Reduce the Risks 1
Running head: EDUCATING AT THE BEDSIDE TO REDUCE THE RISKS
Educating at the Bedside to Reduce the Risks
Associated with Sudden Infant Death Syndrome
Amanda D. Speck Malmberg RN, BSN
San Diego State University
Reduce the Risks 2
Abstract
Purpose: To develop an educational discharge teaching plan on reducing the risks of Sudden
Infant Death Syndrome (SIDS) and to teach postpartum nurses how to implement this plan.
Design and Methods: A descriptive design was used to survey a convenience sample of
practicing maternal/newborn nurses at Sharp Grossmont Hospital OB Special Care Unit. A
questionnaire was used to survey the nurses both pre-and post- SIDS discharge teaching plan.
Results: The pre-education questionnaire revealed that one-half of the nurses knew the American
Academy of Pediatrics (AAP) recommendations on SIDS, but are still teaching patients that
other sleep positions are acceptable. The post-education questionnaire revealed that 100% of
nurses knew the AAP’s stance on risk reduction for SIDS, and 100% of respondents also use the
supine position for sleep to decrease SIDS.
Conclusions: The main focus of this evidenced-based change project was to better educate nurses
on the risk factors of SIDS, and in return, better educate patients. This goal was accomplished by
developing an educational discharge teaching plan on reducing the risks of SIDS and by teaching
postpartum nurses how to implement this plan.
Keywords: Sudden Infant Death, Sudden Infant Death Syndrome, SID, SIDS, Crib Death
Reduce the Risks 3
Educating at the Bedside to Reduce the Risks Associated with Sudden Infant Death Syndrome
Sudden Infant Death Syndrome (SIDS) is the cause of approximately 2,500 infant deaths
each year (National Institute of Health [NIH], 2010). Sadly, some of these deaths may be
avoided if proper education on the risks of SIDS is thoroughly reviewed with new parents and
family members upon discharge from the hospital. Infants (less than one year of age) are all at
danger of being a victim of SIDS, with infants two to four months of age being at the greatest
risk (American Academy of Pediatrics [AAP], 2005). Sharp Grossmont Women’s Center
postpartum nurses have a unique opportunity to ensure their patients are aware of the risk factors
that contribute to SIDS. The purpose of this project was to establish an effective method of
nurse-patient communication to ensure parents and family members are aware of what SIDS is
and the part they can play in decreasing the chance of this tragedy happening to their infant.
Background
As a postpartum nurse, one of the hazards seen on a daily basis is infants being placed in
their cribs incorrectly. This project addressed the misconceptions of infant placement for sleep.
Research started in 1994 by the National Institute of Child Health and Human Development
(NICHD) and the American Academy of Pediatrics (AAP) helped to decrease the death rate of
SIDS by 50%. These two organizations collaborated to develop the “Back to Sleep Campaign.”
This campaign promoted placing infants on their backs to sleep, the use of a firm mattress for the
crib, and the removal of pillows, blankets, and stuffed animals from the infant’s sleep area (NIH,
2010). In addition, this research has also shown that other risk factors include: smoking
prenatally, smoking around the newborn, overheating the infant, and co-sleeping with the infant
(AAP, 2005).
Although a crib that meets the standards of a safe sleep environment is provided for
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parents during their hospital stay, all too often nurses enter the room to find the infant on his/her
side or tummy to sleep, a plethora of items in the crib with the infant, or the baby sleeping on a
soft pillow in bed with mom. Far too many times, parents are not even aware of the risks of
SIDS.
Parents are provided the New Beginnings book at the beginning of their postpartum stay.
This book contains one paragraph about back to sleep and other ways to decrease SIDS.
Unfortunately, most parents do not have the time or energy during their stay to read this book,
and once discharged home, it is unknown how many parents actually read this information. In
order to make certain all parents are receiving the same verbal information, a teaching plan was
created and the postpartum nurses where educated on the plan.
