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Translating Infant Safe Sleep Evidence Into Nursing Practice
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Translating Infant Safe Sleep Evidence Into Nursing Practice Sarah J. M. Shaefer, Sandra E. Herman, Sandra J. Frank, Mary Adkins, and Mary Terhaar
Correspondence Sandra J. Frank, JD, Tomorrow’s Child/Michigan SIDS, 112 E. Allegan, Suite 500, Lansing, MI 48933. sfrank@tomorrowschildmi. org Keywords back to sleep infant safe sleep sudden infant death syndrome (SIDS) sudden unexpected infant death (SUID) evidence based practice translation research research adoption
Sarah J. M. Shaefer, PhD, RN, is an assistant professor, Department of Community-Public Health, Johns Hopkins University School of Nursing, Baltimore, MD. Sandra E. Herman, PhD, is an independent evaluation consultant and past associate director for the Center for Statistical Training and Consulting, Michigan State University, East Lansing, MI. Sandra J. Frank, JD, CAE, is the chief executive officer of Tomorrow’s Child/ Michigan SIDS, Lansing, MI.
ABSTRACT 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.
JOGNN, 39, 618-626; 2010. DOI: 10.1111/j.1552-6909.2010.01194.x Accepted August 2010
nfants who sleep on their backs in a safe sleep environment have a decreased risk of dying suddenly and unexpectedly (American Academy of Pediatrics [AAP], 2005; American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome, 2000; Moon, Horne, & Hauck, 2007; Pollack & Frohna, 2002). The infant safe sleep e¡ort began with the Back to Sleep Campaign of the 1990s, which reduced the number of babies dying from sudden infant death syndrome (SIDS) by half (AAP, 2005). The U.S. Public Health Service, the AAP, the SIDS Alliance, and the Association of SIDS and Infant Mortality Programs implemented the Back to Sleep Campaign across the United States in 1994.
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nation closer to attaining the goals of Healthy People 2020.
Infant Safe Sleep The AAP (2005) has identi¢ed 11 recommendations regarding infant sleep environment to reduce the risk of SIDS and sudden unexpected deaths in healthy infants. The ¢rst is back sleep (supine position) for infants. Neither side nor prone sleeping positions are considered safe. The sleep environment (crib) should have a ¢rm sleep surface, be free of soft material or objects (i.e., pillows, quilts, sheepskins, stu¡ed toys, etc.), should not have loose bedding or pillow-like bumper pads, and if a blanket is used, the baby’s feet are at the bottom of the crib, the blanket is no higher than the baby’s chest, and it is tucked in around the crib mattress. Mothers should not smoke during pregnancy, and infants’ exposure to secondhand smoke should be avoided. A separate but proximal sleeping environment to parents is recommended as most safe. Parents should avoid overheating their infants by keeping the bedroom temperature in a range that is comfortable for lightly clothed adults. The AAP recommends the limited use of paci¢ers when the infant is put down for sleep if the child is willing to accept it. Additionally, the AAP recommends avoiding
The authors report no conflict of interest or relevant financial relationships.
Back sleep is supported by a substantial body of evidence (AAP, 2005; Colson et al., 2009; Dwyer & Ponsonby, 2009) and is a simple, inexpensive intervention for parents and communities. Nevertheless, it is inconsistently adopted in communities and often rejected by parents with concerns about infant comfort, choking, and inconsistent advice from physicians (Colson et al.; VanKororn et al., 2010). Strategies that accelerate adoption of Back to Sleep and infant safe sleep guidelines promise to save lives and move the
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& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Mary Adkins, RN, MSW, is the program director of Tomorrow’s Child/ Michigan SIDS, Lansing, MI. (Continued)
http://jognn.awhonn.org
Shaefer, S. J. M., Herman, S. E., Frank S. J., Adkins, M. and Terhaar, M.
the use of commercial devices marketed to reduce SIDS such as positioners and the use of home respiratory and cardiac monitors. ‘‘Tummy time’’ when the infant is awake and observed is encouraged to avoid positional plagiocephaly. Finally, the AAP supports the continuation of Back to Sleep. In this article, the term infant safe sleep encompasses infant position at bed or nap time and other modi¢able risk factors including infant sleep environment and maternal/infant risk factors. Although information about risk factors is often presented in prenatal educational programs, continuing education on modi¢able risk factors including sleep environment and sleep position at sleep/nap time is important. The most signi¢cant risk factor is prone position. Prone position is associated with an increased risk of death by SIDS (Kemp et al., 2000; Mathews & MacDorman, 2007; Moon et al., 2007). Signi¢cant reductions in the SIDS rates have been related to placing infants on their back to sleep (American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome, 2000; Colson et al., 2009; Dwyer & Ponsonby, 2009). Moon, Oden, Joyner, and Ajao (2010), however, reported that African American mothers often did not understand the relationship between their behaviors and the risk for SIDS, and improvements in the consistency of the message are needed to change how mothers place their infants for sleep.
Nurses as Role Models Given that SIDS accounts for more than 2,500 deaths each year in the United States, increasing adoption of infant safe sleep as common practice promises to save a signi¢cant number of lives (Dwyer & Ponsonby, 2009). Parental knowledge of safe sleep is key to decreasing risk of unexpected infant deaths. Studies have indicated that parents listen to nurses and model their actions regarding the sleep position of their new infant (Carrier, 2009; Hein & Pettit, 2001; Moos, 2006; VanKororn et al., 2010). In a study of African American mothers, Rasinski, Kuby, Bzdusek, Silvestri, and WeeseMayer (2003) reported that verbal messages from doctors and nurses increased the use of back sleeping after discharge. Carrier concluded that parents are likely to do what they see the nurse do in the hospital. Moon and Omron (2002), however, pointed out that though 70% of parents reported receiving information about infant safe sleep from a health care provider, only 10% could recall that back sleep was safest. The nurse’s behavior is essential in in£uencing parents to place their babies in a safe sleep environment. Price, Hillman,
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More than a decade after Back to Sleep was initiated, infant safe sleep practices have not been consistently adopted.
Gardner, Schenk, and Warren (2008) reported that health care professionals’ knowledge acquisition, attitudes, and practice intentions increased signi¢cantly with sta¡ education programs. Translating this knowledge into nursing practice, however, has to date been problematic (Carrier; Hein & Pettit; Mercier et al., 2007).
The Challenge of Translating Evidence Into Practice Delay in implementation of the infant safe sleep message is similar to delays in implementation of other evidence-based strategies that bring new knowledge to bear on practice (Wallin, 2009). Delays between 7 and 11 years are commonly reported and are attributed to three factors: lack of awareness of new knowledge on the part of clinicians who could put innovation into practice, lack of authority to change practice, and lack of infrastructure to facilitate adoption of innovation (Foxcroft & Cole, 2000). When new knowledge is adopted, lack of ¢delity to the model with imperfect or imprecise adherence can be a problem (Dusenbury, Brannigan, Falco, & Weissberg, 2003). When intervention does not closely adhere to the prescription of the evidence, the desired e¡ect can only be partially achieved, if achieved at all. For this reason, ¢delity to evidence-based models is essential to attaining desired outcomes. To reduce delay in implementation and promote ¢delity to best practice, barriers to adoption of new knowledge must be overcome. Implementation is well served by collaboration between researchers and practitioners paying careful attention to the speci¢c practice environment into which the new knowledge is to be translated (Rohrbach, Grana, Sussman, & Valente, 2006). Investment in leadership, structure, goal setting, skills, resources, and competencies will help (Newhouse, Dearholt, Poe, Pugh, & White, 2007). Health education studies suggest that innovations are more likely to be adopted when there are clear instructions, welldeveloped user-friendly materials, and a clear rationale for actions and the desired outcomes (Hallfors & Godette, 2002; Pankratz, Hallfors, & Cho, 2002). Pankratz et al. also found that adoption of innovation in health care was more likely when the relative advantage in terms of cost were low and bene¢ts high, complexity of the innovation was low, and
Mary Terhaar, DNSc, RN, is an assistant professor in the Department of Health Systems and Outcomes and Interim Director, DNP Program, Johns Hopkins University School of Nursing, Baltimore MD.
