EVIDENCE-BASED PRACTICE
An Evidence-Based Safe Sleep Teaching Program Terry Povenelli, RN Donna Manquen, RN Ashley Wagner, RN, BSN Deborah A. Raines, PhD, EdS, RN, ANEF
Disclosure The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity.
ABSTRACT This column describes the experience of the units practice council in developing an evidence-based practice teaching program focused on safe sleep for newborn infants. Keywords: evidence-based practice; parent teaching; discharge teaching
T
HE PROVISION OF SAFE AND EFFECTIVE
Accepted for publication April 2014.
care is at the top of the agenda for most health care agencies. Evidence-based practice has the potential to improve the quality of care and the safety of patients. Nurse researchers and others have generated volumes of evidence about best practices, but, until this evidence is applied in the clinical setting, it does not benefit patient outcomes or well-being. Nurses are key players in applying evidence to the needs of the patient population. Nurses who work with patients on a daily basis know the questions that need to be answered and the best way to use the available evidence to improve patient outcomes in their setting. In addition, nurses involved in developing evidence-based practice guidelines develop leadership skill and demonstrate greater levels of job satisfaction and professional growth.1 This column describes the experience of the unit practice council on the MaternalNewborn Units at Sisters of Charity Hospital in Buffalo, New York, in the development of an evidence-based practice teaching program for new parents.
WHAT IS A UNIT PRACTICE COUNCIL? A unit practice council is a mechanism by which clinical nurses can voice their ideas and make decisions about performance improvement, patient care, and educational activities.2 It is a mechanism for those involved in the daily care of patients to discuss clinical issues and potential solutions. Put a group of neonatal nurses together, and the issues and questions impacting their practice will quickly emerge. A unit practice council is a fertile source for evidence-based practice projects. Unit practice councils are part of a shared governance structure that enables nurses to control their practice and to assume accountability for quality outcomes. The typical unit practice council consists of 5–12 clinical nurses. At Sisters of Charity Hospital, project leadership is assumed by the clinical nurses on the unit practice council. The director of professional practice facilitates the council’s work and communicates with hospital leadership, accessing outside
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resources and helping individual nurses grow as leaders among their peers. Decision making and the work of the unit practice council are accomplished using a consensus model.
THE PROBLEM Based on research and the national SIDS education program, the nursery had adopted the Back to Sleep initiative both in the hospital-based nurseries and as part of the discharge teaching protocol. However, although the Back to Sleep initiative has resulted in a decrease in the number of infant deaths because of sudden infant death syndrome (SIDS), there was a concurrent increase in infant deaths because of accidental suffocation and strangulation.3 In areas with extreme winter weather, such as Buffalo, NY, infant deaths because of suffocation from extra blankets in the sleeping environment may result in infant deaths.4 Thus, the nurses on the unit practice council asked the question, what do we need to be teaching our new parents about safe infant sleep to prevent accidental suffocation and strangulation in the hospital and in the home? TABLE 1
■
THE PROCESS Members of the unit practice council conducted a literature review on infant deaths and infant sleep. Although the focus was on accidental suffocation and strangulation, a review of the SIDS literature was included as a foundation for developing an evidence-based practice education program for new parents. The unit practice council met regularly to share, discuss, and synthesize the evidence from the literature and to extract the practice that contributed to designing a safe sleep education program for parents of newborn infants. Based on the unit practice council members’ immersion in the evidence, the group concluded that initiatives focused on providing education to new parents is an effective method of reducing the incidence of sleep-related deaths in newborns.5,6 Based on the evidence extracted from the literature and their clinical expertise, the unit practice council created teaching materials to be shared with parents during the postpartum hospital stay, as part of the discharge teaching plan, as well as literature and a door hangtag to be sent home with the family as a reminder to parents and a source of information for other infant caregivers in the home. The evidence-based practice teaching program with the supporting evidence is shown in Table 1.