This project took place at Sharp Grossmont Hospital Women’s Center, a not-for-profit
536 bed facility in La Mesa, California, that provides services for many residents throughout San
Diego County. The OB Special Care Unit has between 4 and 12 postpartum couplets at a time,
and 1 to 3 registered nurses depending on the patient census. The Women’s Center opened in
1990, and houses 48 private suites. The center provides services for labor and delivery,
antepartum and postpartum care, and obstetrical and gynecological services. In addition, this
facility also houses a 24 bed, level III neonatal intensive care unit. The Women’s Center proudly
delivers approximately 300 newborns each month or 3,600 babies each year. The nurses at this
Magnet designated facility greatly contribute to the health and well-being of many newborns in
the county (Sharp HealthCare, 2010).
This topic is extremely relevant to nursing practice and is aimed at improving patient
outcomes. As a postpartum nurse, the goal is to educate patients and family members so they feel
competent and ready to go home and care for their newborns. Educating about SIDS is important
Reduce the Risks 5
in the immediate postpartum period to ensure parents start to care for their infants safely. For
example, it is best for parents to learn that infants need to sleep on their backs on a firm mattress
as soon as possible, as to not develop other habits that may harm the infant. Postpartum nurses
are advocates for two patients: the new mother and the newborn. Therefore, it is imperative that
these nurses can provide thorough education on this topic during the postpartum hospital stay, as
well as with discharge teaching.
Conceptual Framework
The conceptual framework used to guide this project was Lewin’s Change Theory. Kurt
Lewin was a German-American psychologist and social scientist that created a three-step theory
of change. This theory illustrates the forces that promote and inhibit change. The three steps:
unfreeze, change, and refreezing are an excellent approach to change in the workplace (Kritsonis,
2004-2005).
The first step of the theory is to unfreeze the existing behavior. This step begins when
something new is implemented that may challenge the status quo in an organization. This step is
essential in order to decrease resistance to the change. According to Lewin, there are three ways
that step one can be completed. First, the people implementing the change must come together to
promote change. Second, “decrease the restraining forces that direct behavior away for the
exiting situation or status quo” (Kritsonis, 2004-2005, ¶ 3). The third method is to combine the
first two methods. The second step of the theory is to actually implement the change within the
organization. This is then followed by the final step, refreezing. Refreezing is used to ensure that
the new change is continued and maintained over time. If refreezing is not used, it is easy for
individuals to revert back to the old way (Kritsonis, 2004-2005).
Lewin’s Change Theory was a relevant conceptual framework model to use for this
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evidenced-based change project. The step of unfreezing is often met with confusion and
frustration. It was important to motivate fellow employees to want to change. This was
accomplished by sharing some of the startling statistics of SIDS, and by illustrating how some
minor adjustments in teaching can really help improve patient outcomes. It was also important
for the developer of the new program to establish a rapport with co-workers, as this step cannot
be successful if co-workers do not trust the developer. Lastly, it was essential to remain open to
opinions and suggestions (Kritsonis, 2004-2005).
During the change step, employees needed help realizing why the change is important
and necessary. The primary researcher was responsible for making the change happen and for
encouraging employees and helping them see why the change was needed. Teamwork is
essential during this step. Lastly, when implementing the refreeze step, the developer had to
reinforce the importance of SIDS education with co-workers (Kritsonis, 2004-2005).
The Adult Learning Theory is an additional conceptual framework that was used for this
project. This theory focuses on the best ways to present new material and change to adults. It
focuses on change that is realistic and relevant. It also stresses the importance of listening to the
concerns of adult learners, giving them some control over how change will occur, and providing
constructive feedback on performance (Speck, 1996).
Review of Literature
Bullock, Mickey, Green, and Heine (2004) surveyed the views of postpartum nurses at
various hospitals in regards to their knowledge on infant sleeping positions during the hospital
stay. The researchers developed a 24-item questionnaire to distribute to the nurses. Five-hundred
twenty-eight nurses returned the questionnaires by mail, and the responses were anonymous. A
total of 1,700 surveys were mailed out, which yielded a 32% response rate. The results showed
Reduce the Risks 7
that although most nurses knew not to place infants prone to sleep, the majority of nurses
surveyed stated that they placed infants on their sides to sleep and that this practice was safe.
