Running head: IMPROVING SLEEP QUALITY

Improving Sleep Quality in Medical-Surgical Patients by Reduction of Nighttime Interruptions

Janet Palmer, RN
Western Washington University
Nursing 402 Translational Research for Evidence Based Practice
Christine Espina DNP, MN, RN and Tom Carson MSN, RN, CEN
February 24, 2017
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Abstract
The hospital is not a place known for a good nights sleep. Frequent care activities, medications,

and other activities interrupt sleep and yet sleep is vital to our healing and wellbeing. This

literature review looked at research regarding inpatient, non-ICU adults for ways to reduce

disturbance of sleep and improve satisfaction. CINAHL database was searched using keywords

to find articles related to our subject. Results point to patient centered care as key to reducing

interruptions to stable patients. Interventions include noise reduction, restructuring the shift to

reduce interruptions, and organization of care. Implications for practice are to that nurses control

the environment of our patients in a large degree, we can work to improve their sleep. This

includes retiming care activities to provide for a do-not-disturb time at night, evaluation of

patient medications, and assessment of the necessity of vital signs.

Keywords: Medical-surgical, Inpatient, Sleep, Sleep Disturbance, Sleep Quality

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Introduction
Sleep is a basic need. It allows us to heal, and yet, in hospitals, sleep can be a scare

resource. Not only are patients trying to sleep in unfamiliar places, there are foreign sounds and

frequent interruptions. These factors contribute to poor quality of sleep in hospitalized medical-

surgical patients.

Nurses have acknowledged the importance of sleep from the very beginning of the

profession. Florence Nightingale knew there was a connection between the health of her patients

and their environment (Salzmann-Erikson, Lagerqvist, & Pousette, 2016). She also identified

that environment was something that nurses could directly control and improve for their patients.

Nightingale also specifically identified noise as a problem for patients (Applebaum, Calo, &

Neville, 2016).

Noise from staff, noise from other patients, alarms, lights, and interruptions are all factors

identified by patients as hindering sleep quality and quantity. Interruptions for patient care at

night include vital signs, assessments, lab draws, and medication administration (Applebaum et

al., 2016). Staff conversations outside of the patient rooms, in the hallways, and at nurses

stations, have also been identified as a reason patients are disturbed from sleep. Alarms from

hospital equipment such as intravenous pumps and monitors, wake patients up more than noise

from staff conversations (Fillary et al., 2015). Patients frequently wake up earlier than they

would at home (Salzmann-Erikson et al., 2016). This culminates in inadequate sleep for

hospitalized patients.
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The effects of sleep deprivation are far reaching. In the short term, it can negatively affect

cognitive function including decreased concentration, mood swings, and difficulties with

memory (Salzmann-Erikson et al., 2016). Long term negative effects include impact on the

immune system, slower wound healing and increased risk for infection (Norton, Flood, Brittin, &

Miles, 2015; Salzmann-Erikson et al., 2016). Inadequate sleep may also lead to lowered pain

tolerance and pain is common in hospitalized patients (Bartick, Thai, Schmidt, Altaye, & Solet,

2010; Fillary et al., 2015). During periods of rest, the body under goes various changes in

regulatory functions with the heart and breathing slowing and the muscles relaxing, but it seems

the brain is the most sensitive organ for sleep deprivation (Salzmann-Erikson et al., 2016).

Sleep is important and effects every part of life. Promotion of sleep for acute inpatients

should be a part of nursing care. Hospitals need to change to be patient focused in all aspects of

care and promoting sleep is one piece of the puzzle.

Purpose

The purpose was to review literature related to sleep quality improvement for adult non-

ICU inpatients to see if the reduction of interruptions to sleep increase the patients adherence to

their care plan and give improved reports of satisfied sleep. PICO: In adult non-ICU inpatients,

does the reduction of interruptions during the night lead to improved levels of sleep quality and

satisfaction?

Methods

CINAHL online database was searched using the keywords inpatient, sleep, surgical

patient, sleep quality, medications, and lab draws. Results were narrowed down to articles

published after 2010. Final selections were made for those articles that focused on interruption
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reduction strategies, excluded the care of ICU patients, and focused on nurse driven strategies.

Seven articles were selected for review.

Findings

Sleep disruption in hospitalized patients is a multifactorial problem. To address this, a

multimodal strategy needs to be implemented and staff from all levels from physicians,

pharmacists, nurses and unlicensed assistive personnel need to be engaged.

