurses Association31 states: “The nursing profession is committed to promoting the health, welfare, and safety of all people.” All people must include our smallest, most vulnerable patients.

References 1. National Institute of Child Health. Key moments in safe sleep history: 1969-1993. http://www.nichd.nih.gov/sts/campaign/moments/pages/ 1969-1993.aspx. Updated September 23, 2013. Accessed May 6, 2014. 2. Center for Disease Control and Prevention. Sudden unexpected infant death and sudden infant death syndrome. http://www.cdc.gov/ sids. Published 2014. Accessed March 4, 2014. 3. National Institute of Child Health. Key moments in safe sleep history: 1994-2003 . http://www.nichd.nih.gov/sts/campaign/moments/ Pages/1994-2003.aspx. Updated September 23, 2013. Accessed May 6, 2014. 4. National Institute of Child Health. Key moments in safe sleep history: 20042013. http://www.nichd.nih.gov/sts/campaign/moments/Pages/ 2004-2013.aspx#2011. Updated September 23, 2013. Accessed May 6, 2014. 5. Center for Disease Control and Prevention. Sudden infant death syndrome: United States, 1983-1994. http://www.cdc.gov/mmwr/ preview/mmwrhtml/00043987.htm/00043987.htm. Published 1998. Accessed May 13, 2014. 6. U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2013. Rockville, MD: U.S. Department of Health and Human Services; 2013. 7. Martin J, Hamilton B, Ventura S. Births: final data for 2010. Nat Vital Statistics Rep. 2012;61(1). 8. American Academy of Pediatrics. Task Force on Sudden Infant Death Syndrome: policy statement SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics. 2011;128(5):1030-1039. 9. Hitchcock S. Endorsing safe infant sleeps: a call to action. Nurs Womens Health. 2012;16(5):386-396. 10. Peeke K, Hershberger M, Kuehn D, Levett J. Infant sleep position: nursing practice and knowledge. MCN Am J Matern Child Nurs. 1999;24(6):301-304. 11. Colson ER, Bergman DM, Shapiro E, Leventhal JH. Position for newborn sleep: associations with parents’ perception of their nursery experience. Birth. 2001;28(4):249-253. 12. Delzell JEJ, Phillips RLJ, Schnitzer PG, Ewigman B. Sleeping position: change in practice, advice, and opinion in the newborn nursery. J Fam Pract. 2001;50(5):448. 13. Hein HA, Pettit SF. Back to sleep: good advice for parents but not for hospitals? Pediatrics. 2001;107(3):537-539. 14. Moon RY, Omron R. Determinants of infant sleep position in an urban population. Clin Pediatr. 2002;41(8):569-573. 15. Bullock LF, Mickey K, Green J, Heine A. Are nurses acting as role models for the prevention of SIDS. MCN Am J Matern Child Nurs. 2004;29(3):172-177. 16. Stastny PF, Ichinose TY, Thayer SD, Olson RJ, Keens TG. Infant sleep positioning by nursery staff and mothers in newborn hospital nurseries. Nurs Res. 2004;53(2):122-129.


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17. Rao H, May C, Hannam S, Rafferty GF, Greenough A. Survey of sleeping position recommendations for prematurely born infants on neonatal intensive care unit discharge. Eur J Pediatr. 2007;166(8): 809-811. 18. Aris C, Stevens TP, Lemura C, et al. NICU nurses’ knowledge and discharge teaching related to infant sleep position and risk of SIDS. Adv Neonatal Care. 2006;6(5):281-294. 19. Colson ER, Levenson S, Rybin D, et al. Barriers to following the supine sleep recommendations among mothers at four centers for the women, infants, and children program. Pediatrics. 2006;118(2): e243-e250. 20. Burd L, Peterson M, Cedar Face G, Face FC, Shervold D, Klug MG. Efficacy of a SIDS risk factor education methodology at a Native American and Caucasian site. Matern Child Health J. 2007;11:365-371. 21. Dattani N, Bhat R, Rafferty GF, Hannam S, Greenough A. Survey of sleeping position recommendations for prematurely born infants. Eur J Pediatr. 2011;170(2):229-232. 22. Grazel R, Phalen AG, Polomano RC. Implementation of the American Academy of Pediatrics recommendations to reduce sudden infant death syndrome risk in neonatal intensive care units: an evaluation of nursing knowledge and practice. Adv Neonatal Care. 2010;10(6):332-342. 23. Yikilkan H, Ünalan PC, Cakir E, et al. Sudden infant death syndrome: how much mothers and health professionals know. Pediatr Int. 2011;53(1):24-28.

24. Efe E, Inal S, Balyilmaz H, et al. Nurses’ and paediatricians’ knowledge about infant sleeping positions and the risk of sudden infant death syndrome in Turkey. Health Med. 2012;6(1):140-147. 25. Luca FD, Boccuzzo G. What do healthcare workers know about sudden infant death syndrome? The results of the Italian campaign “GenitoriPiu.” J Royal Statistics Soc. 2012;177(1):63-82. 26. Ibarra B, Goodstein M. A parent's guide to a safe sleep environment. Adv Neonatal Care. 2011;11(1):27-28. 27. Gelfer P, Cameron R, Masters K, Kennedy KA. Integrating “back to sleep” recommendations into neonatal ICU practice. Pediatrics. 2013;131(4):e1264-e1270. 28. McMullen SL, Lipke B, LeMura C. Sudden infant death syndrome prevention: a model program for NICU’s. Neonatal Netw. 2009;28(1):7-12. 29. Colson ER, Willinger M, Santomauro NL, Heeren TC, Corwin MJ. Reports of sleep behaviors from a national sample of mothers: the Study of Attitudes and Factors Affecting Infant Care (SAFE). 2014. Pediatric Academic Societies’ & Asian Society for Pediatric Research Joint Meeting. Held in Vancouver, Canada, May 3, 2014. 30. Colson ER, Willinger M, Rybin D, et al. Trends and factors associated with infant bed sharing, 1993-2010: the national infant sleep study. AMA Pediatr. 2013;167(11):1032-1037. 31. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. http://www.nursingworld.org/provision-8. Published 2001. Accessed March 4, 2014.

Call for Manuscripts for Clinical Issues in Neonatal Care Section Share your expertise with your colleagues!

Please consider submitting a manuscript related to your neonatal clinical practice. Section Overview: Manuscripts submitted for this section contain information that is fundamental to neonatal nursing practice. The reader will gain knowledge from the article that enriches and expands clinical knowledge and practice. We welcome policy changes, critical review of the literature, and examples of clinical excellence, overall these manuscripts capture the essence neonatal clinical care. Examples of these types of articles are: • Concept analysis of ideas central to neonatal nursing • Clinical excellence related to specific problems • Descriptions of essential nursing care strategies for specific diagnosis from the novice to the expert, or targeted to a specific audience such as the new staff nurse or the advanced practice nurse • Care practices (or bundles) based on evidence-based interventions • Neonatal assessment processes • Neonatal concepts that pertain to all levels of nursing For more details on manuscript submissions. Please see the author guidelines for Advances in Neonatal Care available at http://edmgr.ovid.com/anc/accounts/ifauth.htm Please contact Ksenia Zukowsky, PhD, APRN, NNP-BC, or Linda Ikuta, RN, MN, CCNS, PHN, Section Editors at [email protected] or [email protected] for questions.

www.advancesinneonatalcare.org Copyright © 2015 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.

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