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Organizations have been more successful in adopting innovations when strong leadership, effective administrative structures, and open communication are in place.
observability of the change was high (easy to do). Organizations have been found more successful in e¡orts in adopting innovations when strong leadership, e¡ective administrative structures, and open communication are in place (Berends, Bodilly, & Kirby, 2002; Farrell, Meyer, Kung, & Sullivan, 2001; Kam, Greenberg, & Walls, 2003). Adoption or rejection of innovations (Rogers, 2003), such as adopting infant safe sleep guidelines into routine practice, begins with gaining knowledge (i.e., educating nurses on the AAP guidelines), followed by e¡orts to persuade individuals and/ or organizations of the bene¢ts of adopting the innovation, a decision to adopt, and then implementation of the change (i.e., change in hospital policies to included infant safe sleep guidelines). In the area of infant safe sleep, the innovative process in Michigan had proceeded through the knowledge-gaining phase, but no models were available to move the knowledge into sustainable change in clinical practice.
Institutionalizing Infant Safe Sleep From 2003 to 2005, infant death rates for African Americans were approximately 17.6 compared to White rate of 5.7, and the infant death rate continued to be higher than the average for the country (Michigan Department of Community Health, 2007a, 2007b). The authors describe the development and demonstration of the Infant Safe Sleep Hospital model (ISSHM) in urban Michigan hospitals as a response to the continuing high rates of SIDS and sudden unexpected infant deaths among non-Hispanic African American infants. The e¡ort focused on hospitals’ abilities to develop, implement, and assess compliance with nursing practice policy. The result is a quality improvement process that translates the AAP guidelines on infant safe sleep into hospital-wide and system-wide nursing practice. This article describes 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. The collaborative e¡ort was initiated by Tomorrow’s Child/Michigan SIDS with seven ur-
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ban hospitals to improve adoption of evidence about infant safe sleep in routine hospital care of newborns and their mothers, and to identify the e¡ects of policy changes on nursing practice. The purpose of the project was to develop a model for creating sustainable changes in nurses’ behaviors that could be monitored through quality improvement processes already established within the hospital organization.
Methods Quality Improvement Model Development At the outset of the project, an external evaluator in Michigan was retained to develop and re¢ne data collection procedures and tools. Project sta¡ worked with administrators, sta¡ nurses, and nurse educators at seven hospitals in two phases to develop and demonstrate a quality improvement process. In Phase 1, Tomorrow’s Child invited two hospitals to participate by contacting a nurse educator at each hospital. Both hospitals agreed to participate and formed infant safe sleep workgroups consisting of sta¡ nurses, nurse educators, and nursing supervisors. Workgroups met regularly for the duration of the project. Meetings were convened by Tomorrow’s Child sta¡ to assist in initiating the project activities and to provide guidance. Each workgroup identi¢ed all policies that a¡ected newborns and their mothers at their hospital. Workgroups were charged with reviewing and revising their hospital nursing practice policies to include infant safe sleep in clinical practices and information on infant safe sleep in their patient education materials. They were also responsible for developing methods for implementing the policy changes, including in-service training materials for nurse education, materials for patients, and a tool for auditing cribs during regular visits to patient rooms by workgroup nurses. Hospitals chose not to seek Institutional Review Board (IRB) approval because project activities were implemented by hospital employees as part of regular hospital activities, did not collect identi¢able information about patients or nurses, and were used only for aggregated monitoring of hospital procedures. The evaluator conducted group interviews with members of Phase 1 workgroups to identify successes and barriers in developing and implementing infant safe sleep policies. Results from the Phase 1 group interviews were used to re¢ne the approach used with Phase 2 hospitals. One lesson from Phase 1 was the need to engage management level support at the beginning of the process. Consequently, Phase 2
JOGNN, 39, 618-626; 2010. DOI: 10.1111/j.1552-6909.2010.01194.x
http://jognn.awhonn.org
Shaefer, S. J. M., Herman, S. E., Frank S. J., Adkins, M. and Terhaar, M.
hospitals were approached through the director of nursing and workgroup appointments included management as well as sta¡ nurses, nurse educators, and nursing supervisors. The model policies and assessment tools developed during Phase 1 were used to guide the review and revision process of ¢ve Phase 2 hospitals. Each hospital created policies to ¢t their environments. The Phase 2 hospitals did not choose to seek IRB approval because project activities were implemented by hospital employees as part of regular hospital activities, did not collect identi¢able information about patients or nurses, and were used only for aggregated monitoring of hospital procedures. The evaluator conducted group interviews with members of all seven workgroups to identify successes and barriers in developing and implementing infant safe sleep policies.
Intervention Setting and Sample Size. A total of seven hospitals in three geographically diverse urban regions of Michigan participated from 2004 through 2007. Hospitals from three counties with high disparity in death rates between African American and White infants were invited and agreed to participate. A total of 635 sta¡ nurses, who worked with new mothers and their infants, across the seven hospitals completed the Nurses’ Questionnaire and participated in the in-service trainings. Participating nurses had worked with newborns for an average of 13.37 years (SD 5 9.53, N 5 484). A total of 2,739 cribs were examined during the monitoring phase of the project. A total of 2,678 mothers of newborns were asked to answer three questions during their postdelivery hospital stay. Data on ethnicity collected at the ¢ve Phase 2 hospitals revealed that 53.0% were White (681/1,285), 32.6% (419/1,285) were African American, and 14.4% (185/1,285) all other ethnic groups.
Procedures Nursing Practice Policies. Existing nursing policies were submitted to the evaluator for qualitative analysis. At each hospital, the workgroup drafted new policy documents and procedures for nursing practice policies and parent education. Workgroup members were responsible for obtaining approval from their administration to replace the existing policies with the new policies. Concurrent with the policy development activities, the nurses from the workgroup conducted the initial unannounced audits of cribs of healthy newborn infants. During these visits to patients’ rooms, the nurse noted the location and position of the infant, items in the crib, and asked the mother if she had been told about infant safe sleep. Audits were conducted again 6 to 12
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Adoption of nursing policies was a shorter process and met with fewer barriers when hospital administrators were included early in the process.
months later.The results of the audit were discussed as part of the policy development activities. After the new nursing policies had been approved, in-service trainings on the infant safe sleep were provided to nurses working with mothers and newborns. Nurses were asked to complete a short questionnaire at the beginning of the in-service training and were asked to complete the same questionnaire 6 to 12 months later. Responses to the follow-up questionnaires were not matched with the pre-in-service responses. The average time from initiation of project to ¢nal data collection ranged from 6 to 12 months.
Instruments and Measures Infant Safe Sleep Policy Review Form. The evaluator developed a policy review form based on AAP guidelines (American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome, 2000; AAP, 2005). The ¢rst set of 10 criteria assessed the presence or absence of procedures that described how infants were to be placed in their cribs and how infant safe sleep education was to be provided to mothers and documented. The second set of 10 criteria assessed the presence or absences of the core elements of safe sleep practices in the hospital’s written policies. Crib Audit Form. A single page crib audit form was created to collect information on sleep position of the infant (back, stomach, side); bundling of the infant (tight, loose, not bundled), arms outside of blanket (yes/no); ethnicity of the child (phase-2, post only); and three questions for the mother: (a) had she received information on infant safe sleep (yes/no), (b) did she have a crib at home (yes/no), (c) did she plan to use a crib when she returned home (yes/no). Nurses’ Questionnaire. The Nurses’ Questionnaire was developed to assess nurses’ knowledge of (a) risk factors for SIDS and (b) infant safe sleep practices pre- and posttraining. The nurses’ questionnaire was based on a questionnaire developed by Moon, Gingras, and Erwin (2002). Knowledge of SIDS risk factors was assessed using a list of 11 factors of which seven are risk factors for SIDS and four are not. Nurses checked all the factors they
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thought were risk factors for SIDS. A SIDS knowledge score was created by counting the number items correctly identi¢ed as factors or nonfactors (possible range 0-11). Knowledge of infant safe sleep was assessed using 11 true-false questions based on the AAP guidelines (2000). A safe sleep knowledge score was created by counting the number of items with correct answers (possible range 0-11). Nurses were also asked for their opinions on safest sleep position and to identify the AAP-recommended infant sleep position. Responses to this questionnaire were similar to those found by Moon et al. (2002). The content of the questionnaire accurately re£ected established risk factors for SIDS and the 2005 AAP guidelines on infant safe sleep.Test-retest reliability was not evaluated.
accuracy. Percentages were calculated for audit items. Numbers of responses to each variable di¡er due to missing responses. Cross-tabular analyses with chi-square were used to examine the distribution of responses by time point. Data from the Nurses’ Questionnaire were analyzed to obtain the number of correct responses to items about risk factors for SIDS and the number of correct statements identi¢ed related to knowledge of infant safe sleep practices. Pre- and postpolicy change assessments were compared using independent sample t tests on the pre- and posttraining assessments. Di¡erences between the total number of assessments collected and total responses for variables used in the analyses are due to missing responses.
