Art & science The acute synthesis care of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON IMPROVING PATIENTS SLEEP: REDUCING LIGHT AND NOISE LEVELS ON WARDS AT NIGHT Carol Hewart and Loveday Fethney describe the changes being implemented at one trust to ensure patients have a better chance of getting a good night s rest Correspondence carolhewart@nhs.net Carol Hewart is a clinical site manager Loveday Fethney is an education lead Both in the acute care team at Derriford Hospital, Plymouth Hospitals NHS Trust, Devon Date of submission October 8 2015 Date of acceptance November 11 2015 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines journals.rcni.com/r/ nm-author-guidelines Abstract There is much research concerning the psychological and physical effects of sleep deprivation on patients in healthcare systems, yet interrupted sleep on hospital wards at night remains a problem. Staff at Plymouth Hospitals NHS Trust, Devon, wanted to identify the factors that prevent patients from sleeping well at night. Two audits were carried out, between April and August 2015, to assess noise and light levels on wards at night, and to engage nurses in ways of reducing these. A number of recommendations were made based on the audit findings, many of which have been put into practice. Keywords sleep, noise, light, change in practice, nurse management, patient experience, enhanced recovery SLEEP DEPRIVATION for patients is a long-standing problem in healthcare systems, and research suggests there are multiple causes of poor quality rest (Kowalczyk 2011, Shepherd 2012). Patient feedback questionnaires show that lack of sleep due to hospital noise is detrimental to recovery (Fenton et al 2012, Doyle et al 2013), yet Yoder et al (2012) suggest that this noise is preventable and that reducing it could have a positive effect on patients experiences. Staff at Plymouth Hospitals NHS Trust (PHNT), Devon, wanted to identify the factors that could improve the amount of good quality sleep for patients. Therefore, staff in the acute care team (ACT), comprising a clinical outreach support team and acute pain service, were asked to investigate. This team was chosen partly because members regularly visit all adult wards in the trust and are seen by ward staff as approachable and knowledgeable. Literature review A literature review was undertaken to gain an understanding of sleep and to identify the factors that affect the quality of patients rest. Elliott (2011) notes that we live in an increasingly noisy society and might be unaware of the destructive effects of noise pollution on health, learning, productivity and quality of life. It is possible that, with the advance in technology, hospital staff become noise blind to routine noise and emergency alarms (Phend 2012). However, patients who are not used to these sounds can find them disturbing and intrusive. Sleep is widely recognised as important to health and healing, and sleep deprivation can have long-term consequences, such as hypertension, reduced immune function, delirium, obesity, type 2 diabetes and impaired cardiovascular function (Young et al 2009, Pederson 2012, Stevens 2013, Ubel 2013, White 2013). Numerous articles suggest there is an association between hospital admission and sleep deprivation, and that when patients do manage to sleep it is often interrupted and therefore poor quality (Maiken 2012, Shepherd 2012, Ubel 2013). Yoder et al (2012) began to identify ways in which healthcare professionals could improve the quality and quantity of patients sleep, but did not clarify the interventions that hospitals should introduce 18 February 2016 Volume 22 Number 9 NURSING MANAGEMENT
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Art & science acute sleep deprivation care to achieve this. Other researchers also stop short of suggesting effective solutions to the problem (Young et al 2009, Pedersen 2012) so there is little evidence of progress (Chen 2012). According to Ubel (2013), it is difficult to change hospital cultures, particularly when there is little incentive to do so, but there are a number of reasons why improving patients sleep should be a priority for nurses and trusts. For example, Bartick et al (2010) found that, when sleep was given priority and hospital night-time activities were reduced, there was a significant (49%) decrease in the use of sedatives. Other benefits of this include fewer incidents of delirium and falls, both of which are side effects of these medications (Reddy 2012). Furthermore, if patients are healthier at discharge, they are less likely to be re-admitted, and shorter hospital stays lead to higher turnover, meaning that more patients can be seen, treated and discharged, which will enhance their experience of the NHS (Luthra 2015). Overall, the research shows that the noise generated in hospitals can have a negative effect on the quality of patients sleep, so the ACT set out to identify the extent of the noise and light on wards at night, with the aim of improving patients sleep. Audit There was no existing documentation that could be used for this project, so an audit to identify levels of light and noise was designed and piloted so that adjustments could be made for repeat audits. To ensure that follow-up audits could be replicated, the methodology incorporated a clear process that could be repeated in any acute setting. This process included undertaking the audit on a random, unannounced, midweek night, although paediatric, midwifery, assessment and critical care units were excluded because these settings would not give an accurate