Development and Evaluation of a Shaken Baby Syndrome Prevention Program
Celine Goulet, Jean-Yves Frappier, Sylvie Fortin, Line Deziel, Annie Lampron, and Maryse Boulanger ´ ´
Correspondence Celine Goulet, RN, PhD, ´ CHU Sainte-Justine 3175 chemin Co Ste-Catherine, ˆte ´ Centre de Recherche, Etage A Bloc 7, Montreal, QC, ´ Canada H3T 1C5 Keywords shaken baby syndrome child abuse physical abuse prevention program education program intervention evaluation

Objective: To evaluate parents’ and nurses’ opinions regarding the adequacy of an educational program on shaken baby syndrome: the Perinatal Shaken Baby Syndrome Prevention Program (PSBSPP). Design: Qualitative and quantitative assessments in the form of interviews and questionnaires administered in French. ´ Setting: Two birthing institutions in Montreal, QC, Canada: a university hospital and a regional center. Participants: Two hundred and sixty-three parents (73.8% mothers, 26.2% fathers) received the intervention after the birth of their child, and 69 nurses administered it. Methods: Parents’ and nurses’ assessments of the adequacy and relevance of the program and nurses’ assessments of the training they received to administer the program were evaluated. Results: Both parents and nurses supported this initiative. Most parents appreciated the usefulness of the information. Nurses believed the program was adequate, and their training to deliver the program was satisfactory. All participants reported that the program was highly relevant, especially for new parents. Conclusion: The Perinatal Shaken Baby Syndrome Prevention Program achieves the goals of (a) increasing parents’ knowledge about infant crying, anger, and shaken baby syndrome and (b) helping parents identify coping strategies. The relevance of introducing the PSBSPP in all birthing institutions is supported. Future studies should focus on vulnerable and culturally diverse populations, and longitudinal follow-up could help determine if the PSBSPP reduces the incidence of shaken baby syndrome.

JOGNN, 38, 7-21; 2009. DOI: 10.1111/j.1552-6909.2008.00301.x
Accepted September 2008

Celine Goulet, RN, PhD, is ´ a professor in the Faculty of Nursing, Universite de ´ Montreal and Director of ´ Nursing Research, SainteJustine University Hospital, Montreal, Canada. ´ Jean-Yves Frappier, MD, FRCP(C), MSc, is a professor of Paediatrics at the University of Montreal and head, Social Pediatrics, Sainte-Justine University Hospital, Montreal, Canada. ´ (Continued)


haken baby syndrome (SBS) is a shocking phenomenon that is increasingly recognized as one of the most severe forms of child abuse, with very high rates of morbidity (more than 50%) and mortality (15%-38%) among children under 1 year (American Academy of Pediatrics [AAP], 2001; King, MacKay, Sirnick, & the Canadian Shaken Baby Study Group, 2003; Ward, Bennett, & King, 2004). Shaken baby syndrome is responsible for the majority of deaths that are due to child abuse (King et al.; Morad et al., 2004). About 75% of survivors su¡er neurological, cognitive, developmental, or psychological sequels, and severe functional cerebral palsy-type sequel occur in 60% of survivors (Bonnier et al., 2003; Karandikar, Coles, Jayawant, & Kemp, 2004; King et al.; Perez-Arjona et al., 2003; Ward et al.). These

sequels are often diagnosed in the long term (Bonnier et al.; Karandikar et al.; King et al.; PerezArjona et al.).

Definition and Incidence
Shaken baby syndrome results from violently shaking a child, usually while he or she is being held by the trunk (Duhaime, Christian, Rorke, & Zimmerman, 1998), shoulders, or limbs (Conway, 1998). The extreme whiplash movements result in a sudden acceleration-deceleration of the head and all the internal structures of the cranium. The shaking movements are multidirectional and rotational, with or without external impact (AAP, 2001; Case, Graham, Corey-Handy, Jentzen, & Monteleone, 2001; Fortin & Maisonneuve, 2008).