Many of the nurses believed that side-lying positions decrease the risk of infants aspirating. Only
49% of nurses surveyed stated that sleep positions were associated with SIDS. In addition, 80%
of nurses surveyed, falsely believed that their hospital policy on safe sleep for infants included a
side-lying position. The nurses with more years of experience in postpartum care were less likely
to believe that sleep positions increased the rate of SIDS. On the contrary, the nurses with less
years of experience promoted the “back to sleep” method.
Esposito, Hegyi, and Ostfeld (2007) studied the importance of nurses education and
actions at the hospital bedside. The article describes The Triple-Risk Model for SIDS. This
model speaks of the interactions of a physiological vulnerability, an environmental stressor, and
a certain developmental period (two to four months of life) that may increase the risk of SIDS.
The researchers concluded that a problem in the serotonergic system, which helps to regulate
respiratory function, may lead to a physiological vulnerability in an infant. In addition, when
infants are placed prone, this becomes an environmental stressor. When combined, prone sleep
leads to a deeper sleep, and if infants already have a problem regulating respiratory function,
they may not awaken to take the breath that is needed. This study also found that compliance in
parents after discharge home was greatest when they did not only receive discharge teaching
about the prevention of SIDS, but also when they saw the teaching in action by their nurses.
Heinig and Banuelos (2006) studied the appropriate time to use a pacifier in
breastfeeding infants. While the AAP states that placing an infant back to sleep with a pacifier
may decrease the chance of SIDS, the lactation community has worked with the AAP to promote
the delayed use of pacifiers until approximately one month of age when breastfeeding is well
Reduce the Risks 8
established. It is believed that the use of a pacifier when put to sleep assures that the infant does
not go into a deep sleep, and that he/she can easily awaken if needed. Other studies have shown
that delaying pacifier use until one month of age may not be necessary. This article also
discussed randomized controlled trials by Howard, et al (2003) that have shown breastfeeding is
only affected when pacifiers are given in the first five days of life.
The articles stress the importance of nursing education on SIDS. The literature review
made it clear that nurses are in need of additional teaching in order to be role models for new
parents during the first 24-48 hours of a newborn’s life. Nurses must feel knowledgeable and
confident about the risk factors and prevention of SIDS in order to properly educate new parents.
These caregivers must not only be taught the recommendations of the AAP on SIDS, but must
practice these recommendations in the workplace.
Methodology
A descriptive design was used to survey a convenience sample of postpartum nurses at
Sharp Grossmont Hospital OB Special Care Unit in spring 2011. A maximum of 10 nurses were
expected to complete the survey. Each nurse working on this unit was asked to complete an
anonymous 22-item pre- and post-education questionnaire addressing their knowledge and
beliefs of the safest infant sleep positions, the current AAP recommendations, as well as
questions about actual current practice. An educational component was introduced to increase
the nurses’ knowledge of SIDS. Participation was voluntary and anonymous.
The researcher educated the nurses on the new discharge plan for teaching about the risk
factors of SIDS. A PowerPoint presentation was created to teach the nurses about SIDS, as well
as a new discharge teaching guide. The PowerPoint was placed in the SIDS binder at the nurses
station. The notes section was used to elaborate on further details for each slide. Nurses reviewed
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the PowerPoint while they we working on the unit. The primary researcher was available for
questions by phone, email, or while working on the unit. The primary researcher was able to
discuss the PowerPoint with day shift nurses during change-of-shift. The primary researcher
works night shift on this unit, and was able to discuss this project with other night shift nurses
during their shifts. The discharge teaching guide was created to help ensure that nurses cover all
the aspects of SIDS education and risk reduction during discharge teaching. It consisted of one
page which highlighted the main points of SIDS teaching. The ultimate goal was to better
educate the nurses on the risk factors of SIDS, so they can better educate their patients.
A 22-item questionnaire was used to survey the nurses pre and post the new educational
teaching on SIDS. The content validity of the original questionnaire was established by a panel
of six clinical and research-oriented nurse experts. A pilot test of the survey was completed by
nurse educators, health department personnel, and graduate nursing students. After the pilot test
was completed, changes were sent back to the nurse experts for final approval (Bullock, Mickey,
Green, & Heine, 2004).