picture of patient experiences. All 27 adult wards, other than those just mentioned, were visited by the researchers to establish the levels of lighting and whether any existing light-reduction practices were already in operation. Informal discussions were held with nursing staff to find out what lighting facilities, including patients bed lights, night lights in bays, and main corridor night and day lights, were available on their wards. This analysis was extended in the follow-up audit three months later to include nurses opinions on what might delay light reduction, and what time lights were turned on again in the morning. It was vital not to influence the amount of noise generated on the wards, so the number of wards visited was limited to eight on one night, for 20 minutes each, between 11pm and 3am. The researchers wanted to be present long enough for nursing staff to forget they were there, but not so long that they did not have time to visit the other wards. All specialties, apart from those mentioned above, took part to reduce bias. Two checklists were developed, one for light (Table 1) and one for noise (Table 2), which enabled the researchers to record what they saw and heard quickly and easily. A recording device could have been used for the noise audit, but the researchers Table 1 Light audit checklist Yes No Other Corridor night lights working Typical time ward switches light to reduced level Corridor night lights on Patient bed lights working Bay night lights working Reporting and recording of outstanding maintenance work related to lights Responsible person: Other factors identified by nursing staff relating to delays in turning on night lights after 11pm Time ward visited: 20 February 2016 Volume 22 Number 9 NURSING MANAGEMENT
Table 2 Noise audit checklist Noise generated by Yes No Staff Nurses station discussion Private/personal discussion Clinical/medical discussion Telephone conversation Patient interaction Patients Interaction with staff Interaction with other patients Confused/calling out Equipment Beds Mattresses Patient falls alarms Patient admission Macerators Movement of equipment Observations equipment Commodes Pumps Call bells Operation of clinical support equipment Cardiac monitor Infusion pumps Other state Ward duties Personal protection equipment Bay Bins Sinks Curtain opening/closing Checking emergency equipment Restocking items Other Time ward visited: TV Radio Patient personal items NURSING MANAGEMENT February 2016 Volume 22 Number 9 21
Art & science acute sleep deprivation care wanted a more abstract impression rather than a recording of the actual noise generated. To ensure a consistent position, the checklists were filled out by the researchers while sitting in the bay opposite the nurses station, which is centrally located on each ward, and every time there was a noise they recorded it with a tick. The noise checklist contained five headings, namely noise generated by staff, patients, equipment, ward duties and other, so that issues could be linked. The headings were modified in the repeat audit based on the findings from the pilot. The researchers did not want only to gather information so they gave nursing staff instant feedback on issues they had identified during the 20-minute audit periods, as well as advice on simple ways to reduce noise or light. Results and discussion The pilot audit established that there was a lack of consistency across the trust in terms of light reduction. The general impression the researchers had from most wards was that full lighting was acceptable until all clinical care, including the administration of intravenous medication, was complete. Staff told the researchers that medication had to be given in full light to maintain patient safety, which meant that the main lights were on until after midnight on some wards. When nursing staff were asked about what lighting alternatives they used, many did not know what was available, and there seemed to be a failure to check routinely that all lights were working. Most wards have safety briefings at the start of a shift, during which issues and concerns are highlighted. However, the repeat audit showed that no one was responsible for ensuring that maintenance problems were reported or followed up. During the pilot, the researchers encouraged nursing staff to look at their practice and consider how they might reduce light levels by 11pm over the next three months. By the second audit, staff on all the wards had implemented a target time for dimming the lights, which was adhered to except in exceptional circumstances. More than half the wards had also introduced a policy, instigated by nursing staff, where the lights were gradually reduced bay by bay. The second audit found that full light was not resumed until after the morning medication round had started, or in some cases finished, which highlighted a contradiction. The nurses had said they needed bright light to administer medication safely at night, yet in the morning this did not seem a priority. This suggests that the delay in reducing light levels at night was based more on historical working practice than safety, as the nurses had suggested. The results of the noise pilot audit suggested that nurses gave little consideration to the amount of noise generated on the wards at night and, as with the light audit, this meant challenging established Table 3 Recommendations No cost Turn phone and call bell volume down, for example, to half the day-time level Contact multidisciplinary team from the office to enable private conversations Close bay doors if possible Open restock items away from patient areas Ensure doors are closed before using noisy equipment, such as the dishwasher or macerator Place observation equipment in each bay before settling patients Think twice before switching on bay lights for clinical care, for example, use bed light instead Check bed lights every night and report if not working Turn off bedside TV Consider timing of observations to maximise sleep time Low cost Consider eye masks and ear plugs for patients Purchase nursing station table light Replace light bulbs in corridors and individual bed lights Purchase noise monitoring equipment to increase staff awareness of the level of noise generated Considered cost Install night light capacity on wards that do not have adequate night lights 22 February 2016 Volume 22 Number 9 NURSING MANAGEMENT