Evidence Table: Safe Sleep Parent Education Program
Practice Guideline
Evidence Supporting Practice
Safe sleep in the hospital These practices are shared with parents as part of the admission process after the infant’s birth. • Return baby to crib after feeding and cuddling times. • Do not sleep with the baby in your arms or in your hospital bed. • Do not let family members sleep in the recliner/ sofa with the baby in their arms.
Pain medications can lead to drowsiness.7 Sleeping with the newborn in an adult bed exposes the infant to risk for accidental injury and death such as suffocation, asphyxia, entrapment, falls, and strangulation.8,9 Immature motor skills and muscle strength in the newborn makes it difficult for the infant to escape potential threats to safety.10 Sleeping together is dangerous: • In infants ⬍3 mo of age10–13 • On a soft surface (i.e., adult bed, sofa, or armchair)11,12,14 • When soft bedding accessories are present such as pillows and blankets14 • When parents have consumed medications13
Safe sleep in the home: the ABCs of safe sleeping These practices are shared with parents as part of the discharge teaching, which is integrated throughout the infant’s stay and reinforced on the day of discharge. Alone: Do not sleep with your baby. Prone sleeping and bed sharing increases the risk of overheating, rebreathing exhaled air, and airway obstruction.15 Sleeping with the newborn in an adult bed exposes the infant to risk for accidental injury and death such as suffocation, asphyxia, entrapment, falls, and strangulation.8,9 Sleeping together is dangerous: • In infants ⬍3 months of age10–13 • On a soft surface (i.e., adult bed, sofa, or armchair)11,12,14 • When soft bedding accessories are present such as pillows and blankets14 • When parents have consumed medications13 Babies should be positioned sleeping on their Prone sleeping and bed sharing increases the risk of overheating, rebreathing exhaled air, and backs. airway obstruction.15 Cribs should be cleared of all objects that could Soft bedding (i.e., pillows, crib bumpers, and blankets) increase the potential of suffocation harm or suffocate the infant. and rebreathing.16–18 Soft bedding is associated with accidental suffocation deaths.19 The majority of sleep-related deaths are attributable to suffocation involving pillows, quilts, and extra bedding in the infant’s sleep environment.20,21
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THE OUTCOME Teaching about safe sleep is now part of the standard of care in the nursery and a required component of the discharge instructions and education for new parents. The unit practice council scripted the teaching for consistency of the implementation and delivery of information from the nursing staff. The nursing staff model safe sleep environments while the infant is in the nursery or the mother’s postpartum room. Nursing staff remind mothers to return the baby to the cribs after breastfeeding and cuddling while encouraging room sharing but not bed sharing during this important time in the formation of new family bonds and safe behaviors for family health and well-being. Attention to how the infant is dressed, the use of blankets, and presence of other items in the baby’s sleep environment are consistently discussed. The response to the safe sleep program has been overwhelmingly positive.
REFERENCES 1. Brody AA, Barnes K, Ruble C, Sakowski J. Evidence-based practice councils: potential path to staff nurse empowerment and leadership growth. J Nurs Adm. 2012;42(1):28-33. 2. Erickson SM, McNamara T, Balanay T, Fields W. Clinical nurses find a voice: how nursing practice councils succeeded at one hospital. Am J Nurs. 2008;108(8):76-79. 3. American Academy of Pediatrics. AAP expands guidelines for infant sleep safety and SIDS risk reduction. http://www.aap.org/en-us/about-theaap/aap-press-room/pages/AAP-Expands-Guidelines-for-Infant-SleepSafety-and-SIDS-Risk-Reduction.aspx. Published October 18, 2011. Accessed April 4, 2014. 4. Michel L. Rash of infant deaths spurs warning: babies should sleep alone. http://www.buffalonews.com/city-region/rash-of-infant-deaths-spurswarning-babies-should-sleep-alone-20140215. Published February 15, 2014. Accessed April 4, 2014. 5. Moon RY, Oden RP, Grady KC. Back to Sleep: an educational intervention with women, infants, and children program clients. Pediatrics. 2004;113(3):542-547. 6. Colson ER, Joslin SC. Changing nursery practice gets inner-city infants in the supine position for sleep. Arch Pediatr Adolesc Med. 2002;156(7):717-720. 7. Ammari A, Schulze KF, Ohira-Kist K, et al. Effects of body position on thermal, cardiorespiratory and metabolic activity in low birth weight infants. Early Hum Dev. 2009;85(8):497-501. 8. Drago DA, Dannenberg AL. Infant mechanical suffocation deaths in the United States, 1980-1997. Pediatrics. 1999;103(5):e59. http:// www.pediatrics.org/cgi/content/full/103/5/e59. Accessed April 4, 2014. 9. Ball H. Airway covering during bed-sharing. Child Care Health Dev. 2009;35(5):728-737.
