Running head: THERAPEUTIC NURSING INTERVENTIONS 1

NUR 403: Therapeutic Nursing Interventions

Allison Carlucci

Old Dominion University

THERAPEUTIC NURSING INTERVENTIONS 2

Therapeutic Nursing Interventions

It is necessary to remain aware of current evidence-based interventions and how they can

be applied in ones clinical setting. Therefore, as a nurse, identifying areas in the clinical setting

where there is a need for improvement, as well as appropriate interventions that may aid in

improvement, are vital aspects. The issue being analyzed and examined in this paper is how to

appropriately implement safe sleep interventions in a neonatal intensive care unit (NICU). This

is a significant issue because,

according to the Centers for Disease Control and Prevention (2011), more than 4,500

infants die annually in the United States of no apparent cause of death. These deaths are

defined as sudden unexplained infant deaths (SUID). Half of these SUIDs are because of

sudden infant death syndrome (SIDS). (Flook & Vincze, 2012)

Therefore, while there are policies in place regarding effective safe sleep management in the

NICU, based on observation and a discussion with a registered nurse on this unit (see Appendix:

Organization Mentor Identification Form), these interventions are not consistently being

implemented for a variety of reasons. The specific unit being examined is a 62-bed neonatal

intensive care unit in an urban area. Thus, this paper will seek to identify an area in the clinical

setting that needs improvement as well as appropriate nursing interventions that have the

potential to cause change and improvement.

Clinical Problem

Practicing and implementing safe sleep strategies and interventions are important in the

NICU setting. The problem identified in the NICU that could be improved upon is the failure to

implement safe sleep interventions. Additionally, according to Keene Woods, the lack of
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consistent and uniform safe sleep recommendations has been confusing (2017, p. 94).

Therefore, it is also important to provide consistent, evidence-based safe-sleep interventions, as

well as education to parents.

In the NICU, the infants are being continuously monitored, therefore, staff, at times, can

become a little lax about implementing appropriate safe sleep interventions. Furthermore, this is

more of an issue with infants who are in traditional cribs and for those who are preparing to go

home. Many NICU staff allow for stuffed animals or toys to be in the cribs because it provides

comfort to the family as well as visual stimulation for the older infants. Additionally, sometimes

the infants are placed in the prone position to sleep for reasons such as to allow for better

expansion of their lungs. Failure to implement appropriate safe sleep interventions in the NICU

is a problem because this can set a bad example for the parents who then take the infants home

and do the same things they saw being done in the hospital; however, the infants are not on

monitors at home, and things such as having toys or stuffed animals in the cribs or placing

infants on their stomachs to sleep increases their risk for SIDS.

Current Clinical Practice

When analyzing and evaluating a clinical problem, such as safe sleep practice, it is

necessary to compare formal with informal mechanisms for dealing with this issue for the

purpose of identifying ways in which they can be improved upon. Formal mechanisms for

dealing with a problem include items such as standards of practice and facility policies.

Whereas, informal mechanisms of dealing with a problem are what is actually being

implemented in the clinical setting. The policies in place regarding safe sleep interventions in

the NICU include:

THERAPEUTIC NURSING INTERVENTIONS 4

Position infants on their backs to sleep.

Due to potential safety hazards, soft materials/objects are not permitted in the infants

bassinet or crib (Childrens Hospital of the Kings Daughters, n.d.).

The head of the crib should not be elevated unless ordered by the physician.

Exception for ventilated patients who require VAP (Ventilator Associated Pneumonia)

bundle element of elevated head of bed (Childrens Hospital of the Kings Daughters,

n.d.).

Infants should be warm while sleeping but not overheated. Overheating increases the

risk of SUID/SIDS (Childrens Hospital of the Kings Daughters, n.d.).

The infant should not be over clothed or covered with blankets (Childrens Hospital

of the Kings Daughters, n.d.).

Halo Sleep Sacks replace blankets. An infant who is cold may wear clothing under

the sleep sack. He should not be wrapped in blankets over the sleep sack.

Review safe sleeping/prevention of SUID/SIDS with infants families again at

discharge. Document teaching session on the Interdisciplinary Patient & Family

Teaching Record (Childrens Hospital of the Kings Daughters, n.d.).

Therefore, these policies outline the appropriate interventions that should be implemented in

order to promote safe sleep and enhance parent teaching. Additionally, there are some further

guidelines related to positioning of preterm infants who weigh less than 1250 grams, which

stipulate that they may benefit from prone positioning (Childrens Hospital of The Kings

Daughters, n.d.).