Data Management The evaluator conducted qualitative and quantitative analyses and provided feedback on data collected during the development of the quality improvement process. Data forms were collected at each hospital by the workgroup and given to the Tomorrow’s Child project coordinator. The Tomorrow’s Child project coordinator delivered the forms to the evaluator for data entry. Data from audits and Nurses’ Questionnaires were entered into SPSS Version 17 ¢les by the evaluator for analysis. No names or uniquely identifying information were stored in the data ¢les.
Data Analysis At the start of the project, the existing hospital policies were reviewed by the evaluator using the Infant Safe Sleep Policy Review form. In assessing the existing policies, the evaluator read each hospital policy to identify statements that would instruct the professional sta¡ on expectations related to infant safe sleep, when they are expected to carry out the program, and documentation. The evaluator also looked for statements in the policies that speci¢ed the key elements of infant safe sleep. Completed review forms were provided to each hospital workgroup as feedback and used in further revisions to the policies. The evaluator conducted group interviews with members of the hospital workgroups. The focus of the interviews was to identify barriers and facilitators to development and implementation of this policy. Responses to the group interview were summarized by the evaluator. Factors contributing to success as well as barriers were identi¢ed and con¢rmed with the workgroups. The distributions of variables in the questionnaires and audit form were examined to ensure data entry
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Results Nursing Practice Policies At the beginning of the project, none of the hospitals had nursing policies that met the two sets of criteria for adequate infant safe sleep practice. Each hospital drafted new model policies for nursing practice that were adopted after substantial review and discussion with hospital administration. Adoption of nursing policies was a shorter process and met with fewer barriers in the Phase 2 hospitals where hospital administrators were included early in the process. At Phase 1 hospitals, adoption of the new policies took about 12 months and several meetings of Tomorrow’s Child’s director with the hospital management to successfully complete the policy change. At Phase 2 hospitals, policies were revised and implemented approximately 6 months after initiating the policy change process. Analysis of the group interview responses re£ected the di¡erent approaches used during Phase 1 and Phase 2. Participants from both phases believed that the participation of management, sta¡ nurses, nurse educators, and nursing supervisors, was imperative for success, with Phase 1 hospital participants emphasizing the barriers they encountered because hospital administration was not involved early in the policy development process. Participants uniformly agreed that all levels of administration within hospitals needed to be aware and committed to the implementation of the program. Representation at each level of administration was necessary to champion the initiative and provide continuity to project activities, especially with sta¡ turnover.
JOGNN, 39, 618-626; 2010. DOI: 10.1111/j.1552-6909.2010.01194.x
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PRINCIPLES & PRACTICE
Shaefer, S. J. M., Herman, S. E., Frank S. J., Adkins, M. and Terhaar, M.
Table 1: Nurses’ Opinions Versus Knowledge of Back Sleep Pre- and Postpolicy Change Prepolicy Change
Postpolicy Change
Opinion that back sleep is safest
79.5% (300/395)
89.2% (214/240)
w 2 (1, N 5 633) 5 17.49
Knew that the American Academy
84.8% (335/395)
94.2% (226/240)
w 2 (1, N 5 619) 5 8.53
of Pediatrics recommends back sleep Note. p .001. p .003.
Nursing Knowledge of Infant Safe Sleep and SIDS The Nurses’ Questionnaire assessed nurses’ knowledge of (a) risk factors for SIDS and (b) infant safe sleep practices pre- and posttraining. There was a small but signi¢cant increase in the number of safe sleep items correctly identi¢ed after the education program (pre- M 5 9.43, SD 5 1.33; postM 5 10.29, SD 5 1.04; t(623) 5 8.54, p o .001). When asked to identify SIDS risk factors, there was no signi¢cant di¡erence between nurses’ knowledge before and after the education program. Nurses on average identi¢ed seven out of 11 risk factors (pre- M 5 7.45, SD 5 1.36; post- M 5 7.44, SD 5 1.71). In addition, nurses were asked their opinions on the safest sleep position for an infant and then asked to identify the AAP-recommended sleep position. Following the educational program, signi¢cantly more nurses held the opinion that back sleep was safest and also knew that back sleep was recommended by AAP (Table 1). Of the nurses who still reported that stomach or side was safer, 62.4% at the pretest and 88.0% at the posttest knew that the AAPrecommended position was on the back.
Crib Audits A total of 1,296 cribs were audited prepolicy change, and 1,443 cribs were audited 6 to12 months after the new policies were implemented. At each time point
nearly one half the infants were found in their cribs (pre 44.7% [579/1,296]; post 48% [692/1,443]). Among infants who were in their cribs at the time of the audits, there was a signi¢cant increase in the percentage of infants on their backs from pre- to postpolicy change (Table 2) with all but one hospital having a positive increase in the percentage of infants on their back while in the crib. The hospital with a decrease in the percentage of infants on their backs in cribs extensively consolidated and reorganized obstetrical care with a profound impact on sta⁄ng between the pre- and postaudits. A subsequent follow-up after reinforcement of the new policy indicated that the percentage of infants on their backs was similar to all other hospitals at the postassessment. Findings from the crib audits showed a signi¢cant increase in the percentage of infants loosely or not bundled at the postaudits and a signi¢cant increase in the percentage of infants with their arms free of their blankets increased.
Mother’s Knowledge of Infant Safe Sleep As part of the crib audits, mothers were asked if they had received infant safe sleep information, had a crib at home, and were planning on using the crib. There was a signi¢cant increase in the percentage of mothers who had been told about infant safe sleep from 62.7% (793/1,265) to 91.4% (1,286/ 1,407), w 2 (1, N 5 2,672) 5 318.02, p o .001). At preand postaudits, nearly all mothers indicated that they had cribs at home (pre 97.2% [1,230/1,266],
Table 2: Crib Conditions Pre- and Post-Policy Change Crib Condition
Pre-policy Change
Post-policy Change
Infant on back
80.7% (467/579)
91.9% (636/692)
w 2 (1, N 5 1,271) 5 34.79
Loosely bundled
84.5% (1,045/1,236)
88.5% (1,210/1,367)
w 2 (1, N 5 2,603) 5 8.82
Arms free
46.1% (598/1,296)
62.1% (896/1,443)
w 2 (1, N 5 2,739) 5 70.07
Note. po.01. po.0001.
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post 96.2% [1,358/1,412]) and planned to use them (pre 98.7% [1,248/1,265], post 98.3% [1,386/1,410]).