This survey questioned nurses about their attitude, belief, and current practice in relation
to SIDS. The pre-test was used to gather information on additional teaching that was needed.
After the new teaching plan was implemented for approximately one month, the post test was
given to the nurses to identify if the new teaching plan met their needs. In order to protect human
subjects, the completed questionnaires were placed in the researcher’s SIDS binder at the nurses’
station without any names or identifiers. The data was collected for this project and the results
were analyzed using descriptive statistics (Bullock, Mickey, Green, & Heine, 2004).
Results
The response rate for the pre-education questionnaire was 100% (n=6) and for the post-
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education questionnaire was 83% (n=5). The results are summarized in Table 1.
Pre-Questionnaire
All six nurses work in mother/baby, but one nurse also had labor and delivery experience.
However, there are times when the census is high and labor and delivery nurses work on the unit
as well. Those that participated had anywhere from less than 1 year to 26 years of experience in
this area of nursing. Respondents were all registered nurses. Five of the six nurses have their
Bachelor of Science degree in nursing; the remaining nurse has her Bachelor of Science degree.
One nurse also has a master’s degree in business administration.
One-half (n=3) of the nurses surveyed stated that they knew about the AAP’s stance on
safe sleep positions. However, 50% (n=3) of respondents stated that infants can be placed both
supine and laterally for safe sleep. Infants usually have increased secretions in the first 24 hours
of life due to many changes in their cardiopulmonary systems. Of the nurses surveyed, 50%
(n=3) stated that in the first 24 hours of life, infants can be placed in sleep positions other than
supine (prone and lateral). However, after 24 hours of life, 50% (n=3) of nurses believe that the
supine and lateral positions are safest for babies. When asked which sleep positions they taught
parents to use after discharge home from the hospital, 33% (n=2) reported teaching parents to
place their newborns in the supine and lateral positions. The remaining nurses only teach their
parents about the supine sleep position.
Regardless of years of experience in mother/baby nursing, nurses were also asked if they
believed that sleep positions were related to SIDS. Seventeen percent (n=1) responded yes, while
67% (n=4) were unsure, and 17% (n=1) answered no. One-half (n=3) of the nurses thought that
placing an infant supine for sleep will increase the risk of aspiration. In addition 33% (n=2) of
the participants stated that supine sleep decreases comfort and will cause the infant not to sleep
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well; therefore choosing to place infants in alternative sleep positions. Two nurses (33%) have
seen an infant in distress because of being placed supine. Lastly, when respondents were asked if
the Women’s Center has a written policy regarding safe sleep positions for newborns, one
participant responded that there is not a policy in place. The remaining nurses (n=5, 83%) were
unsure whether a policy was in place. None of the nurses have read any research on SIDS in the
past year.
Post-Questionnaire
All five nurses work in mother/baby, but one nurse also had labor and delivery
experience. Those that participated had anywhere from less than 1 year to 11 years of experience
in this area of nursing. Respondents were all registered nurses. All the nurses have their Bachelor
of Science degree in nursing; one nurse also has her master’s degree in business administration.
All of the nurses surveyed stated that they knew about the AAP’S views on safe sleep
positions for infants. One-hundred percent (n=5) of respondents stated that infants should always
be placed supine for safe sleep in the hospital and at home. Of the nurses surveyed, 100% (n=5)
stated that in the first 24 hours of life, infants should be placed supine. However, after 24 hours
of life, one nurse (20%) stated that the lateral sleep position is safe for babies some of the time.
The remaining participants (n=4, 80%) chose to keep the infant supine 100% of the time after 24
hours of life.
Regardless of years of experience in mother/baby nursing, nurses were also asked if they
believed that sleep positions were related to SIDS, 80% (n=4) responded yes, while 20% (n=1)
stated no. None of the nurses thought that placing an infant supine for sleep will increase the risk
of aspiration. In addition, there were not any participants who stated that supine sleep decreases
comfort or will cause the infant not to sleep well. Three nurses (60%) have seen an infant in
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distress because of being placed supine. Lastly, 40% (n=2) of respondents stated that the
Women’s Center has a written policy regarding safe sleep positions for newborns. One
participant (20%) responded that there is not a policy in place. The remaining nurses (n=2, 40%)
were unsure whether a policy was in place. Three of the nurses have read a research article
pertaining to SIDS in the past year.