& 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses


(b) supporting health professionals in detection and diagnosis. 2001). it is very hard to assess the incidence and prevalence of SBS. Montreal. Sainte-Justine University Hospital became the leader in SBS prevention when it started its Shaken Baby Syndrome Prevention Project in 2001.2008. a stressful event. Such situations are a major source of parental stress and often give rise to feelings of powerlessness. The hospital’s Shaken Baby Syndrome Prevention Project comprises four strategies: (a) promoting awareness among all new parents.. Montreal. is ´ pediatrics program manager at Sainte-Justine University Hospital. 2009. 2001). stress and coping). ´ Maryse Boulanger. ´ Canada. this can trigger psychological and physiological reactions. especially during a crucial stage of transition and adaptation for couples. BSc.5 and 4 months. as many as 3 younger than 1 year of age have died annually from SBS-induced brain injuries. leading to SBS. the theoretical model on which the program is based has both cognitive (knowledge) and adaptive (coping strategies) dimensions (Figure 1). and being overwhelmed. Lehtonen. (c) promoting awareness in the general population.1111/j. that of promoting parental awareness. From 25% to 50% of parents or future parents do not know that shaking a child can result in brain damage or death (Showers. among the more than 100 children younger than the age of 5 who have been hospitalized each year for abuse. Many experts stress the importance of early intervention because the consequences of abuse are more severe and permanent for very young children (less Sylvie Fortin. to all parents at the birth of the ¢rst child.00301. Montreal. 354 were substantiated (n 5 189) or suspected (n 5 165). The incidence reported in the literature is certainly an underestimate (Carbaugh. than 1 year) (Dias et al. Canada developed its own SBS guidelines with the publication of the Joint Statement on Shaken Baby Syndrome. Showers. Contextual Dynamics The incidence of SBS peaks between 2. 7-21. making it all the more important that health professionals be vigilant. almost 12% have been victims of SBS. The potential stressor is a baby’s uncontrollable crying. called the Perinatal Shaken Baby Syndrome Prevention Program (PSBSPP). Paterson. Lazarus and Folkman emphasized the relationships among individual characteristics. Li. and (d) encouraging research and the creation of a database on SBS and other forms of child abuse. Indeed. and coping.RESEARCH Shaken Baby Syndrome Prevention Program About 25% to 50% of parents or future parents do not know that shaking a baby can lead to serious brain damage and death. & Reece. Accordingly. Montreal. Violence can ensue as the expression of an increasing level of anger. Canada. Canada. namely anger. which can lead to a loss of control. In Quebec. analyzed.x http://jognn. Canadian Background Because there is no centralized database and the diagnosis is not always obvious. Sege. MSc Research. (2001) revealed a more morbid situation: 46% of SBS victims appeared to have su¡ered previous abuse before diagnosis. RN. MSc. In 2001. 38. 2006). MSc. and children whose abuse is reported or diagnosed under another category of child abuse. & Young. and discussed with experts over a period of 2 years to conceptualize a model supporting the PSBSPP. 2005). Since then. a child’s uncontrollable crying is reported to be the main trigger of parental violence (Barr. RN.. DiScala. which recommended the development of prevention programs (Health Canada. is a nurse clinical specialist for youth and family at Pierre LeGardeur Hospital Centre. The PSBSPP Many theoretical models were considered. exacerbating anger and causing an adult to lose control. A study by ¤ Trocme et al.1992). Of these. bearing in mind that there are children whose abuse goes unnoticed. ´ Annie Lampron. Canada. environment. Studies on the incidence of SBS must be interpreted cautiously. Infant crying is a very common reason for parents to consult health professionals because they often do not understand its cause and sometimes do not know how to react. ´ Line Deziel.1992. & Cross. irritation. The purpose of the study was to evaluate the relevance of introducing an education program. Anger is often an expression of profound confusion and dismay. Out of 600 possible cases reported to child-protection agencies in Canada in . The left part of Figure 1 shows the methods 8 JOGNN. is head of the Perinatal Shaken Baby Syndrome Prevention Program and senior consultant in child maltreatment at SainteJustine University Hospital. the average age at which crying peaks (Barr. RN. The stress theory allows consideration of the main concept behind the PSBSPP (i. 2005. children who die before their abuse is reported. MacMartin. 2004). Trent. The stress theory of Lazarus and Folkman (1984) served as the basis for this study’s theoretical model.e. These links are neither linear nor static. The current study relates to the ¢rst objective of the hospital’s Shaken Baby Syndrome Prevention Project. is a nursing research professional at Sainte-Justine University Hospital. Many parents have insu⁄cient knowledge of the dangers of shaking a baby and the fragility of the infant brain.awhonn. 2000. DOI: 10.1552-6909. and it is estimated that the ¢rst episode likely occurs around 6 weeks.

its potential progression to violence. causes). The PSBSPP provides speci¢c tools to educate and support parents and professionals and is enhanced by adding the dimension of anger management and a framework that centers on the development and use of parental coping strategies. the PSBSPP considers SBS a public health problem. Fortin. and social support to decrease violence leading to the SBS.. L. empowerment. Issue 1 9 . C. J. the program is intended for all parents of newborns.. RESEARCH Figure 1. and the importance of coping strategies when confronted by increasing anger. this could decrease stress and ensuing violence. and SBS. Vol. the triggered reaction (anger). S. the potential for crying to trigger anger and shaking. the dangers of shaking.-Y. These two parts represent the operational aspect of the model and are linked to the theoretical concepts of the model on the right of the ¢gure. while working on practical strategies to cope with anger. The middle part of the ¢gure describes the speci¢c objectives related to the use of those educational tools. The PSBSPP intervention focuses on the three main factors that contribute to SBS: infant crying. people caring for children. The PSBSPP is based on the principle that education JOGNN 2009. if knowledge can be increased about the stressor (infant crying). M. Frappier. Although inspired by existing programs. and lack of knowledge about SBS (see Figure 1). The logical model of the Perinatal Shaken Baby Syndrome Prevention Program. De´ziel. Lampron. parental anger.. and Boulanger. Whereas most child abuse prevention programs target at-risk parents.Goulet. and educational tools of the intervention... To this end. Information that is provided focuses on the normalcy and progression of crying (frequency. The model emphasizes parental competencies. duration. the PSBSPP has some innovative features. or even children themselves. A. that is. focusing directly on behaviors and attitudes that give rise to violence without considering risk factors. 38.