Noise is often the most cited reason for sleep disruption. Noise is any unwanted sound

without value (Applebaum et al., 2016, p. 669). Interventions to reduce noise on inpatient units

start with nurses. Staff conversations are the common cause of noise on the unit. Visual

reminders to reduce volume such as signs and sound meters have shown to help (Fillary et al.,

2015). Bartick et al. (2012) installed sound meters at nurses stations. These sounds meters

flashed red to indicate when a decibel level of 60dB was reached. Bartick et al. (2012), also

suggests placing IV catheters in locations other than the antecubital fossae and changing IV bags

at the beginning of the night to reduce IV pump alarms. Another simple intervention is to make

sure that doors to patient rooms are closed when it is safe to do so (Fillary et al., 2015). Single

patient rooms are preferred with sliding glass doors to reduce noise while allowing visualization

of patients and should be considered when designing inpatient units (Fillary et al., 2015). Other

noise reducing interventions suggested include offering ear plugs or using white noise to mask

the sounds of provider conversations (Fillary et al., 2015; Norton et al., 2015). Designated quiet

times where interruptions are minimized have shown to have a positive impact on patients

reports of sleep quality. Applebaum et al. (2016) discuss that an hour of quiet time in the evening

had a perceived impact on the environment for the whole day. During this quiet time staff and

visitors were asked to speak quietly and interventions were minimized unless absolutely
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necessary. Bartick et al. (2010) also suggests a quiet time from 2200 to 0600 signaled with a

lullaby on the overhead speakers to ensure staff and visitors are aware quiet time has begun.

The most effective way to reduce interruptions at night is the grouping of tasks and

organization of care. Purposeful rounds in the evening to promote sleep should include the

bundling of care to including evening vitals, assessments, toileting, pain control and replacing IV

fluid bags so they will not cause alarms in the night (Bartick et al., 2010). These rounds could

also include providing ear plugs and eye masks as needed and sleep aid medications (Fillary et

al., 2015).

All care providers should be involved in the reduction of nighttime interruptions.

Morning lab draws happen between 0200 and 0600 for the convenience of physicians. Drawing

labs at this time ensures the results are viewable in a timely manner for physician rounds. By

moving the lab draws, to either later in the morning, or earlier to midnight, improves patient

satisfaction scores (Ramarajan, Chima, & Young, 2016; Sorita et al., 2014). The morning routine

lab rounds causes uneven lab workload and, by moving the lab draws to 0600, the entire

workflow of the lab needed to be adjusted with more staff needed (Ramarajan et al., 2016).

Moving the routine lab draws to midnight allows for a longer period of uninterrupted sleep

without the needed increase in lab staffing and results are viewable in a timely manner for

physicians (Sorita et al., 2014).

Physicians and pharmacists should also be enlisted to reduce unnecessary nighttime

medications. A change to how medications are ordered to be more flexible and reduce nighttime

administrations by changing the orders from Q12, Q8, Q6 hours to BID, TID, QID reduces the

need to wake patients. Timed doses of diuretics earlier in the afternoon to reduce the need for

frequent bathroom trips also has an impact on sleep (Bartick et al., 2010).
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Recommendations

Peacehealth Saint Joseph Medical Center currently does not have a program to reduce

noise or interruptions at night. A cohesive approach to solve this problem will result in higher

patient satisfaction scores. A pilot study that includes education of staff, retiming of routine labs

draws, and evaluation of medications should be undertaken.

Education of staff regarding the quiet at night initiative to reduce interruptions and noise

should be provided to all caregivers on the unit as well as the pharmacists and physicians. This

education should include criteria of a stable patient that could have these interventions without

negative consequences. Staff should be educated, not just on being quieter while going about

nighttime tasks, but encouraged to help each other with reminders. Reminders are to be posted in

nursing care areas as well as information given to patients regarding the initiative. Organization

of care is equally as important as noise reduction and the education should reflect this. Nurses

should group care such as vitals, lab draws and medication administration with other routine

cares as much as possible.

Routine nursing care causes interruptions at night. With eight-hour nursing shifts that

start at 2300, assessments must be done by the oncoming nurse at the beginning of her shift. This

paired with bedside rounding at change of shift causes frequent interruptions between the hours

of 2330 and 0100. Changing all nurses to twelve-hour shifts would allow for earlier assessments,

more organization of care, and fewer disruptions after 2200.