10. Vennemann M, Hense HW, Bajanowski T, et al. Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate? J Pediatr. 2012;160(1):44-48.e2. 11. Blair PS, Fleming PJ, Smith IJ, et al. Babies sleeping with parents: casecontrol study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI research group. BMJ. 1999;319(7223):1457-1461. 12. McGarvey C, McDonnell M, Chong A, O’Regan M, Matthews T. Factors relating to the infant’s last sleep environment in sudden infant death syndrome in the Republic of Ireland. Arch Dis Child. 2003;88(12):1058-1064. 13. Carpenter RG, Irgens LM, Blair PS, et al. Sudden unexplained infant death in 20 regions in Europe: case control study. Lancet. 2004;363(9404):185-191. 14. Hauck FR, Herman SM, Donovan M, et al. Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago Infant Mortality Study. Pediatrics. 2003;111(5, pt 2):1207-1214. 15. Wong FY, Witcombe NB, Yiallourou SR, et al. Cerebral oxygenation is depressed during sleep in healthy term infants when they sleep prone. Pediatrics. 2011;127(3):e558-e565. http://www.pediatrics.org/cgi/ content/full/127/3/e558. Accessed April 4, 2014. 16. Kanetake J, Aoki Y, Funayama M. Evaluation of rebreathing potential on bedding for infant use. Pediatr Int. 2003;45(3):284-289. 17. Patel AL, Harris K, Thach BT. Inspired CO(2) and O(2) in sleeping infants rebreathing from bedding: relevance for sudden infant death syndrome. J Appl Physiol. 2001;91(6):2537-2545. 18. Sakai J, Kanetake J, Takahashi S, Kanawaku Y, Funayama M. Gas dispersal potential of bedding as a cause for sudden infant death. Forensic Sci Int. 2008;180(2-3):93-97. 19. Kemp JS, Unger B, Wilkins D, et al. Unsafe sleep practices and an analysis of bed sharing among infants dying suddenly and unexpectedly: results of a four-year, population-based, death-scene investigation study of sudden infant death syndrome and related deaths. Pediatrics. 2000;106(3):E41. http://www.pediatrics.org/cgi/content/full/106/3/e41. Accessed April 4, 2014. 20. Chowdhury RT. Nursery Product-Related Injuries and Deaths among Children under Age Five. Washington, DC: US Consumer Product Safety Commission; 2009. 21. Moon RY. “And things that go bump in the night”: nothing to fear? J Pediatr. 2007;151(3):237-238.
About the Authors Terry Povenelli, RN, Donna Manquen, RN, Ashley Wagner, RN, BSN are nurses in the newborn nursery and members of the Unit Practice Council at Sisters of Charity Hospital, Buffalo NY. Deborah A. Raines, PhD, EdS, RN, ANEF, is a researcher, educational technologist, and perinatal nurse specialist. She is currently on the faculty of the University at Buffalo: SUNY. For further information, please contact: Deborah A. Raines, PhD, EdS, RN, ANEF 3435 Main Street Buffalo, NY 14214 E-mail: [email protected]
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An Evidence-Based Safe Sleep Teaching Program Terry Povenelli, RN Donna Manquen, RN Ashley Wagner, RN, BSN Deborah A. Raines, PhD, EdS, RN, ANEF
Disclosure The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article. No commercial support or sponsorship was provided for this educational activity.