and relationship with baby ( . 38.awhonn. Determining nurses’ assessments of their training to deliver the program.000 births annually. parents at both institutions received the SBS educational intervention during their postnatal hospital stay and were asked if they wanted to participate in the study. The ¢rst card described what to expect in terms of crying at various stages of the baby’s early development. and the third card informed parents about the dangers and consequences of shaking a baby. This interview had been previously tested in a pilot study. particularly considering that coping strategies are understood. answered any questions. A questionnaire was distributed to all eligible nurses by a research assistant at least 2 months after the nurses had been trained to administer the intervention and after they had completed at least ¢ve interventions with parents. Eligible nurses met the following criteria: (a) had been trained to administer the SBS intervention and (b) had delivered the intervention to at least ¢ve families. education. The purpose of the signatures was to add moral weight to the plan for the bene¢t of the parents only. Between 6 and 9 weeks after discharge. After ensuring that the parents understood the information. the nurse asked them to formulate an action plan for dealing with incessant crying. 7-21. This questionnaire and the consent form were collected separately to protect anonymity.00301.500 births annually. (b) had spent at least 24 hours in the hospital. monitoring data have shown that the intervention was given to both parents in 80% of the cases. and asked the parents to sign the plan. and no revision was needed. mother’s partner. qualitative. Methods Evaluation of the intervention program was conducted in two hospitals: Sainte-Justine University ¤ Hospital in Montreal. other). including several Likert-type questions. participants were asked to complete a brief sociodemographic questionnaire. 7 days a week. the parents participated in a telephone interview that was timed to coincide with the peak period of infant crying (Barr & the National Center on Shaken Baby Syndrome. 2005).. adding her own signature. All nurses working in the perinatal units of the two institutions were invited to participate in the prevention program.2008. 1 parent participant in 10 was recruited for a longer. with about 2. taped interview by telephone. Last. 2009. anger. and lack of knowledge about SBS (Figures 2 through 4). Determining parents’ and nurses’ assessments of the adequacy and relevance of the program. comprised closed questions.RESEARCH Shaken Baby Syndrome Prevention Program could reduce parents’ recourse to violence. There were two study groups: the parents receiving the intervention and the nurses delivering it.1552-6909. Eligible parents met the following criteria: (a) mother or father of a term infant. allowing for the acquisition of information needed to improve the intervention before it is more widely introduced as well as assessing the achievement of the program goals and satisfaction of the participants. In addition. Barr et al. No o⁄cial copy of the signed action plan was kept by the institution and it carried no legal implications. DOI: 10. Measures The parents’ baseline questionnaire contained sociodemographic questions regarding country of birth. and (d) spoke and read French. the nurse veri¢ed that parents knew about the prevention hotline for parents available 24 hours a day. Data were collected over a 6-month period. The objectives of the current study were to evaluate the suitability of the PSBSPP for widespread use by: 1. (c) had received the SBSprevention intervention. Between July and December 2005. at approximately 6 weeks.1111/j.x http://jognn. 2. Since the study. father. The study combined qualitative and quantitative measures. and Pierre Le Gardeur Hospi¤ tal in suburban Montreal. age. The nurse then discussed the plan with them. which has approximately 3. After consent was obtained. 2002. cards to address the three main factors: crying. The telephone questionnaire dealt with the relevance and usefulness of the information given in the intervention. The parents were left alone for a few minutes so that they could think about their strategies and write them down. This approach served both the formative and summative purposes of the study. the timing Intervention The parents received the SBS education program from a nurse who used three double-sided cue 10 JOGNN. The subsequent telephone questionnaire. the second card dealt with parental anger and strategies to manage it. The nurses received 3 hours training and materials aimed at increasing their knowledge and improving their skills in educating parents about SBS.

. J. Vol. Issue 1 11 .. Fortin. and Boulanger. 38. JOGNN 2009.-Y. S. The cue card on crying. A. L... RESEARCH Figure 2. De´ziel. C. Frappier.Goulet.. Lampron. M.

12 JOGNN. .1552-6909. 38. DOI: 10. The cue card for anger.RESEARCH Shaken Baby Syndrome Prevention Program anger Figure 3.2008.x http://jognn.awhonn.00301. 2009.1111/j.

Lampron. Fortin. A. De´ziel. Frappier.-Y.. and Boulanger. L.. M. JOGNN 2009. RESEARCH Figure 4. S. J.. C. Issue 1 13 . Vol.Goulet. 38.. The cue card explaining shaken baby syndrome..