Discussion Since 1992, the AAP has recommended supine sleep for infants to reduce the risk of SIDS. However, infant safe sleep practices have not been consistently adopted, and SIDS continues to account for more than 2,500 deaths each year in the United States. Parent knowledge of infant safe sleep can decrease risk of SIDS and sudden unexpected infant death. Studies indicate that parents listen to nurses and model their behavior regarding infant sleep practices. In 2005, the AAP recommended that health care professionals in intensive care nurseries, as well as those in well-infant nurseries, implement these recommendations well before an anticipated discharge. In the ISSHM project, some nurses were aware of the AAP-recommended sleep position but continued to believe that other positions were safer. The results indicate that in-service training improved from 80% to 90% nurses’ correct identi¢cation of safe sleep factors. Regardless, opinions lagged behind knowledge, and 10% of nurses still believed prone or side sleep to be the safest. This project and similar e¡orts (Carrier, 2009; Hein & Pettit, 2001; Macdonald, 2002; Mercier et al., 2007) demonstrate that education alone does not change practice and outcomes: knowledge of safe sleep recommendations may not change nurses’ beliefs and behavior. This change requires more effort. ISSHM extended infant safe sleep knowledge into sustainable safe sleep practices and behaviors because policies directed it and administration required it. New nursing practice policies resulted in changed nurse behavior. Pre- and postpolicy crib audits demonstrated the percentage of infants on their backs signi¢cantly increased from 80.7% to 91.9%. Nurses changed their behaviors to model correct sleep positioning of infants. Revised nursing practice policies resulted in more mothers receiving infant safe sleep information during their hospital stay as well as greater consistency and accuracy of that education. In the pretest 62.7% of new mothers had received instruction from hospital nurses to place babies on their back to sleep. In the posttest, 91.4% of the mothers had received instruction about infant safe sleep. VanKororn et al. (2010) found that the likelihood of mothers placing their babies in a supine position for sleep increased when a nurse was
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the source of information. Insuring that mothers hear a consistent message from nurses and see consistent behavior by nurses will increase the likelihood that mothers place infants in supine positions for sleep. Commitment at all levels of hospital administration was key to adopting and monitoring the desired change in nursing practice policies. Sta¡ turnover is a constant in nursing administration. As a potential barrier it should be anticipated and managed. This would require safe sleep practices to become part of orientation and an ongoing measure in any e¡ective performance improvement program. Additional considerations go beyond the hospital but can have an impact on the e¡ectiveness of parent education. Culture is an important consideration, particularly in African American and other communities where multigenerational households and support systems often hold to older practices, such as prone sleeping positions and bed sharing of infants with their mothers (Blair et al., 2009; Colson et al., 2009; Flick, Vemulapalli, Stulac, & Kemp, 2001; Hauck, Signore, Fein, & Raju, 2008; Moon, Oden, & Grady, 2004; Moon et al., 2010; VanKororn et al., 2010). Comments made by nurses on the audit forms point to this as a potential barrier. Overall, the results of this project demonstrate that sustainable infant safe sleep practices can be consistently and e¡ectively established in the hospital setting. These ¢ndings are consistent with Pankratz et al. (2002). The ISSHM has low cost and high bene¢t for protecting infants. The ISSHM approach is simple, easy to implement, and maintains ¢delity with well-documented best practices. Quarterly audits of infant safe sleep practices can be integrated into ongoing quality improvement activities to reinforce e¡ectiveness and ensure adherence to policy. Infant safe sleep training can be incorporated into annual competency requirements for nurses, and professional development programs can be o¡ered on a regular basis to reinforce the critical importance of infant safe sleep practices. Visual displays such as bulletin boards, information racks, and posters can be used to present continuing reminders for hospital sta¡, parents, and family members of infants. All can help to reinforce new behavior. Teaching new mothers about infant safe sleep needs to extend outside the hospital. Prenatal and postnatal clinics are important partners for teaching and reinforcing infant safe sleep practices as are child care centers, churches, and community.
JOGNN, 39, 618-626; 2010. DOI: 10.1111/j.1552-6909.2010.01194.x
http://jognn.awhonn.org
Shaefer, S. J. M., Herman, S. E., Frank S. J., Adkins, M. and Terhaar, M.
Limitations This was a demonstration project intended to achieve sustainable change in nurses’ behavior and parent education. As such, the ¢ndings are limited in generalizability. Careful consideration of hospital policies and conditions is needed if the results are to be achieved in other settings. More rigorous evaluation methods that track change in individual nurses’ knowledge and behavior as well as parents’ behaviors over time are needed to establish with con¢dence the e¡ect of the policy change on infant safe sleep practices. Interobserver reliability for crib audits was not established. The audit form was designed to limit di¡erences among observers (e.g., the infant is on his/her back or stomach or side) yet variability in observation was possible. Establishing consistency across observers would strengthen the tool for use in future quality improvement activities.
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American Academy of Pediatrics,Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. (2000). Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics, 105, 650-656. Berends, M., Bodilly, S. J., & Kirby, S. N. (2002). Facing the challenges of whole-school reform. New American schools after a decade. Santa Monica, CA: RAND. Blair, P. S., Sidebothan, P., Evanson-Coombe, C., Edmonds, M., HeckstallSmiht, E., & Fleming, P. (2009). Hazardous cosleeping environments and risk factors amenable to change: Case-control study of SIDS in south west England. British Medical Journal, 339, b3666. Carrier, C. T. (2009). Back to sleep: A culture change to improve practice. Newborn and Infant Nursing Reviews, 9,163-168. Coleman, J. J. (2009). Culture care meanings of African American parents related to infant mortality and health care. Journal of Cultural Diversity, 16,109-119. Colson, E. R., Rybin, D., Smith, L. A., Colton, T., Lister, G., & Corwin, M. J. (2009). Trends and factors associated with infant sleeping position: The National Infant Sleep Position Study, 1993-2007. Archives of Pediatric and Adolescent Medicine, 163,1122-1128. Dusenbury, L., Brannigan, R., Falco, M., & Weissberg, R. P. (2003). A review of research on ¢delity of implementation: Implications for drug
Conclusions Adoption of new evidence is a challenge that requires time, attention to detail, and follow through. Education may change knowledge; but change in practice requires authority and infrastructure. Sustained change in clinical practice needs commitment of both administration and line sta¡ focused on a common goal.
abuse prevention in school settings. Health Education Research, 18, 237-256. Dwyer, T., & Ponsonby, A. L. (2009). Sudden infant death syndrome and prone sleeping position. Annals of Epidemiology, 19, 245-249. Farrell, A. D., Meyer, A. L., Kung, E. M., & Sullivan,T. N. (2001). Development and evaluation of school based violence prevention programs. Journal of Clinical Child Psychology, 30, 207-220. Flick, L., Vemulapalli, C., Stulac, B., & Kemp, J. S. (2001). The In£uence of grandmothers and other senior caregivers on sleep position used by African American infants. Archives of Pediatric and Adolescent Medicine, 155, 1231-1237.
The goal of this project was to develop an approach to create sustainable change in nurses’ behaviors through quality improvement processes already established within the hospital organization. As a result of collaboration betweenTomorrow’s Child and multiple independent hospitals and nursing sta¡s, a shared goal was achieved. Safe sleep practices were adopted by nurses, demonstrated and taught to parents, and implemented in the community. The longterm outcomes are still to be documented. And yet the immediate practice improvements are impressive. The ultimate improvement is the saving of infant lives.
Foxcroft, D., & Cole, N. (2000). Organizational infrastructures to promote evidence based nursing practice. Cochrane Database of Systematic Reviews, 3. Art. No.: CD002212. doi:10.1002/14651858.CD002212 Hallfors, D., & Godette, D. (2002). Will principles of e¡ectiveness improve prevention practice? Early ¢ndings from a di¡usion study. Health Education Research: Theory and Practice, 17, 461-470. Hauck, F. R., Signore, C., Fein, S. B., & Raju, T. (2008). Infant sleeping arrangements and practices during the ¢rst year of life. Pediatrics, 122,113-120. Hein, H. A., & Pettit, S. F. (2001). Back to sleep: Good advice for parents but not for hospitals? Pediatrics, 107, 537-539. Kam, C. M., Greenberg, M. T., & Walls, C. T. (2003). Examining the role of implementation quality in school based prevention using the PATHS curriculum. Prevention Science, 4, 55-63. Kemp, J. S., Unger, B., Wilkins, D., Psara, R. M., Ledbetter, T. L., Graham, M. A., et al. (2000). Unsafe sleep practices and an analysis of bed-
Acknowledgments Supported by a grant from The Skillman Foundation, Detroit, Michigan toTomorrow’s Child/Michigan SIDS, Lansing, Michigan. The authors acknowledge the Michigan Department of Community Health for ongoing support of Infant Safe Sleep.
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, 111,106-113. Macdonald, G. (2002). Transformative unlearning: Safety, discernment and communities of learning. Nursing Inquiry, 9,170-178. Mathews, T. J., & MacDorman, M. F. (2007). Infant mortality statistics from the 2004 period linked birth/infant death data set (National Vital Statistics Reports, 55(15)). Hyattsville, MD: National Center for
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from http://www.mdch.state.mi.us/pha/osr/InDxMain/BckCoTbl. asp Michigan Department of Community Health. (2007b). White three-year moving average infant death rates by county. Retrieved from http://www.mdch.state.mi.us/pha/osr/InDxMain/WtCoTbl.asp Moon, R. Y., Gingras, J. L., & Erwin, R. (2002). Physician beliefs and practices regarding SIDS and SIDS risk reduction. Clinical Pediatrics, 41, 391-395. Moon, R. Y., Horne, R., & Hauck, F. (2007). Sudden infant death syndrome. Lancet, 370, 1578-1587. Moon, R. Y., Oden, R. P., & Grady, K. C. (2004). Back to sleep: An educational intervention with women, infants, and children program clients. Pediatrics, 113, 542-547. Moon, R.Y., Oden, R. P., Joyner, B. L., & Ajao,T. I. (2010). Qualitative analysis
to sleep campaign. Pediatrics, 109, 608-614. Price, S. K., Hillman, L., Gardner, P., Schenk, K., & Warren, C. (2008). Changing hospital newborn nursery practice: Results from a statewide ‘‘Back to Sleep’’ nurses training program. Maternal and Child Health Journal, 12, 363-371. Rasinski, K., Kuby, A., Bzdusek, S. A., Silvestri, J. M., & Weese-Mayer, D. E. (2003). E¡ect of a sudden infant death syndrome risk reduction education program on risk factor compliance and information sources in primarily black urban communities. Pediatrics, 111, 347-354. Rogers, E. M. (2003). Di¡usion of innovations (5th ed.). New York: Free Press.