Discussion
Postpartum nurses have a unique opportunity to teach their patients about risk reduction
for SIDS. They serve as role models for their patients during the hospital stay. Analysis of the
pre-education and post-education questionnaires yielded noteworthy results. The pre-education
questionnaire showed that the majority of respondents (n=4 67%) were unsure if sleep positions
are associated with SIDS. After the SIDS education was initiated and the SIDS discharge plan
was implemented, the majority of nurses questioned (n=4 80%) stated that sleep positions were
related to SIDS. These results show that the teaching was effective in educating the nurses about
the risk factors of SIDS.
In addition, it was discovered that nurses may use alternative sleep positions due to fear
of infants aspirating on their backs. According to the post-education results, a decreased number
of nurses believe that aspiration is related to a supine sleep position. However, results also
showed that there are still nurses that use the lateral sleep position for infants. Although this is
great progress, it is clear that all nurses are not following the AAP guidelines all the time.
While only one-half (n=3 50%) of the participants in the pre-education questionnaire
knew about the AAP recommendations on SIDS, after the SIDS self-study PowerPoint, 100%
(n=5) of nurses surveyed knew about the AAP’s views on this topic. This concluded that the
educational PowerPoint was effective in educating the nurses on current best practice.
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Although more nurses responded yes to the question “Does your institution have a
written policy regarding sleep position for healthy infants on the unit?” it is evident that more
teaching needs to be initiated concerning the policies and procedures of the unit. The new order
set in Cerner includes a standing order to place infants supine while in the hospital. This
information is also located under the newborn guidelines of care. It is important that if this
information is taught to new parents, that nurses are also documenting this teaching. The results
do show that this education has led to an improvement in nurse-patient communication. This
additional discharge teaching component may help save an infant from dying of SIDS. It is
recommended to continue this teaching for all maternal/newborn nurses at Sharp Grossmont
Hospital, as this project has shown that more education is needed in this area.
Limitations
There were some limitations to this project. Labor and delivery nurses that floated to the
unit may have completed an anonymous questionnaire. This has the potential to skew the results,
considering they have less postpartum and newborn care experience. The sample size may be too
small to generalize results outside of the OB Special Care Unit. In addition, this project was
launched during a high patient census. Many of the nurses voiced their concerns of not having
enough time during their shifts to review the self-study SIDS PowerPoint, or enough time to
thoroughly discuss the SIDS discharge guide with parents.
This project may have been strengthened if the primary researcher spent more time
teaching the nurses one-on-one; however, working different shifts made this difficult. Lastly,
since the questionnaires were anonymous, it is impossible to know if the same nurse completed
both the pre-education and post-education questionnaires. Therefore, it cannot be fully concluded
that the educational component alone increased the nurses’ knowledge of SIDS risk reduction.
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The only risk of participating in this evidenced-based change project was the possibility of
delaying a discharge in order to ensure adequate teaching was completed.
Conclusion
SIDS is the cause of death for an alarming number of infants world-wide. Postpartum
nurses have a unique opportunity to educate parents and family members on the risk factors for
SIDS. The main focus was to better educate nurses on the risk factors for SIDS, and in return,
better educate patients. This goal was accomplished by developing an educational discharge
teaching plan on reducing the risks of SIDS and by teaching postpartum nurses how to
implement this plan.
Results showed that after the new educational plan was implemented, more nurses
believed that sleep position was a risk factor for SIDS. However, it was also shown that not all
nurses are placing infants supine all of the time, even after the educational plan was completed.
Therefore, it is concluded that not all nurses are following the AAP guidelines, even though they
are aware of these guidelines. This project has increased the amount of time nurses spend
teaching their patients about SIDS risk reduction. This evidenced-based change project has
increased the knowledge and awareness of the risk factors of SIDS on this nursing unit. It is
important to continue work in this area, as more education and teaching is needed. Hopefully, by
continuing this new discharge educational program, the nurses on the OB Special Care Unit can
decrease the chance of a family loosing their infant to SIDS.