ABSTRACT This column describes the experience of the units practice council in developing an evidence-based practice teaching program focused on safe sleep for newborn infants. Keywords: evidence-based practice; parent teaching; discharge teaching
T
HE PROVISION OF SAFE AND EFFECTIVE
Accepted for publication April 2014.
care is at the top of the agenda for most health care agencies. Evidence-based practice has the potential to improve the quality of care and the safety of patients. Nurse researchers and others have generated volumes of evidence about best practices, but, until this evidence is applied in the clinical setting, it does not benefit patient outcomes or well-being. Nurses are key players in applying evidence to the needs of the patient population. Nurses who work with patients on a daily basis know the questions that need to be answered and the best way to use the available evidence to improve patient outcomes in their setting. In addition, nurses involved in developing evidence-based practice guidelines develop leadership skill and demonstrate greater levels of job satisfaction and professional growth.1 This column describes the experience of the unit practice council on the MaternalNewborn Units at Sisters of Charity Hospital in Buffalo, New York, in the development of an evidence-based practice teaching program for new parents.
WHAT IS A UNIT PRACTICE COUNCIL? A unit practice council is a mechanism by which clinical nurses can voice their ideas and make decisions about performance improvement, patient care, and educational activities.2 It is a mechanism for those involved in the daily care of patients to discuss clinical issues and potential solutions. Put a group of neonatal nurses together, and the issues and questions impacting their practice will quickly emerge. A unit practice council is a fertile source for evidence-based practice projects. Unit practice councils are part of a shared governance structure that enables nurses to control their practice and to assume accountability for quality outcomes. The typical unit practice council consists of 5–12 clinical nurses. At Sisters of Charity Hospital, project leadership is assumed by the clinical nurses on the unit practice council. The director of professional practice facilitates the council’s work and communicates with hospital leadership, accessing outside
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resources and helping individual nurses grow as leaders among their peers. Decision making and the work of the unit practice council are accomplished using a consensus model.
THE PROBLEM Based on research and the national SIDS education program, the nursery had adopted the Back to Sleep initiative both in the hospital-based nurseries and as part of the discharge teaching protocol. However, although the Back to Sleep initiative has resulted in a decrease in the number of infant deaths because of sudden infant death syndrome (SIDS), there was a concurrent increase in infant deaths because of accidental suffocation and strangulation.3 In areas with extreme winter weather, such as Buffalo, NY, infant deaths because of suffocation from extra blankets in the sleeping environment may result in infant deaths.4 Thus, the nurses on the unit practice council asked the question, what do we need to be teaching our new parents about safe infant sleep to prevent accidental suffocation and strangulation in the hospital and in the home? TABLE 1
■
THE PROCESS Members of the unit practice council conducted a literature review on infant deaths and infant sleep. Although the focus was on accidental suffocation and strangulation, a review of the SIDS literature was included as a foundation for developing an evidence-based practice education program for new parents. The unit practice council met regularly to share, discuss, and synthesize the evidence from the literature and to extract the practice that contributed to designing a safe sleep education program for parents of newborn infants. Based on the unit practice council members’ immersion in the evidence, the group concluded that initiatives focused on providing education to new parents is an effective method of reducing the incidence of sleep-related deaths in newborns.5,6 Based on the evidence extracted from the literature and their clinical expertise, the unit practice council created teaching materials to be shared with parents during the postpartum hospital stay, as part of the discharge teaching plan, as well as literature and a door hangtag to be sent home with the family as a reminder to parents and a source of information for other infant caregivers in the home. The evidence-based practice teaching program with the supporting evidence is shown in Table 1.