Ivory Coast (1). Argentina (1). Belgium (1).5 10 30 16 38 14 33 7. and the setting in which the intervention was administered. c Other countries included: Haiti (9). Bulgaria (1).8 4. a Other countries included: Haiti (7). The 20 minutes qualitative telephone interview. Portugal (1). and the parents’ assessment of the information cards.1 13.2 136 2 95. Germany (1). including 34 couples. Only descriptive data from the interviews and direct quotes from taped interviews with parents are presented here. Interviews were transcribed and analyzed. Togo (1).0 9.00301.1111/j.4 214 24 89. Argentina (1).9 10. Bivariate analyses also allowed for the study of relationships Table 1: Sociodemographic Profile of Parents Total Sample (N 5 263) Variable Education Incomplete high school Completed high school Incomplete community college Completed community college Incomplete university degree Completed university degree Country of birth Canada Other a Sainte-Justine (n 5 99) n % Pierre LeGardeur (n 5 164) n % n % 20 43 22 51 19 82 8.8 12. Vietnam (1). 2009.8 30.3 21.0 138 4 97. 14 JOGNN. Data Analysis Descriptive statistics were used for the demographic pro¢le and to show trends. El Salvador (1). Algeria (3).2 2. Egypt (1). More than half (57%) of the respondents were age 27 to 35 years.8 138 4 97. 7-21. completed by 1 out of 10 participants. All questionnaires and interviews were administered in .2 71 25 74. 38. Vietnam (1).5 8. The majority (64%) of participants had a postsecondary degree. Finland (1).2 20.2008. The study was approved by the Research Ethics Committees of SainteJustine University Hospital and Pierre Le Gardeur Hospital. parity.4 18. About half (49%) of the families already had children. DOI: 10.3 11. and responses.2 2. Germany (1). Anonymity and con¢dentiality were ensured. Morocco (3). Chile (1). Belgium (1).1552-6909. Egypt (1).7 67 29 69.1 9. Morocco (2). Belgium (1). Cuba (1). Results Parent Profile A total of 263 parents participated: 73.3 14. Vietnam (1). The nurses’ questionnaire comprised closed questions regarding the nurses’ sociodemographic pro¢le. El Salvador (1). Italy (2). and most (90%) were born in Canada (Table 1).RESEARCH Shaken Baby Syndrome Prevention Program of the intervention. 29% were 18 to 26. Morocco (1).2 Note. Germany (1).1 49.6 10 13 6 13 5 49 10.9 23. El Salvador (1).1 5.1 21.1 76 20 79. France (7).8% mothers and 26. b Other countries included: Haiti (9).2% fathers.1 13. Italy (2).0 26.awhonn.1 6. Argentina (1). Togo (1).0 34.8 Country of birth of parent’s mother Canada Otherb Country of birth of parent’s father Canada Other c 209 29 87. among parent gender. Egypt (2). Algeria (3). Algeria (3).8 203 35 85. and 14% were over 35. France (4). their assessment of the training they had received to administer the intervention.3 27. France (3). Bulgaria (1). their assessment of the intervention and the relevance of the information given to the parents. provided evidence to complement the data gathered in the questionnaire. Switzerland (1).x http://jognn. Bulgaria (1).

0 20. RESEARCH Nurse Profile A total of 85 nurses from Sainte-Justine and 72 from Pierre Le Gardeur were trained to carry out the intervention with parents.8) 1 (2.9% would have preferred dealing with the subject before the birth of their infant.5 37..0 2.5 25.0 36.5 36.4 Æ 9.. Vol. . M. especially for new parents. Table 2: Sociodemographic Profile of Nurses Total Sample (N 5 69) Variable Years of nursing experience M Æ SD Median Range 17.0) 51 (73.5 years (Table 2).9) and a median of 18. There was less agreement on the time chosen for the intervention. Although 60.3 Æ 11.0) 2 (4.8 Æ 7. Issue 1 15 .8 Æ 9.8) 10.3 14.. x  Pierre LeGardeur (n 5 27) n (%). I found we weren’t left on our own. De´ziel.4 7. . Fortin. and 99.0 36. and there’s an injury. and 17. feeling a little overwhelmed by the situation and saying. . . 69 nurses completed the study. whereas 26% held an undergraduate degree. .9) 18 (26. The results indicate that the PSBSPP was highly relevant. and Boulanger. Almost all (98%) parents appreciated the intervention.2) 2 (7. SD 5 9.1) 28 (66. Lampron. . and that’s that . . however. You could say it reassured me to know it was normal .0 32. . take the cards and read them. x  Years of perinatal nursing experience M Æ SD Median Range Degree obtained College diploma Undergraduate Status of nurse Regular sta¡ On-call sta¡ Assistant unit head Other 44 (74.. therefore.. The nurses had somewhat less perinatal experience (M 5 10.2) 4 (14.9 3. It wouldn’t have been right to say.Goulet. with an average of 17. That the crying peak is at six weeks.5% of parents preferred receiving the intervention in the hospital.9) 2 (3. there was no doubt as to the relevance of the nurses’ participation. A.8) 23 (85. okay. Frappier.8 25. 21.4) 8 (19. . . . C. J. well .9 18.1) 10 (16.4.8 12. I thought it was good .7% would have preferred to receive it during the postnatal home visit by the nurse. It doesn’t take much. the majority (94%) of parents agreed that simply receiving the information cards without the nurses’ participation would have been insu⁄cient. Overall Assessment of the Intervention and of the Nurses’ Role Table 3 describes parents’ overall assessment of the intervention and the nurses’ role. S. so there was no risk that we would not read the cards.4) 0 (0. .4. x  Sainte-Justine (n 5 42) n (%). Nearly 74% of the nurses had a community-college diploma.4) 31 (73.-Y. you could say I focussed on that . 38. Like we don’t feel we’re bad parents for all that . median 5 7 years).0 n (%). results from both institutions were combined.2 Æ 10. L.4) 2 (7.5% of parents considered the information they received to be of no use at all.3) 23 (85. Only 1. ‘‘So quit crying!’’ . Chi-square analyses showed no di¡erences between results for parents or nurses from each hospital .6) 3 (5.3 years (SD 5 11.0 JOGNN 2009. when my little boy was six weeks old. However. .6% agreed that it should be continued.7) 14 (33. They had from 0 to 37 years of nursing experience. .0 9.9 7.3 Æ 12.