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Moon, R.Y., & Omron, R. (2002). Determinants of infant sleep position in an urban population. Clinical Pediatrics, 41, 569-573. Moos, M. (2006). The prevention chronicles, responding to the newest evidence about SIDS. AWHONN Lifelines, 10,163-166. Newhouse, R. P., Dearholt, S., Poe, S., Pugh, L. C., & White, K. M. (2007). Organizational change strategies for evidence based practice. Journal of Nursing Administration, 37, 552-557.
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302-333. VanKororn, I. V., Corwin, M. J., Rybin, D. V., Heeren,T. C., Lister, G., & Colson, E. R. (2010). In£uence of prior advice and beliefs of mothers on infant sleep position. Archives of Pediatric and Adolescent Medicine, 164, 363-369. Wallin, L. (2009). Knowledge translation and implementation research in nursing. International Journal of Nursing Studies, 46, 576-587.
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Translating Infant Safe Sleep Evidence Into Nursing Practice Sarah J. M. Shaefer, Sandra E. Herman, Sandra J. Frank, Mary Adkins, and Mary Terhaar
Correspondence Sandra J. Frank, JD, Tomorrow’s Child/Michigan SIDS, 112 E. Allegan, Suite 500, Lansing, MI 48933. sfrank@tomorrowschildmi. org Keywords back to sleep infant safe sleep sudden infant death syndrome (SIDS) sudden unexpected infant death (SUID) evidence based practice translation research research adoption
Sarah J. M. Shaefer, PhD, RN, is an assistant professor, Department of Community-Public Health, Johns Hopkins University School of Nursing, Baltimore, MD. Sandra E. Herman, PhD, is an independent evaluation consultant and past associate director for the Center for Statistical Training and Consulting, Michigan State University, East Lansing, MI. Sandra J. Frank, JD, CAE, is the chief executive officer of Tomorrow’s Child/ Michigan SIDS, Lansing, MI.
ABSTRACT 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.
JOGNN, 39, 618-626; 2010. DOI: 10.1111/j.1552-6909.2010.01194.x Accepted August 2010
nfants who sleep on their backs in a safe sleep environment have a decreased risk of dying suddenly and unexpectedly (American Academy of Pediatrics [AAP], 2005; American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome, 2000; Moon, Horne, & Hauck, 2007; Pollack & Frohna, 2002). The infant safe sleep e¡ort began with the Back to Sleep Campaign of the 1990s, which reduced the number of babies dying from sudden infant death syndrome (SIDS) by half (AAP, 2005). The U.S. Public Health Service, the AAP, the SIDS Alliance, and the Association of SIDS and Infant Mortality Programs implemented the Back to Sleep Campaign across the United States in 1994.
I
nation closer to attaining the goals of Healthy People 2020.
Infant Safe Sleep The AAP (2005) has identi¢ed 11 recommendations regarding infant sleep environment to reduce the risk of SIDS and sudden unexpected deaths in healthy infants. The ¢rst is back sleep (supine position) for infants. Neither side nor prone sleeping positions are considered safe. The sleep environment (crib) should have a ¢rm sleep surface, be free of soft material or objects (i.e., pillows, quilts, sheepskins, stu¡ed toys, etc.), should not have loose bedding or pillow-like bumper pads, and if a blanket is used, the baby’s feet are at the bottom of the crib, the blanket is no higher than the baby’s chest, and it is tucked in around the crib mattress. Mothers should not smoke during pregnancy, and infants’ exposure to secondhand smoke should be avoided. A separate but proximal sleeping environment to parents is recommended as most safe. Parents should avoid overheating their infants by keeping the bedroom temperature in a range that is comfortable for lightly clothed adults. The AAP recommends the limited use of paci¢ers when the infant is put down for sleep if the child is willing to accept it. Additionally, the AAP recommends avoiding
The authors report no conflict of interest or relevant financial relationships.
Back sleep is supported by a substantial body of evidence (AAP, 2005; Colson et al., 2009; Dwyer & Ponsonby, 2009) and is a simple, inexpensive intervention for parents and communities. Nevertheless, it is inconsistently adopted in communities and often rejected by parents with concerns about infant comfort, choking, and inconsistent advice from physicians (Colson et al.; VanKororn et al., 2010). Strategies that accelerate adoption of Back to Sleep and infant safe sleep guidelines promise to save lives and move the
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& 2010 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Mary Adkins, RN, MSW, is the program director of Tomorrow’s Child/ Michigan SIDS, Lansing, MI. (Continued)
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Shaefer, S. J. M., Herman, S. E., Frank S. J., Adkins, M. and Terhaar, M.
the use of commercial devices marketed to reduce SIDS such as positioners and the use of home respiratory and cardiac monitors. ‘‘Tummy time’’ when the infant is awake and observed is encouraged to avoid positional plagiocephaly. Finally, the AAP supports the continuation of Back to Sleep. In this article, the term infant safe sleep encompasses infant position at bed or nap time and other modi¢able risk factors including infant sleep environment and maternal/infant risk factors. Although information about risk factors is often presented in prenatal educational programs, continuing education on modi¢able risk factors including sleep environment and sleep position at sleep/nap time is important. The most signi¢cant risk factor is prone position. Prone position is associated with an increased risk of death by SIDS (Kemp et al., 2000; Mathews & MacDorman, 2007; Moon et al., 2007). Signi¢cant reductions in the SIDS rates have been related to placing infants on their back to sleep (American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome, 2000; Colson et al., 2009; Dwyer & Ponsonby, 2009). Moon, Oden, Joyner, and Ajao (2010), however, reported that African American mothers often did not understand the relationship between their behaviors and the risk for SIDS, and improvements in the consistency of the message are needed to change how mothers place their infants for sleep.
Nurses as Role Models Given that SIDS accounts for more than 2,500 deaths each year in the United States, increasing adoption of infant safe sleep as common practice promises to save a signi¢cant number of lives (Dwyer & Ponsonby, 2009). Parental knowledge of safe sleep is key to decreasing risk of unexpected infant deaths. Studies have indicated that parents listen to nurses and model their actions regarding the sleep position of their new infant (Carrier, 2009; Hein & Pettit, 2001; Moos, 2006; VanKororn et al., 2010). In a study of African American mothers, Rasinski, Kuby, Bzdusek, Silvestri, and WeeseMayer (2003) reported that verbal messages from doctors and nurses increased the use of back sleeping after discharge. Carrier concluded that parents are likely to do what they see the nurse do in the hospital. Moon and Omron (2002), however, pointed out that though 70% of parents reported receiving information about infant safe sleep from a health care provider, only 10% could recall that back sleep was safest. The nurse’s behavior is essential in in£uencing parents to place their babies in a safe sleep environment. Price, Hillman,
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More than a decade after Back to Sleep was initiated, infant safe sleep practices have not been consistently adopted.
Gardner, Schenk, and Warren (2008) reported that health care professionals’ knowledge acquisition, attitudes, and practice intentions increased signi¢cantly with sta¡ education programs. Translating this knowledge into nursing practice, however, has to date been problematic (Carrier; Hein & Pettit; Mercier et al., 2007).
