Back to Sleep: A Culture Change to Improve Practice

Transition to a Safe Home Sleep Environment for the NICU Patient

Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.

Crafting effective messages to enhance safe infant sleep

BACKGROUND

Health care professionals are continually challenged by the need to provide health information in a way that successfully changes health practices. Research has documented this as a concern in relation to safe infant sleep health campaigns. Often, caregivers' knowledge of recommended practices is not associated with a change in infant sleep choices.

PURPOSE

Health campaigns, including most safe infant sleep efforts, often share specific risk factors and steps for avoiding risk, that is, in a verbatim format. Research has shown that caregivers' behavior may be more likely to change when presented with messages based on their general understanding of risk, that is, gist-based format. This research examines caregivers' responses as related to verbatim- and gist-based safe sleep information.

METHODS

Five hundred forty-one caregivers of infants were shown 12 images depicting infants in safe or unsafe sleep spaces. Images varied across three commercially available spaces, infant race, and presence/absence of one policy-based risk factor.

RESULTS

Differences in caregivers' discernment of safe and unsafe sleep images paralleled reported differences in knowledge of safe sleep recommendations. Discernment of safe/unsafe images was greater for White than Black caregivers, as well as for females in comparison with male caregivers. Gist-based considerations, such as familiarity with the sleeper depicted or infant race, were also associated with caregivers' discernment of safe/unsafe images.

IMPLICATIONS FOR PRACTICE

Attending to both gist- and verbatim-based knowledge regarding safe infant sleep campaign information may help to effectively facilitate caregivers' ability to always create safe sleep spaces for their infants.

Understanding the Risks Sitting and Carrying Devices Pose to Safe Infant Sleep

There have been various campaigns and recommendations to decrease the incidence of sudden unexpected infant death. Despite this, caregivers continue to place infants in unsafe sleeping environments. These environments, such as sitting devices, slings, carriers, and car seats, pose a significant risk to an infant's safety because of the risk from suffocation and cardiorespiratory instability. It is important for health care providers to understand the appropriate use of car seats, slings, and other sitting devices, to model appropriate behaviors, and to educate parents and caregivers. All parents, hospital staff, and other caregivers should understand the potential dangers associated with the inappropriate use of sitting devices for routine sleep.

Safe sleep for pediatric inpatients

PURPOSE

To improve sleep environment safety for inpatient infants.

DESIGN AND METHODS

This quality improvement project involved assessment of sleep environment safety for inpatient infants before and after a bundled intervention of staff education and introduction of swaddle sacks and bedside storage bins.

RESULTS

The proportion of infant cribs without loose objects in them increased (32-72%, p = .025), and safe sleep positioning remained stable (82% vs. 95%, p = .183).

PRACTICE IMPLICATIONS

Staff education, swaddle sleep sacks, and bedside storage containers were associated with improved sleep safety among pediatric inpatients at our institution and may help at other institutions.

Neonatal nurses' beliefs, knowledge, and practices in relation to sudden infant death syndrome risk-reduction recommendations

BACKGROUND

Sudden infant death syndrome (SIDS) remains the third leading cause of infant death in the United States and the leading cause of death beyond 1 month of age. In 2011, the American Academy of Pediatrics (AAP) released the newest SIDS risk-reduction recommendations, which address healthcare providers in neonatal intensive care units (NICUs). Little is known about neonatal nurses' SIDS prevention strategies since the release of these newest recommendations.

PURPOSE

To assess neonatal nurses' beliefs, knowledge, and practices regarding SIDS prevention in both the NICU and step-down transitional care unit (TCU).

METHODS

A prospective-descriptive design was used. The 33-item SIDS Risk-Reduction Questionnaire was distributed to a convenience sample of nurses in a level III NICU/TCU in the Midwest.

RESULTS

Two hundred questionnaires were distributed; 96 (48%) were returned completed. Fifty-three percent of nurses strongly agreed that SIDS recommendations make a difference in preventing SIDS and 20% strongly believed that parents model SIDS prevention practices employed by staff. A majority of nurses correctly identified 2011 recommendations. Sixty-three percent of nurses often or always gave parents verbal information and 28% often or always gave parents written information regarding SIDS. Differences were seen between NICU and TCU nurses concerning beliefs and practices, suggesting that TCU nurses more consistently follow SIDS recommendations.

IMPLICATIONS FOR PRACTICE

Increased neonatal nursing and parental education regarding SIDS prevention and updated hospital policies promoting safe sleep are paramount.

IMPLICATIONS FOR RESEARCH

Larger multicenter studies in level II/III NICUs are needed to provide further data on SIDS attitudes and practices.

Endorsing safe infant sleep: a call to action

The American Academy of Pediatrics (AAP) safe sleep recommendations are considered best practice and are effective in preventing sudden infant death syndrome (SIDS). Yet studies have found that nurses' practice in newborn nurseries and neonatal intensive care units is often inconsistent with safe sleep recommendations. Such inconsistencies cause confusion and hinder SIDS prevention efforts. In 2011, the AAP added significant content to its 2005 safe sleep recommendations and neonatal nurses are now being asked to endorse the recommendations from birth. This article reviews the recommendations, examines barriers and controversies and offers suggestions for how an organization might initiate change and move toward a unified endorsement of safe sleep strategies.

Translating infant safe sleep evidence into nursing practice

The authors describe a 4-year demonstration project (2004-2007) to reduce infant deaths related to sleep environments by changing attitudes and practices among nurses who work with African American parents and caregivers in urban Michigan hospitals. An approach was developed for creating sustainable change in nursing practice by implementing nursing practice policies that could be monitored through quality improvement processes already established within the hospital organization. Following the policy change effort, nurses changed their behavior and placed infants on the back to sleep.

A case study of teen parenting

PURPOSE

The purpose of this case study is to demonstrate how the use of the standard nursing languages of NANDA International (NANDA-I), the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) help a teen mother provide safe care for her newborn. In addition, this study aims to demonstrate how important standardized nursing languages are in documenting the care provided.

DATA SOURCES

The data sources for this article are clinical nursing practice, research evidence in the form of care directives from the American Academy of Pediatrics regarding newborn safety and feeding, and the books that provide directions for the use of NANDA-I, NIC, and NOC.

DATA SYNTHESIS

This case demonstrates the use of the nursing process in providing care for a teen mother and a newborn.

CONCLUSIONS

Many new mothers, especially teens, are poorly informed regarding normal newborn care and safety upon hospital discharge. For this reason, teen mothers should be referred for nursing assessments in the home environment after discharge.

IMPLICATIONS FOR NURSING

This case demonstrates the need for education of all parents prior to hospital discharge and supports the need for home-based evaluations to ensure the safety of the infant. This case also supports the use of standardized nursing language to document the care provided.