. 45% strongly agree). and among those who did. very few of the nurses (n 5 2) felt that the intervention had failed to meet the parents’ needs.1111/j. well laid out. The nurses felt comfortable intervening with parents about SBS. they were unanimous that the intervention was appropriate and that its continuation was very important.awhonn.1 53. a Response categories ranged from 1 5appreciate not at all/not at all useful/agree not at all/not at all important to 4 5 appreciate very much/very useful/very much agree/very important. or a very great deal (6%) from the card about crying.5 2. 2009. and easy to understand. A total of 57% of the parents said they learned either a great deal (51%).8 56.1 ç 60. The card on SBS had the greatest impact in terms of disseminating new knowledge: 61% of parents reported learning either a great deal (45%) or a very great deal (16%) from it. and 10. it was very clear. 16 JOGNN.6 50. . . SBS 5 shaken baby syndrome. ing. particularly the quantity of information they provided and their visual presentation (see Table 4). Almost all of them agreed that the intervention was well received by the parents (53% somewhat agree. Almost all (99.3 ç 1.6 ç 19.6%) parents emphasized the importance of giving the cards to every parent at the birth of their child. however.4 62. . . 7-21.3 73. Most parents (63. Graphically it looks good .2008. As for the nurses.5% did so four times or more. But you can read short cards like that quickly.9 8. I think it made me aware of the fact that. DOI: 10. On the other hand. The information is really clear. 59% did so only once. I remember that.5% did so two or three times.7 48. . it was good .8 45. and you’ve got the point.6 41. I liked the little lines where we could write in our solutions. They also noted the quality of the cards.1 1.9 ç ç 35. like.9 1.1552-6909.0 41.RESEARCH Shaken Baby Syndrome Prevention Program The information on the cards concerning infant crying and parental anger helped almost half of the parents in situations of an infant’s intense crying. . Yes.4 ç ç 39. basically. 38. I think it might have been discouraging.9 7. If it’d been a document with lots of writ- Table 3: Overall Assessment of the Intervention and the Role of the Nurse (%) 1 Variable Parents (n 5 263) Appreciate nurse’s intervention Information given is useful Nurses (n 5 69) Recommended intervention seems appropriate Intervention does not seem to meet parents’ needs Nurse feels comfortable intervening with parents about SBS Not all nurses can perform this SBS intervention Nurse’s intervention is well received by the parents It is important that the program continue 32.7 35.9 43.3 8. we have to have our resources ready .00301. but 28% believed that not all nurses could perform this type of intervention. the majority (55%) did not think about them often.3 Not At All a 2 Not Very Much 3 Somewhat 4 Very Much Note. and 52% said they learned either a great deal (46%) or a very great deal (6%) from the card about anger. highly relevant.x http://jognn. I think that’s the main thing.5%) did not look at the cards again. the cue cards were appreciated. Information Cue Cards According to the majority of the parents. exactly who’s going to help us get through these times that everyone experiences? Almost 80% of parents said they thought about the information cards after returning home.1 26.7 1.

De´ziel. but a baby crying for a whole day gets to be hard to take . Vol.5 ç 35. No.9 ç ç 73.5 38.4 3.5%) of the parents found the cards about crying and anger helpful in situations where the baby’s crying was particularly intense.7 NA NA NA NA ç ç 19.. Only 1.6 68.8 38.8 NA NA NA NA ç 1. nearly half the participants (47%) remembered one or two actions from their plan. venting for the anger.4 61.1 1.6% did not consider it useful (see Table 5).. The parents’ action plans included about 20 di¡erent actions.0 35.. I didn’t get into an extreme situation. doing crosswords.8 59. The ¢rst two coping strategies were given as examples on the information card.0 4. on my part.4 70.1 26. J. For their part. Action Plan Almost every (98%) parent wrote an action plan at the hospital and con¢rmed that it was useful. The actions parents identi¢ed most often to respond to stress brought on by their baby’s crying were as follows: putting the baby to bed and leaving the room (32%). Fortin. M. Six to eight weeks after returning home. .2 1. they nonetheless indicate that almost half (44.9 ç ç ç 1.7 83. or for no reason we could ¢nd. I think I applied it anyway .. Yes. RESEARCH Table 4: Information Cards Parents’ Component (n 5 263) Strongly Criterion Relevance Information on the cards is interesting Information on the cards is useful Cards support the intervention well Comfortable with information on cards Speci¢c criteria Amount of information is appropriate Visual presentation is not pleasing Information provided is hard to understand Educational characteristics Cards allowed us to acquire new knowledge 5. Furthermore.8 Disagree Somewhat Disagree Nurses’ Component (n 5 69) Somewhat Disagree Somewhat Strongly Agree Agree Somewhat Strongly Strongly Agree Agree Disagree Although these results cannot show whether the information cards helped reduce parental stress.5 36. they were almost unanimous in saying that they learned something new.3 62. which was not measured. 38. C.7 98.4 34. I did that . all the nurses agreed on the importance of giving the three information cards to the parents. or doing yoga.. You might not think it.1 1.9 40. Putting the baby in a safe place and.8 57.0 17.8 59. A. well. I did that.9 42. and only 8% did not remember any at all. Calling a friend or relative. . All nurses reported having bene¢ted from the support of the information cards in their meetings with the parents. that’s where you’re vulnerable. .7 25. . .4 3. Frappier. calling a family member or friend for help or support.7 80.Goulet. S. . but there was one day when the baby cried all day for no reason .9 ç ç ç 1.0 3. but JOGNN 2009. Lampron. and Boulanger. They agreed that the information on the cards was relevant and easy to understand and that the amount of information and the visual quality of the cards were adequate (see Table 4).1 ç 1. or taking a walk and letting their spouse take over. . But in practice.1 98. taking a drive. including listening to music. . Just to say.-Y.5 ç 14.5 28.2 58. Issue 1 17 . L.3 0.0 ç 3. that’s it.