The Challenge of Translating Evidence Into Practice Delay in implementation of the infant safe sleep message is similar to delays in implementation of other evidence-based strategies that bring new knowledge to bear on practice (Wallin, 2009). Delays between 7 and 11 years are commonly reported and are attributed to three factors: lack of awareness of new knowledge on the part of clinicians who could put innovation into practice, lack of authority to change practice, and lack of infrastructure to facilitate adoption of innovation (Foxcroft & Cole, 2000). When new knowledge is adopted, lack of ¢delity to the model with imperfect or imprecise adherence can be a problem (Dusenbury, Brannigan, Falco, & Weissberg, 2003). When intervention does not closely adhere to the prescription of the evidence, the desired e¡ect can only be partially achieved, if achieved at all. For this reason, ¢delity to evidence-based models is essential to attaining desired outcomes. To reduce delay in implementation and promote ¢delity to best practice, barriers to adoption of new knowledge must be overcome. Implementation is well served by collaboration between researchers and practitioners paying careful attention to the speci¢c practice environment into which the new knowledge is to be translated (Rohrbach, Grana, Sussman, & Valente, 2006). Investment in leadership, structure, goal setting, skills, resources, and competencies will help (Newhouse, Dearholt, Poe, Pugh, & White, 2007). Health education studies suggest that innovations are more likely to be adopted when there are clear instructions, welldeveloped user-friendly materials, and a clear rationale for actions and the desired outcomes (Hallfors & Godette, 2002; Pankratz, Hallfors, & Cho, 2002). Pankratz et al. also found that adoption of innovation in health care was more likely when the relative advantage in terms of cost were low and bene¢ts high, complexity of the innovation was low, and
Mary Terhaar, DNSc, RN, is an assistant professor in the Department of Health Systems and Outcomes and Interim Director, DNP Program, Johns Hopkins University School of Nursing, Baltimore MD.
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Organizations have been more successful in adopting innovations when strong leadership, effective administrative structures, and open communication are in place.
observability of the change was high (easy to do). Organizations have been found more successful in e¡orts in adopting innovations when strong leadership, e¡ective administrative structures, and open communication are in place (Berends, Bodilly, & Kirby, 2002; Farrell, Meyer, Kung, & Sullivan, 2001; Kam, Greenberg, & Walls, 2003). Adoption or rejection of innovations (Rogers, 2003), such as adopting infant safe sleep guidelines into routine practice, begins with gaining knowledge (i.e., educating nurses on the AAP guidelines), followed by e¡orts to persuade individuals and/ or organizations of the bene¢ts of adopting the innovation, a decision to adopt, and then implementation of the change (i.e., change in hospital policies to included infant safe sleep guidelines). In the area of infant safe sleep, the innovative process in Michigan had proceeded through the knowledge-gaining phase, but no models were available to move the knowledge into sustainable change in clinical practice.
Institutionalizing Infant Safe Sleep From 2003 to 2005, infant death rates for African Americans were approximately 17.6 compared to White rate of 5.7, and the infant death rate continued to be higher than the average for the country (Michigan Department of Community Health, 2007a, 2007b). The authors describe the development and demonstration of the Infant Safe Sleep Hospital model (ISSHM) in urban Michigan hospitals as a response to the continuing high rates of SIDS and sudden unexpected infant deaths among non-Hispanic African American infants. The e¡ort focused on hospitals’ abilities to develop, implement, and assess compliance with nursing practice policy. The result is a quality improvement process that translates the AAP guidelines on infant safe sleep into hospital-wide and system-wide nursing practice. This article describes 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. The collaborative e¡ort was initiated by Tomorrow’s Child/Michigan SIDS with seven ur-
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ban hospitals to improve adoption of evidence about infant safe sleep in routine hospital care of newborns and their mothers, and to identify the e¡ects of policy changes on nursing practice. The purpose of the project was to develop a model for creating sustainable changes in nurses’ behaviors that could be monitored through quality improvement processes already established within the hospital organization.
Methods Quality Improvement Model Development At the outset of the project, an external evaluator in Michigan was retained to develop and re¢ne data collection procedures and tools. Project sta¡ worked with administrators, sta¡ nurses, and nurse educators at seven hospitals in two phases to develop and demonstrate a quality improvement process. In Phase 1, Tomorrow’s Child invited two hospitals to participate by contacting a nurse educator at each hospital. Both hospitals agreed to participate and formed infant safe sleep workgroups consisting of sta¡ nurses, nurse educators, and nursing supervisors. Workgroups met regularly for the duration of the project. Meetings were convened by Tomorrow’s Child sta¡ to assist in initiating the project activities and to provide guidance. Each workgroup identi¢ed all policies that a¡ected newborns and their mothers at their hospital. Workgroups were charged with reviewing and revising their hospital nursing practice policies to include infant safe sleep in clinical practices and information on infant safe sleep in their patient education materials. They were also responsible for developing methods for implementing the policy changes, including in-service training materials for nurse education, materials for patients, and a tool for auditing cribs during regular visits to patient rooms by workgroup nurses. Hospitals chose not to seek Institutional Review Board (IRB) approval because project activities were implemented by hospital employees as part of regular hospital activities, did not collect identi¢able information about patients or nurses, and were used only for aggregated monitoring of hospital procedures. The evaluator conducted group interviews with members of Phase 1 workgroups to identify successes and barriers in developing and implementing infant safe sleep policies. Results from the Phase 1 group interviews were used to re¢ne the approach used with Phase 2 hospitals. One lesson from Phase 1 was the need to engage management level support at the beginning of the process. Consequently, Phase 2
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Shaefer, S. J. M., Herman, S. E., Frank S. J., Adkins, M. and Terhaar, M.
hospitals were approached through the director of nursing and workgroup appointments included management as well as sta¡ nurses, nurse educators, and nursing supervisors. The model policies and assessment tools developed during Phase 1 were used to guide the review and revision process of ¢ve Phase 2 hospitals. Each hospital created policies to ¢t their environments. The Phase 2 hospitals did not choose to seek IRB approval because project activities were implemented by hospital employees as part of regular hospital activities, did not collect identi¢able information about patients or nurses, and were used only for aggregated monitoring of hospital procedures. The evaluator conducted group interviews with members of all seven workgroups to identify successes and barriers in developing and implementing infant safe sleep policies.
Intervention Setting and Sample Size. A total of seven hospitals in three geographically diverse urban regions of Michigan participated from 2004 through 2007. Hospitals from three counties with high disparity in death rates between African American and White infants were invited and agreed to participate. A total of 635 sta¡ nurses, who worked with new mothers and their infants, across the seven hospitals completed the Nurses’ Questionnaire and participated in the in-service trainings. Participating nurses had worked with newborns for an average of 13.37 years (SD 5 9.53, N 5 484). A total of 2,739 cribs were examined during the monitoring phase of the project. A total of 2,678 mothers of newborns were asked to answer three questions during their postdelivery hospital stay. Data on ethnicity collected at the ¢ve Phase 2 hospitals revealed that 53.0% were White (681/1,285), 32.6% (419/1,285) were African American, and 14.4% (185/1,285) all other ethnic groups.
Procedures Nursing Practice Policies. Existing nursing policies were submitted to the evaluator for qualitative analysis. At each hospital, the workgroup drafted new policy documents and procedures for nursing practice policies and parent education. Workgroup members were responsible for obtaining approval from their administration to replace the existing policies with the new policies. Concurrent with the policy development activities, the nurses from the workgroup conducted the initial unannounced audits of cribs of healthy newborn infants. During these visits to patients’ rooms, the nurse noted the location and position of the infant, items in the crib, and asked the mother if she had been told about infant safe sleep. Audits were conducted again 6 to 12
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Adoption of nursing policies was a shorter process and met with fewer barriers when hospital administrators were included early in the process.
months later.The results of the audit were discussed as part of the policy development activities. After the new nursing policies had been approved, in-service trainings on the infant safe sleep were provided to nurses working with mothers and newborns. Nurses were asked to complete a short questionnaire at the beginning of the in-service training and were asked to complete the same questionnaire 6 to 12 months later. Responses to the follow-up questionnaires were not matched with the pre-in-service responses. The average time from initiation of project to ¢nal data collection ranged from 6 to 12 months.