practice. The researchers gained the impression that the nurses thought that noise at night was a necessary part of clinical care and could not be avoided or reduced. Noise at the nurses station was the main problem and could be clearly heard by the researchers sitting in the opposite bay, which also raised confidentiality issues. On half the wards there was an increase in noise levels during interactions between patients and staff. Noise from further away from the nurses station was generally caused by lack of consideration about the volume and, again, historical working practices. For example, poor practice, such as leaving the sluice door open when the macerator was on, checking the resuscitation trolley in the main corridor near the patients bed spaces, using protective equipment, such as aprons and gloves from holders in the bays when they were available elsewhere, and moving equipment from bay to bay, all increased noise levels. Yet when the researchers discussed these findings, the nurses were surprised that the noise travelled so far. Once the researchers had shared their findings with the staff involved, they encouraged them to modify their practice to reduce noise levels, and monitored this in the intervening period. During the repeat audit the researchers noticed a significant reduction in general chatter, and that staff communicated with other members of the multidisciplinary team away from the nurses station. The researchers made a number of suggestions based on the audit findings; these included changing working practice and introducing target times for reduced lighting, which could enhance patients night-time experiences. These were organised under three headings, no cost, low cost and considered cost, but most incurred no cost. The recommendations are listed in Table 3. Conclusion The repeat audit shows that the nurses are fully engaged with strategies that aim to reduce noise and light levels, and that they are implementing their own solutions by focusing on their patients specific needs. Some of these solutions include the gradual reduction of lights as clinical care is completed in each bay, communicating with other members of the multidisciplinary team away from patient areas, and restocking earlier in the shift. The researchers concluded that this is a work in progress and that, to build on this promising start, further audits will be required to reinforce the positive changes, and encourage the establishment of new working practices. A further audit is planned within six months. Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared References Bartick M, Thai X, Schmidt T et al (2010) Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff. Journal of Hospital Medicine. 5, 3, 20-24. Chen P (2012) The Clatter of the Hospital Room. tinyurl.com/gpflysr (Last accessed: Doyle C, Lennox L, Bell D (2013) A Systematic Review of Evidence on the Links between Patient Experience and Clinical Safety and Effectiveness. tinyurl.com/qbauaex (Last accessed: Elliott G (2011) Shh! Join the Quiet Revolution! Noise Abatement Society. tinyurl.com/pffe48k (Last accessed: Fenton J, Jerant A, Bertakis K et al (2012) National study of patient satisfaction, health care utilization, expenditures, and mortality. Archives of Internal Medicine. 172, 5, 405-411. Kowalczyk L (2011) Hospital Noise Hinders Recovery. tinyurl.com/nuqe6oa (Last accessed: Luthra S (2015) For Hospitals, Sleep and Patient Satisfaction May Go Hand in Hand. tinyurl.com/ pek9ftl (Last accessed: January 15 2016.) Maiken S (2012) Reducing Noise Levels in Hospitals Crucial for Patients Sleep. tinyurl.com/ qem3la5 (Last accessed: Pederson T (2012) Hospital Noises Disturb Sleep, Hinder Recovery. tinyurl.com/qefud4v (Last accessed: Phend C (2012) Hospital Noise Fractures Sleep, Slows Healing. tinyurl.com/boxbur7 (Last accessed: Reddy S (2012) How Hospital Noise Harms Health. tinyurl.com/pp9c9ab (Last accessed: Shepherd R (2012) Hospital noise spoiling patients sleep. Medical News Today. tinyurl.com/peamjbx (Last accessed: Stevens S (2013) Normal Sleep, Sleep Physiology, and Sleep Deprivation. tinyurl.com/ cd4ra4b (Last accessed: Ubel P (2013) Sleep Deprivation in Hospitals is a Real Problem. tinyurl.com/ps2uspr (Last accessed: White J (2013) How Improving Patients Sleep in the Hospital is Key to Recovery. tinyurl.com/ p22rfxu (Last accessed: Yoder J, Staisiunas P, Meltzer D et al (2012) Noise and sleep among adult medical inpatients: far from a quiet night. Archives of Internal Medicine. 172, 1, 68-70. Young J, Bourgeois J, Hilty D et al (2009) Sleep in hospitalised medical patients, part 2: behavioural and pharmacological management of sleep disturbances. Journal of Hospital Medicine. 4, 1, 50-59. NURSING MANAGEMENT February 2016 Volume 22 Number 9 23