Evidence Table: Safe Sleep Parent Education Program
Practice Guideline
Evidence Supporting Practice
Safe sleep in the hospital These practices are shared with parents as part of the admission process after the infant’s birth. • Return baby to crib after feeding and cuddling times. • Do not sleep with the baby in your arms or in your hospital bed. • Do not let family members sleep in the recliner/ sofa with the baby in their arms.
Pain medications can lead to drowsiness.7 Sleeping with the newborn in an adult bed exposes the infant to risk for accidental injury and death such as suffocation, asphyxia, entrapment, falls, and strangulation.8,9 Immature motor skills and muscle strength in the newborn makes it difficult for the infant to escape potential threats to safety.10 Sleeping together is dangerous: • In infants ⬍3 mo of age10–13 • On a soft surface (i.e., adult bed, sofa, or armchair)11,12,14 • When soft bedding accessories are present such as pillows and blankets14 • When parents have consumed medications13
Safe sleep in the home: the ABCs of safe sleeping These practices are shared with parents as part of the discharge teaching, which is integrated throughout the infant’s stay and reinforced on the day of discharge. Alone: Do not sleep with your baby. Prone sleeping and bed sharing increases the risk of overheating, rebreathing exhaled air, and airway obstruction.15 Sleeping with the newborn in an adult bed exposes the infant to risk for accidental injury and death such as suffocation, asphyxia, entrapment, falls, and strangulation.8,9 Sleeping together is dangerous: • In infants ⬍3 months of age10–13 • On a soft surface (i.e., adult bed, sofa, or armchair)11,12,14 • When soft bedding accessories are present such as pillows and blankets14 • When parents have consumed medications13 Babies should be positioned sleeping on their Prone sleeping and bed sharing increases the risk of overheating, rebreathing exhaled air, and backs. airway obstruction.15 Cribs should be cleared of all objects that could Soft bedding (i.e., pillows, crib bumpers, and blankets) increase the potential of suffocation harm or suffocate the infant. and rebreathing.16–18 Soft bedding is associated with accidental suffocation deaths.19 The majority of sleep-related deaths are attributable to suffocation involving pillows, quilts, and extra bedding in the infant’s sleep environment.20,21
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THE OUTCOME Teaching about safe sleep is now part of the standard of care in the nursery and a required component of the discharge instructions and education for new parents. The unit practice council scripted the teaching for consistency of the implementation and delivery of information from the nursing staff. The nursing staff model safe sleep environments while the infant is in the nursery or the mother’s postpartum room. Nursing staff remind mothers to return the baby to the cribs after breastfeeding and cuddling while encouraging room sharing but not bed sharing during this important time in the formation of new family bonds and safe behaviors for family health and well-being. Attention to how the infant is dressed, the use of blankets, and presence of other items in the baby’s sleep environment are consistently discussed. The response to the safe sleep program has been overwhelmingly positive.
REFERENCES 1. Brody AA, Barnes K, Ruble C, Sakowski J. Evidence-based practice councils: potential path to staff nurse empowerment and leadership growth. J Nurs Adm. 2012;42(1):28-33. 2. Erickson SM, McNamara T, Balanay T, Fields W. Clinical nurses find a voice: how nursing practice councils succeeded at one hospital. Am J Nurs. 2008;108(8):76-79. 3. American Academy of Pediatrics. AAP expands guidelines for infant sleep safety and SIDS risk reduction. http://www.aap.org/en-us/about-theaap/aap-press-room/pages/AAP-Expands-Guidelines-for-Infant-SleepSafety-and-SIDS-Risk-Reduction.aspx. Published October 18, 2011. Accessed April 4, 2014. 4. Michel L. Rash of infant deaths spurs warning: babies should sleep alone. http://www.buffalonews.com/city-region/rash-of-infant-deaths-spurswarning-babies-should-sleep-alone-20140215. Published February 15, 2014. Accessed April 4, 2014. 5. Moon RY, Oden RP, Grady KC. Back to Sleep: an educational intervention with women, infants, and children program clients. Pediatrics. 2004;113(3):542-547. 6. Colson ER, Joslin SC. Changing nursery practice gets inner-city infants in the supine position for sleep. Arch Pediatr Adolesc Med. 2002;156(7):717-720. 7. Ammari A, Schulze KF, Ohira-Kist K, et al. Effects of body position on thermal, cardiorespiratory and metabolic activity in low birth weight infants. Early Hum Dev. 2009;85(8):497-501. 8. Drago DA, Dannenberg AL. Infant mechanical suffocation deaths in the United States, 1980-1997. Pediatrics. 1999;103(5):e59. http:// www.pediatrics.org/cgi/content/full/103/5/e59. Accessed April 4, 2014. 9. Ball H. Airway covering during bed-sharing. Child Care Health Dev. 2009;35(5):728-737.