w 2 (3. The majority agreed with the following statements: ‘‘The information given is easy to understand. as I say.00301.029. 259) 5 13. and more detailed information on SBS. Furthermore.5 Note. and 51% thought it had either little (37%) or no relevance at all (14%).7 29. p 5 .7 15.6 2 Not Very 13.02.004. particularly during the peak crying period (6 weeks).3 Not at All 1.6 13.’’ ‘‘the learning activities foster the appropriation of knowledge.01.’’ Furthermore. DOI: 10.5%) supported signing the plan. Response categories ranged from 1 5not at all useful/relevant to 4 5 very useful/very relevant.2 32.RESEARCH Shaken Baby Syndrome Prevention Program Table 5: Relevance of Action Plan and Signatures Parents’ Component (n 5 269) 1 Item Usefulness of action plan Relevance of signing the action plan Relevance of nurse’s signature 18. As for the nurses’ signatures. so it’s still fresh in my mind.002.1111/j.5%) or highly satis¢ed (72.9 38. 2009.0 .’’ and ‘‘the length of training is well suited to the content. pictures explain everything.0 3 Somewhat 35.2008. the nurses said the support materials they received in the form of a quick-reference card and guide booklet were relevant and facilitated their administration of the intervention. Differences According to Parent Gender and Parity Bivariate analyses suggested that new parents found the information more useful than those who already had children.2% of the nurses believed the parents’ signatures had no relevance. .awhonn. particularly the ones on crying. Most of the parents (93. More fathers than mothers quali¢ed their answers as somewhat agree.7 19.’’ ‘‘there is good balance between the quantity of scienti¢c information and the practical exercises. 48% of parents and 39% of nurses thought the nurses’ signatures had little relevance or no relevance at all. The relevance of the parents’ and nurses’ signatures was not convincingly demonstrated. . and SBS. Moreover. N 5 Introduction of the Program More than three fourths of the nurses mentioned that implementation of the program was well 18 JOGNN. N 5 259) 5 10.040. whereas more mothers said they strongly agreed with the statements regarding the usefulness of the cue cards. w 2 (4.6 3 Somewhat 39.x http://jognn. and 6% said she had not. w 2 (4. 29. N 5 259) 5 9. 38. A few moreçperhaps more explicitç pictures . The only di¡erences by gender pertained to the degree of satisfaction.5%) with the training they received and felt that the information given during their training was interesting (see Table 6).4 36.’’ ‘‘the training is good preparation for intervening with parents. Assessment of the Training Given to the Nurses All of the nurses were either somewhat satis¢ed (27.1 37.69. p 5 .3 10.1552-6909. And with pictures. N 5 259) 5 16. p 5 . In particular.3 4 Very 43. Furthermore. I’ve given you the answers I wrote down two months ago. 7-21. but only 19% considered the exercise very relevant.6 29.7 30.1 Nurses’ Component (n 5 69) 1 Not at All 3. Parents’ Suggestions for Improving the Program The parents’ two most frequent suggestions for improving the program were for follow-up after their return home. w 2 (3. they said the nurses’ guide booklet facilitated their participation in the training and agreed it should be given to every nurse as part of the training. they wanted more information about the injuries and consequences for babies who are victims of SBS and were interested in examples from daily life of parents who were at the end of their tether because of persistent crying.6 24. 26% of parents did not recall if the nurse had actually signed. New parents also thought more about the information after returning home.8 27.8 2 Not Very 8. and learned more from the cue cards. The majority of nurses believed that the quick-reference card helped them understand the prevention program and adequately supported them in preparing for the intervention and almost all of the nurses said it should be given during their formal training. p 5 .4 32.1 4 Very 54.