Instruments and Measures Infant Safe Sleep Policy Review Form. The evaluator developed a policy review form based on AAP guidelines (American Academy of Pediatrics, Task Force on Infant Sleep Position and Sudden Infant Death Syndrome, 2000; AAP, 2005). The ¢rst set of 10 criteria assessed the presence or absence of procedures that described how infants were to be placed in their cribs and how infant safe sleep education was to be provided to mothers and documented. The second set of 10 criteria assessed the presence or absences of the core elements of safe sleep practices in the hospital’s written policies. Crib Audit Form. A single page crib audit form was created to collect information on sleep position of the infant (back, stomach, side); bundling of the infant (tight, loose, not bundled), arms outside of blanket (yes/no); ethnicity of the child (phase-2, post only); and three questions for the mother: (a) had she received information on infant safe sleep (yes/no), (b) did she have a crib at home (yes/no), (c) did she plan to use a crib when she returned home (yes/no). Nurses’ Questionnaire. The Nurses’ Questionnaire was developed to assess nurses’ knowledge of (a) risk factors for SIDS and (b) infant safe sleep practices pre- and posttraining. The nurses’ questionnaire was based on a questionnaire developed by Moon, Gingras, and Erwin (2002). Knowledge of SIDS risk factors was assessed using a list of 11 factors of which seven are risk factors for SIDS and four are not. Nurses checked all the factors they
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thought were risk factors for SIDS. A SIDS knowledge score was created by counting the number items correctly identi¢ed as factors or nonfactors (possible range 0-11). Knowledge of infant safe sleep was assessed using 11 true-false questions based on the AAP guidelines (2000). A safe sleep knowledge score was created by counting the number of items with correct answers (possible range 0-11). Nurses were also asked for their opinions on safest sleep position and to identify the AAP-recommended infant sleep position. Responses to this questionnaire were similar to those found by Moon et al. (2002). The content of the questionnaire accurately re£ected established risk factors for SIDS and the 2005 AAP guidelines on infant safe sleep.Test-retest reliability was not evaluated.
accuracy. Percentages were calculated for audit items. Numbers of responses to each variable di¡er due to missing responses. Cross-tabular analyses with chi-square were used to examine the distribution of responses by time point. Data from the Nurses’ Questionnaire were analyzed to obtain the number of correct responses to items about risk factors for SIDS and the number of correct statements identi¢ed related to knowledge of infant safe sleep practices. Pre- and postpolicy change assessments were compared using independent sample t tests on the pre- and posttraining assessments. Di¡erences between the total number of assessments collected and total responses for variables used in the analyses are due to missing responses.
Data Management The evaluator conducted qualitative and quantitative analyses and provided feedback on data collected during the development of the quality improvement process. Data forms were collected at each hospital by the workgroup and given to the Tomorrow’s Child project coordinator. The Tomorrow’s Child project coordinator delivered the forms to the evaluator for data entry. Data from audits and Nurses’ Questionnaires were entered into SPSS Version 17 ¢les by the evaluator for analysis. No names or uniquely identifying information were stored in the data ¢les.
Data Analysis At the start of the project, the existing hospital policies were reviewed by the evaluator using the Infant Safe Sleep Policy Review form. In assessing the existing policies, the evaluator read each hospital policy to identify statements that would instruct the professional sta¡ on expectations related to infant safe sleep, when they are expected to carry out the program, and documentation. The evaluator also looked for statements in the policies that speci¢ed the key elements of infant safe sleep. Completed review forms were provided to each hospital workgroup as feedback and used in further revisions to the policies. The evaluator conducted group interviews with members of the hospital workgroups. The focus of the interviews was to identify barriers and facilitators to development and implementation of this policy. Responses to the group interview were summarized by the evaluator. Factors contributing to success as well as barriers were identi¢ed and con¢rmed with the workgroups. The distributions of variables in the questionnaires and audit form were examined to ensure data entry
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Results Nursing Practice Policies At the beginning of the project, none of the hospitals had nursing policies that met the two sets of criteria for adequate infant safe sleep practice. Each hospital drafted new model policies for nursing practice that were adopted after substantial review and discussion with hospital administration. Adoption of nursing policies was a shorter process and met with fewer barriers in the Phase 2 hospitals where hospital administrators were included early in the process. At Phase 1 hospitals, adoption of the new policies took about 12 months and several meetings of Tomorrow’s Child’s director with the hospital management to successfully complete the policy change. At Phase 2 hospitals, policies were revised and implemented approximately 6 months after initiating the policy change process. Analysis of the group interview responses re£ected the di¡erent approaches used during Phase 1 and Phase 2. Participants from both phases believed that the participation of management, sta¡ nurses, nurse educators, and nursing supervisors, was imperative for success, with Phase 1 hospital participants emphasizing the barriers they encountered because hospital administration was not involved early in the policy development process. Participants uniformly agreed that all levels of administration within hospitals needed to be aware and committed to the implementation of the program. Representation at each level of administration was necessary to champion the initiative and provide continuity to project activities, especially with sta¡ turnover.
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Table 1: Nurses’ Opinions Versus Knowledge of Back Sleep Pre- and Postpolicy Change Prepolicy Change
Postpolicy Change
Opinion that back sleep is safest
79.5% (300/395)
89.2% (214/240)
w 2 (1, N 5 633) 5 17.49
Knew that the American Academy
84.8% (335/395)
94.2% (226/240)
w 2 (1, N 5 619) 5 8.53
of Pediatrics recommends back sleep Note. p .001. p .003.
Nursing Knowledge of Infant Safe Sleep and SIDS The Nurses’ Questionnaire assessed nurses’ knowledge of (a) risk factors for SIDS and (b) infant safe sleep practices pre- and posttraining. There was a small but signi¢cant increase in the number of safe sleep items correctly identi¢ed after the education program (pre- M 5 9.43, SD 5 1.33; postM 5 10.29, SD 5 1.04; t(623) 5 8.54, p o .001). When asked to identify SIDS risk factors, there was no signi¢cant di¡erence between nurses’ knowledge before and after the education program. Nurses on average identi¢ed seven out of 11 risk factors (pre- M 5 7.45, SD 5 1.36; post- M 5 7.44, SD 5 1.71). In addition, nurses were asked their opinions on the safest sleep position for an infant and then asked to identify the AAP-recommended sleep position. Following the educational program, signi¢cantly more nurses held the opinion that back sleep was safest and also knew that back sleep was recommended by AAP (Table 1). Of the nurses who still reported that stomach or side was safer, 62.4% at the pretest and 88.0% at the posttest knew that the AAPrecommended position was on the back.
Crib Audits A total of 1,296 cribs were audited prepolicy change, and 1,443 cribs were audited 6 to12 months after the new policies were implemented. At each time point
nearly one half the infants were found in their cribs (pre 44.7% [579/1,296]; post 48% [692/1,443]). Among infants who were in their cribs at the time of the audits, there was a signi¢cant increase in the percentage of infants on their backs from pre- to postpolicy change (Table 2) with all but one hospital having a positive increase in the percentage of infants on their back while in the crib. The hospital with a decrease in the percentage of infants on their backs in cribs extensively consolidated and reorganized obstetrical care with a profound impact on sta⁄ng between the pre- and postaudits. A subsequent follow-up after reinforcement of the new policy indicated that the percentage of infants on their backs was similar to all other hospitals at the postassessment. Findings from the crib audits showed a signi¢cant increase in the percentage of infants loosely or not bundled at the postaudits and a signi¢cant increase in the percentage of infants with their arms free of their blankets increased.
Mother’s Knowledge of Infant Safe Sleep As part of the crib audits, mothers were asked if they had received infant safe sleep information, had a crib at home, and were planning on using the crib. There was a signi¢cant increase in the percentage of mothers who had been told about infant safe sleep from 62.7% (793/1,265) to 91.4% (1,286/ 1,407), w 2 (1, N 5 2,672) 5 318.02, p o .001). At preand postaudits, nearly all mothers indicated that they had cribs at home (pre 97.2% [1,230/1,266],
Table 2: Crib Conditions Pre- and Post-Policy Change Crib Condition
Pre-policy Change
Post-policy Change
Infant on back
80.7% (467/579)
91.9% (636/692)
w 2 (1, N 5 1,271) 5 34.79
Loosely bundled
84.5% (1,045/1,236)
88.5% (1,210/1,367)
w 2 (1, N 5 2,603) 5 8.82
Arms free
46.1% (598/1,296)
62.1% (896/1,443)
w 2 (1, N 5 2,739) 5 70.07
Note. po.01. po.0001.
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post 96.2% [1,358/1,412]) and planned to use them (pre 98.7% [1,248/1,265], post 98.3% [1,386/1,410]).