10. Vennemann M, Hense HW, Bajanowski T, et al. Bed sharing and the risk of sudden infant death syndrome: can we resolve the debate? J Pediatr. 2012;160(1):44-48.e2. 11. Blair PS, Fleming PJ, Smith IJ, et al. Babies sleeping with parents: casecontrol study of factors influencing the risk of the sudden infant death syndrome. CESDI SUDI research group. BMJ. 1999;319(7223):1457-1461. 12. McGarvey C, McDonnell M, Chong A, O’Regan M, Matthews T. Factors relating to the infant’s last sleep environment in sudden infant death syndrome in the Republic of Ireland. Arch Dis Child. 2003;88(12):1058-1064. 13. Carpenter RG, Irgens LM, Blair PS, et al. Sudden unexplained infant death in 20 regions in Europe: case control study. Lancet. 2004;363(9404):185-191. 14. Hauck FR, Herman SM, Donovan M, et al. Sleep environment and the risk of sudden infant death syndrome in an urban population: the Chicago Infant Mortality Study. Pediatrics. 2003;111(5, pt 2):1207-1214. 15. Wong FY, Witcombe NB, Yiallourou SR, et al. Cerebral oxygenation is depressed during sleep in healthy term infants when they sleep prone. Pediatrics. 2011;127(3):e558-e565. http://www.pediatrics.org/cgi/ content/full/127/3/e558. Accessed April 4, 2014. 16. Kanetake J, Aoki Y, Funayama M. Evaluation of rebreathing potential on bedding for infant use. Pediatr Int. 2003;45(3):284-289. 17. Patel AL, Harris K, Thach BT. Inspired CO(2) and O(2) in sleeping infants rebreathing from bedding: relevance for sudden infant death syndrome. J Appl Physiol. 2001;91(6):2537-2545. 18. Sakai J, Kanetake J, Takahashi S, Kanawaku Y, Funayama M. Gas dispersal potential of bedding as a cause for sudden infant death. Forensic Sci Int. 2008;180(2-3):93-97. 19. Kemp JS, Unger B, Wilkins D, et al. Unsafe sleep practices and an analysis of bed sharing among infants dying suddenly and unexpectedly: results of a four-year, population-based, death-scene investigation study of sudden infant death syndrome and related deaths. Pediatrics. 2000;106(3):E41. http://www.pediatrics.org/cgi/content/full/106/3/e41. Accessed April 4, 2014. 20. Chowdhury RT. Nursery Product-Related Injuries and Deaths among Children under Age Five. Washington, DC: US Consumer Product Safety Commission; 2009. 21. Moon RY. “And things that go bump in the night”: nothing to fear? J Pediatr. 2007;151(3):237-238.
About the Authors Terry Povenelli, RN, Donna Manquen, RN, Ashley Wagner, RN, BSN are nurses in the newborn nursery and members of the Unit Practice Council at Sisters of Charity Hospital, Buffalo NY. Deborah A. Raines, PhD, EdS, RN, ANEF, is a researcher, educational technologist, and perinatal nurse specialist. She is currently on the faculty of the University at Buffalo: SUNY. For further information, please contact: Deborah A. Raines, PhD, EdS, RN, ANEF 3435 Main Street Buffalo, NY 14214 E-mail: [email protected]
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