Why Are Nurses Reluctant to Put Infants 'Back to Sleep'?

Laura A. Stokowski, RN, MS


June 19, 2015

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

Patton C, Stiltner D, Wright KB, Kautz DD
Adv Neonatal Care. 2015;15:8-22

Safe Sleep Modeling in the NICU

The "Back to Sleep" campaign of the mid-1990s[1] brought a dramatic decline in deaths from sudden infant death syndrome (SIDS) and prompted a flurry of investigations into methods of reducing SIDS rates still further. In 2011, the American Academy of Pediatrics (AAP) collated the body of research on the relationship of infant sleep environment to SIDS to produce an evidence-based list of safe sleep practices for infants.[2] These recommendations became the foundation for teaching new parents how to put their babies down to sleep in the safest way known to date.

In summary, the AAP recommends the following for "safe sleep":

  • Supine sleep position on a flat, firm mattress with a fitted sheet

  • No soft objects in the baby's bed (no loose bedding, pillows, toys, quilts, blankets, or bumper pads)

  • Room sharing but not bed sharing

  • Use of a pacifier when putting the infant in bed to sleep

  • No sleep positioners or other devices

  • Breastfeeding

  • Prevention of overheating

  • Appropriate immunizations

  • Parent avoidance of alcohol and illicit drugs

Preterm infants are at higher risk for SIDS than full-term infants,[3] so a strong emphasis on safe sleep environments is even more important in the neonatal intensive care unit (NICU). Nurses work most closely with infants and parents and perform most of the one-on-one teaching about infant care and safety. The 2011 safe sleep recommendations specifically called upon nurses to be educated about safe sleep environments to enable them to serve as role models for family members in promoting safe sleep.

Unfortunately, either from a lack of awareness or understanding of safe sleep recommendations, or from disagreement with the recommendations themselves, a significant proportion of nurses still fail to model appropriate safe sleep practices in the hospital setting.[4,5,6,7,8] To examine this phenomenon more closely, Patton and colleagues conducted an integrative review of the literature published between 1999 and 2013, focusing on the years before and after the release of the AAP's 2011 expanded safe sleep recommendations, to determine whether these recommendations were temporally associated with a change in knowledge and practice among neonatal nurses.

Sixteen studies, primarily self-report surveys describing the infant sleep practices of nurses, parents, and other healthcare professionals, were included in the review. Some studies showed that many nurses are still not aware of evidence-based safe sleep recommendations. Other studies revealed that even when the nurse's awareness of safe sleep recommendations was high, disagreement with the recommendations was also high, resulting in noncompliance.

Most studies concluded that a significant proportion of nurses and mothers persisted in using nonsupine (primarily lateral) positioning when putting babies down to sleep. The risk for aspiration, a belief that other positions were more comfortable or resulted in better sleep, and taking advice from family members were the primary reasons given for deviating from supine sleep recommendations. No clear pattern of improvement in practice emerged following the major safe sleeping campaigns. Years after "Back to Sleep," many nurses still favor, and use, a side-lying position for infants under their care.


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