Compared to the formal mechanisms for dealing with this issue, the informal mechanisms

include what is currently being done in the clinical setting. Based on observations, as well as a
THERAPEUTIC NURSING INTERVENTIONS 5

discussion with a registered nurse on the unit, the policies regarding safe sleep practice are not

consistently being implemented. Many nurses allow parents and family members to place

stuffed animals and toys in the infants crib because it provides a sense of home and comfort to

the parents as well as provides some visual stimulation to the older infants. One reason why this

is allowed is because the infants are being continuously monitored, so the nurses will be alerted

were something to happen to the infant. Additionally, infants are sometimes placed in the prone

position to sleep for reasons such as to allow for better lung expansion or because it helps them

to relax and calm down. However, the issue here is that these practices set bad examples for the

parents when they get to take their infant home. Thus, better implementation of safe sleep

interventions is important not only for the safety of the infant but also to aid in improved parent

teaching.

Nursing Interventions

As a future nurse, it is also vital to be able to identify potential interventions based on

current research that may be able to be used to improve problems such as those regarding safe

sleep. Therapeutic nursing interventions are those that are focused on patient-centered care and

improving patient outcomes. In a research article entitled Implementation of safe sleep

practices in the neonatal intensive care unit, a study was conducted which sought to evaluate

how the implementation of safe sleep practices affected parent teaching and compliance after

discharge. Additionally, this study found that interventions such as integrating safe sleep

practices in the NICU, which include placing infants on their backs to sleep as well as removing

soft items from the cribs, in addition to implementing these interventions to provide parent

teaching weeks to months prior to discharge, increased adherence to safe sleep practices (Hwang

et al., 2015). Therefore, this study demonstrates the importance of implementing safe sleep
THERAPEUTIC NURSING INTERVENTIONS 6

practices, such as placing infants on their backs to sleep and removing soft items from the cribs,

far in advance of discharge.

Education is a vital aspect of nursing. Educating parents on the recommended guidelines

for safe sleep is an important component in preventing SIDS after discharge (Hilton, 2016, p.

16). An additional study entitled Integration of safe sleep and sudden infant death syndrome

(SIDS) education among parents of preterm infants in the Neonatal Intensive Care Unit (NICU),

sought to enhance parents knowledge of safe sleep practices as well as their compliance. This

study utilized educational sessions for parents in addition to written information as the form of

therapeutic intervention. The parents were given a test prior to the session as well as after the

educational session. The results of this study showed that parents knowledge of safe sleep

practices as well as compliance were significantly improved following the education sessions as

well as after receiving the written information. Furthermore, the results supported previous

findings that providing current written material along with modeling safe sleep practices in the

hospital prior to discharge to home can help further reduce the incidence of SIDS (Dufer &

Godfrey, 2017). Thus, these findings support the implementation of improved parent education

regarding safe sleep practices through education sessions and written information.

A further research study entitled Integrating Back to Sleep Recommendations Into

Neonatal ICU Practice, used interventions such as an algorithm detailing when to start safe

sleep practices, a Back to Sleep crib card, educational programs for nurses and parents, a crib

audit tool, and postdischarge telephone reminders (Gelfer, Cameron, Masters, & Kennedy,

2013) in order to promote adherence to safe sleep practices in the NICU. The results of this

study found that in the NICU adherence with supine positioning increased from 39% to 83%

(P < .001), provision of a firm sleeping surface increased from 5% to 96% (P < .001), and the
THERAPEUTIC NURSING INTERVENTIONS 7

removal of soft objects from the bed improved from 45% to 75%... (Gelfer, Cameron, Masters,

& Kennedy, 2013). Additionally, this study demonstrated improved parental compliance after

discharge through the implementation of a post discharge telephone survey (Gelfer, Cameron,

Masters, & Kennedy, 2013).

Therefore, based on the findings of three different research studies, important

interventions for the improvement of safe sleep practices in the NICU as well as after discharge

include implementing interventions such as placing infants on their backs to sleep and removing

soft items from their cribs months to weeks prior to discharge, providing education sessions and

written information regarding safe sleep to parents, in addition to a Back to Sleep crib card, a

crib audit tool, and a post discharge telephone survey for parents. Additionally, based on these

findings, a major source of the problem relates to the failure to implement safe sleeping practices

in the NICU early enough, resulting in poor parent education. Thus, my hypothesis related to the

problem of failing to implement appropriate safe sleep practices in the NICU is: were safe sleep

practices to be implemented within the initial phase of care, excluding situations where prone

positioning is needed, then there would be an overall improvement in adherence to safe sleep

practices in the NICU as well as after discharge.