this program is a cost e¡ective intervention.6 4.7 1.9 4. role playing) do not make the appropriation of knowledge easy Overall.0 31. Most parents (61%) agreed with the inhospital intervention.8 38.Goulet. The timing of the intervention has been extensively discussed with public health authorities in this region. 1992).4 9.9 1. Nurses were satis¢ed with the training they had for this intervention. during the usually JOGNN 2009. short length of stay in the hospital.7 28.-Y. Lampron.0 1. Fortin. Although nearly two thirds of them agreed that the intervention ¢t well with their regular activities.4 18. community centers.2 66. Both parents and nurses embraced the initiative and stressed its signi¢cance. anger.6 50.7 40. and they found that the intervention was well received by parents. Issue 1 19 . The educational tools were highly appreciated.6 50.4 8.7 59. and SBS. the nurses could ¢nd the time to deliver the intervention to both parents most of the time.1 3. L. and community health departments.. M.7 58. and very few (18%) would have preferred a prenatal intervention. approximately 70% felt that it was not easy to ¢nd an appropriate time for the intervention. Nurses also mentioned it was a sensitive but realistic intervention (5-10 minutes).7 ç 2.0 3.7 61.1 42. Frappier. Vol. Another goal of the program was also attained in that parents had identi¢ed and used anger management skills and personal coping strategies for infant crying.8 ç ç 18. This study supports the relevance of introducing the PSBSPP in all hospitals. An ongoing monitoring program in the two hospitals reveals that more than 85% of parents are now receiving the intervention.4 ç 26. S.. J.9 4.0 ç 76.3 54.. 2005. However. particularly because it involved both parents. and similar interventions have been proven e¡ective in reducing SBS (Dias et al. Shower. Moreover. RESEARCH Table 6: Assessment of Nurses’ Training Strongly Assessment variable Various aspects of training Information provided in the training is interesting Information provided in the training is hard to understand Training is well balanced in terms of the amount of scienti¢c information and practical exercises Learning activities (quizzes.5 79.4 Disagree Somewhat Disagree Somewhat Agree Strongly Agree received.8 2. simulations. Comparing the 3 hours training session for nurses with the cost of caring for a child victim of SBS.. training prepares a nurse well for intervening with parents Length of the training is well suited to the content Educational tools distributed during training Nurse’s guide booklet and quick reference card help the nurses adequately Quick-reference card supports the intervention adequately Quick-reference card does not help one understand the prevention program Quick-reference card should be given to all nurses as part of the training Nurse’s guide booklet makes it easier for her to take part Nurse’s guide booklet does not have to be given to all nurses as part of the training 3. De´ziel.7 1. although it was sometimes di⁄cult to ¢nd a time where both parents were present.. 38. this intervention relied on a sound theoretical framework that incorporated anger as a factor between infant crying and SBS and the practice of re£ecting and writing in advance one’s own coping strategies.4 25.6 37.1 ç 69. and Boulanger.. A.1 ç ç 65.9 10.6 89.1 ç 42. It was mentioned that in the prenatal phase mothers and fathers were not preoccupied by these topics and infant crying became a reality when they were in contact with their baby. Prevention programs that have shown a positive e¡ect on parents’ knowledge Discussion The PSBSPP achieved its goal of increasing parents’ knowledge about infant crying. C.9 4.

20 JOGNN. (1998). coping strategies. 7-21. L. Understanding shaken baby syndrome. R. might the program be suitable to speci¢c groups (e. L. Barr. Case. it relied on perception of increased knowledge. L. almost half of parents mentioned the information was helpful in situations where the baby’s crying was particularly intense.. 115. Trent.. G. September). information on SBS should be provided to all families.. etc. R. The intention in this study was to add a second phase to the PSBSPP. T. To this end. The intervention was given 24 to 48 hours postbirth. The results also do not allow the authors to state that a one-time intervention is su⁄cient to decrease SBS. Position paper on fatal abusive head injuries in infants and young children. In the interviews. parents indicated that stress was reduced in some cases.. & Young. Advances in Neonatal Care. it is possible that parents will forget their coping strategies.. K. UT. R. Jentzen. anger. & Sha¡er.. Non-accidental head injury in infantsçThe shaken baby syndrome. G. N. one would need a national register of cases of SBS. e470-e477. ¤ ¤ ¤ Fortin. 2005. 22. (2002. it was clear that parents learned about infant crying. L. S. R. Barr. Conway. A.112-122. Archives of Pediatrics and Adolescent Medicine. DiScala. 27... A. DeGuehery. but it is di⁄cult to assess objectively if stress was reduced during all episodes of infant crying. Corey-Handy. & Monteleone. although 61% of the parents mentioned they preferred to receive the intervention at that time. Lehtonen..RESEARCH Shaken Baby Syndrome Prevention Program Both parents and nurses confirmed that the program was relevant and that its introduction would be important at all birthing institutions. Shower. ethnic. C. Nassogne. 30. Sege. F.g. P. Kadhim. Child abuse and unintentional injuries: A 10-year retrospective. M. J. Bonnier.. Ministere de la ¤ ¤ Sante et des Services Sociaux du Quebec.) to provide a culturally congruent approach? It also is important to develop a national SBS registry so that a randomized trial or a longitudinal follow-up study could determine if implementation of the PSBSPP reduces the incidence of SBS. (2001). New England Journal of Medicine. Barr. V. 18221829. with a follow-up during the postnatal home visit or a follow-up during the ¢rst vaccination session at 2 months. A. K.. Pediatrics. Carbaugh. A. 206210. To do so. Dias. B. 338. Shaken baby syndrome: Rotational cranial injuriesçtechnical report. 4. At a time of intense stress. Age-related incidence curve of hospitalized shaken baby syndrome cases: Convergent evidence for crying as a trigger to shaking. . M. J. & Reece. Mesples. Justice Canada/National Crime Prevention Committee.. (2000). M.. C. 16-22. This would reinforce the parents’ coping strategies and provide a ‘‘booster’’ to the hospital postnatal intervention. 2009. (2001). E. Nonaccidental head injury in infants: ‘‘The shaken baby syndrome revisited. Rorke. car seats. E. Smith.. D. and Sainte-Justine Health Promotion Funds. like information on breastfeeding. & Maisonneuve.awhonn. C. (2004). and vaccination. R. However. Developmental and Behavioral Pediatrics.x http://jognn. 26.. G.’’ Pediatric Annals. MacMartin. & Sebire. B.. S. linguistic. (2006). 108.. W. Pediatrics.. Dias et al.. 105-114.1111/j. (2003). 1992). Preventing abusive head trauma among infants and young children: A hospital-based. Li... Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome. Future studies are needed to ensure that this intervention is as powerful as it seems. Paper presented at the 4th National Conference on SBS. A.. C. The period of purple crying. & Cross. However. M. 154. The study did not measure whether the intervention actually decreased the incidence of SBS. R. & the National Center on Shaken Baby Syndrome. Christian.. (2005). (1998). Mazur. J. All men and women who feel powerless when faced with a crying infant are at risk of losing control over their emotions and actions. DOI: 10. and SBS. L. G. M. Paterson. Pediatrics. The reduction of death and sequelae resulting from SBS depends on implementing preventive measures.00301. The study did not measure actual knowledge. M. parent education program. (2005). In addition. This study has some limitations. (2008). Child Abuse and Neglect.. Syndrome du bebe secoue. although in the verbatim transcripts. 7-16. particularly with parents but also with others who care for an infant.1552-6909. Duhaime. and parents’ readiness and receptivity could have been less than optimal. future studies could evaluate its implementation and outcomes with more vulnerable populations. REFERENCES American Academy of Pediatrics. H.. Even though the program is intended for universal application and has been developed to educate all parents.. (2005) did a onetime intervention and found a decrease in SBS. An important restructuring of nursing work at one site during the study explains the low participation rate of nurses. mieux “ ¤ ¤ comprendre le trauma cranio-ce rebral non accidentel de l’enfant [Shaken baby syndrome : A better understanding of non accidental craniocerebral trauma in children] [CD-ROM].. M. 38. Saint-Martin.. C. American Journal of Forensic Medicine and Pathology. Li.. Acknowledgments ' Supported by the Hogg Foundation.. G. B. S. and a decrease of SBS emphasize early and inhospital intervention (Dias et al. whether at home or in a child care environment. Graham. Prolonged and unsoothable crying bouts in infants with and without colic. & Zimmerman. M. 112. 14-23. 808-814.This program should be part of the educational training of all health professionals. 677-690.2008. Salt Lake City. G. C.