Medication ordering needs to be reviewed and changed to help encourage sleep at night.

Pharmacy should review medication times to make certain they are appropriate. This includes

administration of diuretics before 1700. Standards of practice around antibiotics and other
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medications should be adhered to, but accommodate uninterrupted periods of sleep where

feasible.

Routine blood draws should be changed to either a later morning draw, such as 0600, or

changed to be drawn early in the night at midnight to better accommodate uninterrupted periods

of sleep.

Implications for Practice

Changing routine lab draws to midnight will change the work flow routine in the lab and

with the phlebotomists. However, this change would cause less need for change than if the

routine labs were drawn at 0600. Ramarajan et al. (2015) found there was a need to increase lab

staffing when labs were moved to 0600. Physicians would need education about labs and

encouragement to not reorder stat labs in the morning during rounds for more recent results.

Midnight lab draws do not change results on routine daily labs (Sorita et al., 2014).

Organization of the shifts work would change to better accommodate the organization of

care. Adherence to the quiet at night initiative would affect nursing care throughout the shift. The

nurse would need to work closely with the unlicensed assistive personnel to coordinate care

during quiet hours. The nurses workflow may bottleneck after 0600 as morning medications are

given and vital signs taken.

Restructuring nursing shifts to accommodate twelve-hour shifts would be a large amount

of work. Positions might be removed as less nurses are needed with 12 hours shift than with 8

hour shifts. Nurses may also be reluctant to change shifts and schedule patterns. This change

would affect nurses on all shifts, not just those who work at night.
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Pharmacy already reviews medication orders for appropriateness of the dose and order.

This review could include whether the time of administration of the medication is appropriate

and fits with standards of care.

These changes will increase patient satisfaction scores. Ramarajan et al. (2015) saw

improvement in Hospital Consumer Assessment of Healthcare Providers and Systems

(HCAHPS) scores of 7.5 points by moving lab times. With these interventions all shown to

improve patient satisfaction, there is the possibility that implementing a multi-faceted approach

will improve these scores by more than whtat is documented in the research.

Conclusion

Most interventions to create a quiet night with less frequent interruptions from staff are

simple and cost effective. Organization of care is the biggest factor related to interruptions as

perceived by the patients. Nurses have a key role in advocating for their patients and their sleep

needs. Patients will have a more satisfying hospital stay and have better outcomes with a good

nights rest while under our care.

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Referenes

Applebaum, D., Calo, O., & Neville, K. (2016). Implementation of Quiet Time for Noise

Reduction on a Medical-Surgical Unit. Journal of Nursing Administration, 46(12), 669

674. https://doi.org/10.1097/NNA.0000000000000424

Bartick, M. C., Thai, X., Schmidt, T., Altaye, A., & Solet, J. M. (2010). Decrease in asneeded

sedative use by limiting nighttime sleep disruptions from hospital staff. Journal of

Hospital Medicine, 5(3). https://doi.org/10.1002/jhm.549

Fillary, J., Chaplin, H., Jones, G., Thompson, A., Holme, A., & Wilson, P. (2015). Noise at night

in hospital general wards: a mapping of the literature. British Journal of Nursing, 24(10),

536540. https://doi.org/10.12968/bjon.2015.24.10.536

Norton, C., Flood, D., Brittin, A., & Miles, J. (2015). Improving sleep for patients in acute

hospitals. Nursing Standard, 29(28), 3542. https://doi.org/10.7748/ns.29.28.35.e8947

Ramarajan, V., Chima, H. S., & Young, L. (2016). Implementation of Later Morning Specimen

Draws to Improve Patient Health and Satisfaction. Laboratory Medicine, 47(1), e1e4.

https://doi.org/10.1093/labmed/lmv013

Salzmann-Erikson, M., Lagerqvist, L., & Pousette, S. (2016). Keep calm and have a good night:

nurses strategies to promote inpatients sleep in the hospital environment. Scandinavian

Journal of Caring Sciences, 30(2), 356364. https://doi.org/10.1111/scs.12255

Sorita, A., Patterson, A., Landazuri, P., De-Lin, S., Fischer, C., Husk, G., & Sivaprasad, L.

(2014). The Feasibility and Impact of Midnight Routine Blood Draws on Laboratory

Orders and Processing Time. American Journal of Clinical Pathology, 141(6), 805810.

https://doi.org/10.1309/AJCPPL8KFH3KFHNV