This story about adjusting overnight practices to allow residents to sleep without being woken up throughout the night was originally published in our October Newsletter. Pat Maben, RN, MN, comments on the effectiveness and particulars of these practices.

The story from Rosedale Green is an example of integrating a deep knowing of the resident, allowing residents to live their own lives and using evidence based care.  For too long those of us in long-term care have required residents to adapt to schedules that reflect the needs of the community and not the usual rhythm of the resident’s day.

Research studies in the past ten years in nursing homes conclude that awakening residents at night can cause sleep deprivation.  Sleep deprivation can lead to depression, confusion and agitation. Residents are awakened by noise in the hallway, staff entering room to restock supplies, turning on the overhead light to check and change incontinence briefs, and repositioning residents every two hours routinely.  Collection of laboratory samples and scheduled administration of medications on the night shift is a common practice.  As Action Pact’s clients work to create a resident-directed environment, one of the things we study is adapting clinical systems based on each resident’s individual choice, preference and rhythm of his/her day. In addition to bathing and medication administration, we focus on promoting adequate sleep for residents.

Part of the assessment process should include information about the resident’s usual sleep pattern. It is essential that information about the resident’s sleep patterns be obtained from the resident and/or family.

• What are your bedtime rituals i.e. bathe, read, listen to music etc.?
• Do you have a preferred bedtime snack?
• What time do you usually go to bed?
• Do you have to go to the bathroom at night?  Is there a usual time?
• What disturbs your sleep?
• Is there anything that helps you to sleep?
• What time do you usually wake up in the morning?

Awakening residents every two hours to check and change incontinence briefs and reposition is an ingrained practice. Research studies have collected data on self-repositioning by residents at night. One study found that many of the residents that triggered the Pressure Ulcer RAP repositioned themselves. Night staff should assess residents at move in, hospital return or after a decline in functioning to determine whether they self-reposition.  A nurse should evaluate if there is a need to assist with repositioning based on their risk for pressure ulcers.  Repositioning residents by weight shifting can be done in a manner that does not awaken the resident, and has also be shown to be safe for residents with risk for pressure ulcers.  The need for repositioning must be based on an assessment of each resident.

Additionally, there are incontinence briefs designed specifically for use at night. The material used in the brief is designed to wick urine away from the skin. The use of this type of brief has been demonstrated to be safe for residents that are not at high risk for pressure ulcers. Again the decision not to change a resident every two hours must be based on the individual resident’s condition.

Developing a sleep promotion team that includes night staff is one way to address this important issue. Night staff can be encouraged to review their own practices and to identify ways they can promote sleep for residents.  Current practices that create situations where a resident is awakened at night need to be explored to determine if a change in policies and procedures need to be considered.  Encourage the team to write and share their stories about the improvement of the lives of residents after implementing systems to promote sleep.

Patricia Maben, MN, RN,  has experience as Director of Nursing in two nursing facilities and for 15 years was the Director of Long-Term Care Program for the State of Kansas.  She served on the Case Mix and Quality Improvement Demonstration Project that developed the case mix reimbursement system for nursing facilities.  Pat participated in an expert panel for the Quality Indicators project.  She is the author of the Creating Home Policy and Procedure Manual in the Household Matters Toolkit.