Summary

Failure to implement the appropriate safe sleep practices in neonatal intensive care units

is a problem that has the potential to lead to SIUD/SIDS in the hospital as well as at home after

discharge. Therefore, it is important to identify therapeutic interventions that may be

implemented for the purpose of improving patient safety as well as outcomes. The interventions

identified through various research articles include implementing safe sleep practices in a timely

manner, weeks to months prior to discharge, providing education sessions and written
THERAPEUTIC NURSING INTERVENTIONS 8

information to parents related to safe sleep practices, and using crib audit tools and post

discharge telephone surveys. Furthermore, based on these findings, a significant source of the

problem that could be improved upon is the early implementation of safe sleep practices in the

NICU. This will promote infant safety and enhance the continuity of care by setting a good

example for the parents prior to discharge.

THERAPEUTIC NURSING INTERVENTIONS 9

References

Childrens Hospital of The Kings Daughters. (n.d.). Safe Sleeping Environment for Infants and

Children. Department Manual: Nursing Policy/Procedure/Competency.

Dufer, H., & Godfrey, K. (2017). Integration of safe sleep and sudden infant death syndrome

(SIDS) education among parents of preterm infants in the Neonatal Intensive Care Unit

(NICU). Journal Of Neonatal Nursing, 23(2), 103-108. doi:10.1016/j.jnn.2016.09.001

Flook, D. M., & Vincze, D. L. (2012). Infant Safe Sleep: Efforts to Improve Education and

Awareness. Journal Of Pediatric Nursing, 27(2), 186-188.

doi:10.1016/j.pedn.2011.12.003

Gelfer, P., Cameron, R., Masters, K., & Kennedy, K. A. (2013). Integrating Back to Sleep

Recommendations Into Neonatal ICU Practice. American Academy of Pediatrics.

Retrieved October 06, 2017, from

http://pediatrics.aappublications.org/content/early/2013/02/26/peds.2012-1857

Hilton, L. (2016). Counseling parents about safe infant sleep. Contemporary

Pediatrics, 33(5), 16-20.

Hwang, S. S., O'Sullivan, A., Fitzgerald, E., Melvin, P., Gorman, T., & Fiascone, J. M. (2015).

Implementation of safe sleep practices in the neonatal intensive care unit. Journal Of

Perinatology, 35(10), 862-866. doi:10.1038/jp.2015.79

Keene Woods, N. (2017). Same Room, Safe Place. Journal Of Primary Care & Community

Health, 8(2), 94-96. doi:10.1177/2150131916670067

THERAPEUTIC NURSING INTERVENTIONS 10

I pledge to support the Honor System of Old Dominion University. I will refrain from any form
of academic dishonesty or deception, such as cheating or plagiarism. I am aware that as a
member of the academic community it is responsibility to turn in all suspected violators of the
Honor Code. I will report to a hearing if summoned.
Name: Allison Carlucci
Signature: Allison Carlucci
Date: October 10, 2017
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Appendix
Organization Mentor Identification Form

OLD DOMINION UNIVERSITY SCHOOL OF NURISNG

NURS 403 Clinical Implementation Project
Organization Mentor Identification Form

Student Name: Allison Carlucci

Course Number: NURS 403

Semester and Year: Fall 2017
Experience Site: NICU, CHKD
Experience Mentor: Devin Powell RN BSN
Brief description of experience:
While doing my role transition in the NICU at CHKD, I had the opportunity to observe
and discuss with my preceptor areas that could be improved upon. We discussed several topics,
but the one that stood out to me was the issue of safe sleep. In the NICU, the babies are being
continuously monitored, therefore, my preceptor talked about how sometimes staff can get a
little lax about implementing appropriate safe sleep interventions. This is more of an issue for
babies who are in traditional cribs and for those who are getting ready to go home. A lot of time
they allow for stuffed animals or toys to be in the cribs because it provides comfort to the family
as well as stimulation for the older babies. Additionally, they sometimes put the babies in the
prone position to sleep for various reasons. However, this may set a bad example for the parents,
who then take the babies home and do the same things they saw being done at the hospital,
however, the babies are not on monitors at home, and things such as having toys or stuffed
animals in the cribs or placing a baby to sleep on their stomachs, increases their risk for SIDS.
My preceptor and I looked up the policies related to safe sleep and discussed ways in which this
could be improved upon.
Objectives for experience (3-4 broad objectives)
Review current nursing interventions and policies to promote safe sleep practices
Provide nursing interventions based on research or best practices for safe sleep in a paper
Succinctly critique a research article related to the topic of safe sleep practices
Develop a research hypothesis regarding interventions that promote safe sleep