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References
American Academy of Pediatrics. (2005). The changing concept of sudden infant death
syndrome: diagnostic coding shifts, controversies regarding the sleeping environment,
and new variables to consider in reducing risks. Pediatrics, 116 (5), 1245-1255.
Bullock, L, Mickey, K, Green, J, & Heine, A. (2004). Are nurses acting as role models for the
prevention of SIDS. The American Journal of Maternal/Child Health, 29 (3), 172-177.
Esposito, L., Hegyi, T., & Ostfeld, B. (2007). Educating parents about the risk factors of sudden
infant death syndrome: The role of the neonatal intensive care unit and well baby nursery
nurses. The Journal of Perinatal & Neonatal Nursing, 21 (2), 158-164.
Heinig, J. & Banuelos, J. (2006). American academy of pediatrics task force on sudden infant
death syndrome (SIDS) statement on SIDS reduction: Friend or foe of breastfeeding?
Journal of Human Lactation, 22 (1), 7-9.
Howard, C., Howard, F., Lanphear, B., Eberly, S., deBlieck, E., Oakes, D., et al. (2003).
Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect
on breastfeeding. Pediatrics, 111 (3), 511-518.
Kritsonis, A. (2004-2005). Comparison of change theories. International Journal of Scholarly
Academic Intellectual Diversity, 8 (1), Retrieved October 1, 2010, from http://www.
nationalforum.com/Electronic%20Journal%20Volumes/Kritsonis%2C%20Alicia%20Co
mparison%20of%20Change%20Theories.pdf
National Institute of Health. (2010). National Institute of Child Health and Human Development.
Research on sudden infant death syndrome. Retrieved September 21, 2010, from
http://www.nichd.nih.gov/womenshealth/research/pregbirth/sids.cfm
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Sharp HealthCare. (2010). Sharp Grossmont Hospital. Women’s Health Center at Sharp
Grossmont Hospital. Retrieved September 21, 2010, from http://www.sharp.com/
grossmont/womens-services.cfm
Speck, M. (1996, Spring). Best practice in professional development for sustained educational
change. ERS Spectrum, 14 (2), 33-41.
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Table 1 Questionnaire Results
Questions
Pre-Questionnaire Post-Questionnaire
Yes
%
Yes
(n)
%
Have you ever encountered a healthy newborn in
distress because he/she was placed in the supine
(back) position?
33% (2)
60% (3)
Have you ever encountered a healthy newborn in
distress because he/she was placed in the prone
(tummy) position?
0
0
Have you ever encountered a healthy newborn in
distress because he/she was placed in the lateral
(side) position?
0
20% (1)
In your opinion, are infant sleep positions
associated with Sudden Infant Death Syndrome
(SIDS)?
16.7% (1)
80% (4)
Are you currently aware of the American Academy 50% (3)
of Pediatrics recommendations regarding sleep
positions for healthy infants?
100% (5)
In the last year, have you read a research article
pertaining to SIDS?
60% (3)
0
In your clinical experience, have you found that 50% (3)
placing an infant on his/her back for sleeping will
increase the risk of aspiration?
0
In your clinical experience, have you found that 33% (2)
placing an infant on his/her back for sleeping will
decrease comfort for the infant?
0
(n)
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In your clinical experience, have you found that 33% (2)
placing an infant on his/her back for sleeping will
cause the infant not to sleep well?
0
In your clinical experience, have you found that 33% (2)
placing an infant on his/her back for sleeping will
decrease the risk for SIDS?
100% (5)
Does your institution have a written policy
regarding sleep position for healthy infants on the
unit?
40% (2)
0
Does your patient discharge information include 100% (6)
sleep position and AAP recommendations related to
SIDS risk reduction?
100% (5)
If you answered yes, do you thoroughly review this 50% (3)
information with your patients?
100% (5)
Do you document what was taught regarding sleep 50% (3)
positions?
60% (3)