Discussion Since 1992, the AAP has recommended supine sleep for infants to reduce the risk of SIDS. However, infant safe sleep practices have not been consistently adopted, and SIDS continues to account for more than 2,500 deaths each year in the United States. Parent knowledge of infant safe sleep can decrease risk of SIDS and sudden unexpected infant death. Studies indicate that parents listen to nurses and model their behavior regarding infant sleep practices. In 2005, the AAP recommended that health care professionals in intensive care nurseries, as well as those in well-infant nurseries, implement these recommendations well before an anticipated discharge. In the ISSHM project, some nurses were aware of the AAP-recommended sleep position but continued to believe that other positions were safer. The results indicate that in-service training improved from 80% to 90% nurses’ correct identi¢cation of safe sleep factors. Regardless, opinions lagged behind knowledge, and 10% of nurses still believed prone or side sleep to be the safest. This project and similar e¡orts (Carrier, 2009; Hein & Pettit, 2001; Macdonald, 2002; Mercier et al., 2007) demonstrate that education alone does not change practice and outcomes: knowledge of safe sleep recommendations may not change nurses’ beliefs and behavior. This change requires more effort. ISSHM extended infant safe sleep knowledge into sustainable safe sleep practices and behaviors because policies directed it and administration required it. New nursing practice policies resulted in changed nurse behavior. Pre- and postpolicy crib audits demonstrated the percentage of infants on their backs signi¢cantly increased from 80.7% to 91.9%. Nurses changed their behaviors to model correct sleep positioning of infants. Revised nursing practice policies resulted in more mothers receiving infant safe sleep information during their hospital stay as well as greater consistency and accuracy of that education. In the pretest 62.7% of new mothers had received instruction from hospital nurses to place babies on their back to sleep. In the posttest, 91.4% of the mothers had received instruction about infant safe sleep. VanKororn et al. (2010) found that the likelihood of mothers placing their babies in a supine position for sleep increased when a nurse was
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the source of information. Insuring that mothers hear a consistent message from nurses and see consistent behavior by nurses will increase the likelihood that mothers place infants in supine positions for sleep. Commitment at all levels of hospital administration was key to adopting and monitoring the desired change in nursing practice policies. Sta¡ turnover is a constant in nursing administration. As a potential barrier it should be anticipated and managed. This would require safe sleep practices to become part of orientation and an ongoing measure in any e¡ective performance improvement program. Additional considerations go beyond the hospital but can have an impact on the e¡ectiveness of parent education. Culture is an important consideration, particularly in African American and other communities where multigenerational households and support systems often hold to older practices, such as prone sleeping positions and bed sharing of infants with their mothers (Blair et al., 2009; Colson et al., 2009; Flick, Vemulapalli, Stulac, & Kemp, 2001; Hauck, Signore, Fein, & Raju, 2008; Moon, Oden, & Grady, 2004; Moon et al., 2010; VanKororn et al., 2010). Comments made by nurses on the audit forms point to this as a potential barrier. Overall, the results of this project demonstrate that sustainable infant safe sleep practices can be consistently and e¡ectively established in the hospital setting. These ¢ndings are consistent with Pankratz et al. (2002). The ISSHM has low cost and high bene¢t for protecting infants. The ISSHM approach is simple, easy to implement, and maintains ¢delity with well-documented best practices. Quarterly audits of infant safe sleep practices can be integrated into ongoing quality improvement activities to reinforce e¡ectiveness and ensure adherence to policy. Infant safe sleep training can be incorporated into annual competency requirements for nurses, and professional development programs can be o¡ered on a regular basis to reinforce the critical importance of infant safe sleep practices. Visual displays such as bulletin boards, information racks, and posters can be used to present continuing reminders for hospital sta¡, parents, and family members of infants. All can help to reinforce new behavior. Teaching new mothers about infant safe sleep needs to extend outside the hospital. Prenatal and postnatal clinics are important partners for teaching and reinforcing infant safe sleep practices as are child care centers, churches, and community.
JOGNN, 39, 618-626; 2010. DOI: 10.1111/j.1552-6909.2010.01194.x
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Shaefer, S. J. M., Herman, S. E., Frank S. J., Adkins, M. and Terhaar, M.
Limitations This was a demonstration project intended to achieve sustainable change in nurses’ behavior and parent education. As such, the ¢ndings are limited in generalizability. Careful consideration of hospital policies and conditions is needed if the results are to be achieved in other settings. More rigorous evaluation methods that track change in individual nurses’ knowledge and behavior as well as parents’ behaviors over time are needed to establish with con¢dence the e¡ect of the policy change on infant safe sleep practices. Interobserver reliability for crib audits was not established. The audit form was designed to limit di¡erences among observers (e.g., the infant is on his/her back or stomach or side) yet variability in observation was possible. Establishing consistency across observers would strengthen the tool for use in future quality improvement activities.
PRINCIPLES & PRACTICE
American Academy of Pediatrics,Task Force on Infant Sleep Position and Sudden Infant Death Syndrome. (2000). Changing concepts of sudden infant death syndrome: Implications for infant sleeping environment and sleep position. Pediatrics, 105, 650-656. Berends, M., Bodilly, S. J., & Kirby, S. N. (2002). Facing the challenges of whole-school reform. New American schools after a decade. Santa Monica, CA: RAND. Blair, P. S., Sidebothan, P., Evanson-Coombe, C., Edmonds, M., HeckstallSmiht, E., & Fleming, P. (2009). Hazardous cosleeping environments and risk factors amenable to change: Case-control study of SIDS in south west England. British Medical Journal, 339, b3666. Carrier, C. T. (2009). Back to sleep: A culture change to improve practice. Newborn and Infant Nursing Reviews, 9,163-168. Coleman, J. J. (2009). Culture care meanings of African American parents related to infant mortality and health care. Journal of Cultural Diversity, 16,109-119. Colson, E. R., Rybin, D., Smith, L. A., Colton, T., Lister, G., & Corwin, M. J. (2009). Trends and factors associated with infant sleeping position: The National Infant Sleep Position Study, 1993-2007. Archives of Pediatric and Adolescent Medicine, 163,1122-1128. Dusenbury, L., Brannigan, R., Falco, M., & Weissberg, R. P. (2003). A review of research on ¢delity of implementation: Implications for drug
Conclusions Adoption of new evidence is a challenge that requires time, attention to detail, and follow through. Education may change knowledge; but change in practice requires authority and infrastructure. Sustained change in clinical practice needs commitment of both administration and line sta¡ focused on a common goal.
abuse prevention in school settings. Health Education Research, 18, 237-256. Dwyer, T., & Ponsonby, A. L. (2009). Sudden infant death syndrome and prone sleeping position. Annals of Epidemiology, 19, 245-249. Farrell, A. D., Meyer, A. L., Kung, E. M., & Sullivan,T. N. (2001). Development and evaluation of school based violence prevention programs. Journal of Clinical Child Psychology, 30, 207-220. Flick, L., Vemulapalli, C., Stulac, B., & Kemp, J. S. (2001). The In£uence of grandmothers and other senior caregivers on sleep position used by African American infants. Archives of Pediatric and Adolescent Medicine, 155, 1231-1237.
The goal of this project was to develop an approach to create sustainable change in nurses’ behaviors through quality improvement processes already established within the hospital organization. As a result of collaboration betweenTomorrow’s Child and multiple independent hospitals and nursing sta¡s, a shared goal was achieved. Safe sleep practices were adopted by nurses, demonstrated and taught to parents, and implemented in the community. The longterm outcomes are still to be documented. And yet the immediate practice improvements are impressive. The ultimate improvement is the saving of infant lives.
Foxcroft, D., & Cole, N. (2000). Organizational infrastructures to promote evidence based nursing practice. Cochrane Database of Systematic Reviews, 3. Art. No.: CD002212. doi:10.1002/14651858.CD002212 Hallfors, D., & Godette, D. (2002). Will principles of e¡ectiveness improve prevention practice? Early ¢ndings from a di¡usion study. Health Education Research: Theory and Practice, 17, 461-470. Hauck, F. R., Signore, C., Fein, S. B., & Raju, T. (2008). Infant sleeping arrangements and practices during the ¢rst year of life. Pediatrics, 122,113-120. Hein, H. A., & Pettit, S. F. (2001). Back to sleep: Good advice for parents but not for hospitals? Pediatrics, 107, 537-539. Kam, C. M., Greenberg, M. T., & Walls, C. T. (2003). Examining the role of implementation quality in school based prevention using the PATHS curriculum. Prevention Science, 4, 55-63. Kemp, J. S., Unger, B., Wilkins, D., Psara, R. M., Ledbetter, T. L., Graham, M. A., et al. (2000). Unsafe sleep practices and an analysis of bed-
Acknowledgments Supported by a grant from The Skillman Foundation, Detroit, Michigan toTomorrow’s Child/Michigan SIDS, Lansing, Michigan. The authors acknowledge the Michigan Department of Community Health for ongoing support of Infant Safe Sleep.
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, 111,106-113. Macdonald, G. (2002). Transformative unlearning: Safety, discernment and communities of learning. Nursing Inquiry, 9,170-178. Mathews, T. J., & MacDorman, M. F. (2007). Infant mortality statistics from the 2004 period linked birth/infant death data set (National Vital Statistics Reports, 55(15)). Hyattsville, MD: National Center for
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