Sleeping Position: Change in Practice, Advice, and Opinion in the Newborn Nursery

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Original Research

Sleeping Position: Change in Practice, Advice, and Opinion in the Newborn Nursery

J Fam Pract. 2001 May;50(5):448

References

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The overall change in head nurse opinions of the AAP recommendations is also encouraging. Between 1992 and 1999, head nurses who disagreed with the AAP recommendations declined from 63% to 25%. This opinion conversion is critical, because nurses who disagreed with the AAP recommendations did not use supine positioning as their standard practice. In 1999 there was 75% agreement between what nurses did and what they advised.

Changing behavior is difficult, but public policies can lead to change.¹⁴ There has been considerable research devoted to the effect that clinical guidelines have on practitioner behavior.¹⁵ Several barriers to behavioral change have been identified¹⁶ including familiarity, awareness, and agreement with the guideline. Our study demonstrates the effectiveness of a clinical policy and a public campaign to change clinical behavior and identifies targets for future educational programs. We believe the Back to Sleep Program was successful due to a multifaceted approach that included the general press, professional society outreach, nursing and physician involvement, and education of parents. The diversity of influences applied in this campaign offers a model for eliciting specific behavioral change by clinicians and patients. Even so, our findings suggest that some clinicians may still cling to behaviors, and changing these behaviors may require specific targeted actions.

Newborn nursery nurses have an important role in influencing infant sleep positioning at home. There is increasing evidence that what advice and observation regarding infant sleep positioning while in the hospital is important for what they do at home. A study of inner city mothers found that the most important determinant of intended and actual home sleep positioning was the mothers’ observation of the sleep position used in the hospital. These mothers observed their babies in prone positions 14% to 17% of the time in the newborn nursery, despite hospital policies regarding side or supine positioning in all 3 participating hospitals.⁹ This finding is of concern, because in our study nurses who disagreed with AAP recommendations made exceptions and positioned some babies prone. So, even though prone positioning is no longer standard practice, it is still used in some nurseries and may be witnessed by parents.

Lesko and colleagues¹⁷ found that advice from a health care professional had the most important influence on a mother’s decision to use nonprone sleep positions at 1 month. Gibson and coworkers¹⁸ found that nearly half of parents in suburban and inner city clinics reported that health professional advice influenced how they positioned their infants. The Centers for Disease Control and Prevention (CDC)¹⁹ recently cited this evidence in recommending that outreach programs to influence infant sleep position should consider the role of advice from health professionals. This should reinforce the important role that family physicians have in recommending supine positioning over all other sleep positions. We believe that the change in advice given to parents demonstrated in our study has an important effect on home infant sleep positioning. The strong correlation found between position used and advice given may indicate that nurses who make exceptions for prone or side positioning may also bias their advice.

Limitations and Strengths

Our study had several limitations. We relied solely on the head nurses’ reporting of the conditions within their institutions. We did not conduct any observations of nursery practices, contact parents of new infants to corroborate their experience with the responses from head nurses, or otherwise validate survey responses. It is possible that actual practice differs from what was reported. We were also unable to match hospitals from the 1992 and 1999 data because of the way the 1992 hospital data were collected. The individual surveys completed in 1992 did not include the name of the hospital on the data form, which made it impossible to compare them with the individual hospitals in 1999.

Despite these limitations, this study has several strengths. We contacted and interviewed head nurses at every hospital newborn nursery in Missouri shortly after the AAP infant sleep position recommendation was released and again 7 years later. Also, the same obstetrical nurse clinician conducted the interviews using identical questions, which provided consistency between surveys.

Conclusions

Important change has occurred in nursery practice, opinion, and advice to parents since the announcement of the AAP recommendation on infant sleep position in 1992; however, some head nurses still disagree with this recommendation, and this may affect the nursery positioning practice and the advice given to mothers. Infant sleep position and advice from newborn nursery nurses should be consistent with current AAP recommendations and hospital policy. Our study further supports the CDC recommendation that outreach programs to influence infant sleep position should consider the role of advice from health professionals¹⁹ and emphasizes the importance of family physicians in parental choice for infant sleep position. Our study should remind all health care professionals of the impact of their advice to parents regarding infant sleep position. With the overwhelming evidence supporting the supine position, increased educational efforts focused on influencing nursery staff practice and advice may be necessary to increase infant supine sleep positioning. These educational efforts should include the family physician’s role in influencing nursery staff practices.