Retreived November 26... NY: Haworth Press. Park. Issue 1 21 .-Y. Canada: Centre Hospitalier Universitaire appraisal and coping. Canada: Minister of Public Works and Government Services. M. The neurodevelopmental outcome in infants who have sustained a subdural haemorrhage from non-accidental head injury. S. S. M. Ottawa. J. Ottawa. S. 11-18. Vol. K. (1984). B. Child Abuse and Neglect.gc. (1992). J. 69-81. 319-321. New York: Springer. Y. Coles. S. Case. (2004). Perez-Arjona. J. Daciuck.. Late outcome following central nervous system injury in child abuse.. W. Etude canadienne sur l’incidence des signalements ¤ des cas de violence et de ne gligence envers les enfants [Canadian incidence study of reported child abuse and neglect]. R. S.. Capra. Bennett. 13.. Health Canada. King. Lazarus.. F. J. Prevention of shaken baby syndrome: Never shake a baby. 16. 2008. (2004).. G. Journal of the American Association for Pediatric Ophthalmology and Strabismus.. MacKay. Frappier. (2001). A. phac-aspc. S.. pdf. Paediatric Child Health.Goulet. Showers. Shaken baby syndrome in Canada: Clinical characteristics and outcomes of hospital cases. Dujovny. The shaken baby syndrome: A multidisciplinary approach (pp. L. A.. Preventing shaken baby syndrome.. & Kemp. DelProposte. ¤ Trocme. and Boulanger. E.. MacLaurin..... JOGNN 2009. S. Canadian Medical Association Journal. R. Showers. S.178-187. Jayawant. Lazoritz & V.. 168. Stress. ON. D. Joint statement on shaken baby syndrome. (2003).. Don’t shake the baby: The e¡ectiveness of a prevention program. Morad.. (2004). (2003). Bliingsley.. & Folkman. 349-365). Z. B.. J. M. 38. De´ziel. 155-159. Fallon.. J. Avni. RESEARCH ¤ Montreal. et al.). 8. E. I. & King. Kodsi. A. Ward. the Canadian Shaken Baby Study Group.. L. M. Child Abuse Review. 19. On. N. In S. C. Feldman. QC... 521-527.. M. W... L. (2001). et al. & Sirnick. J. K. Shaken baby syndrome without intracranial hemorrhage on initial computed tomography.Tourigny. Palusci (Eds. M. Canada: Ministre des Travaux publics et des Services gouvernementaux. Vinas. Karandikar. Ł et al. H. (2001). Binghamton.. Child Nervous System.. M.. Lampron. 9. Lizarraga. from http://www. Fortin..

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