how do clinicians assess, communicate about, and manage

JONAVolume 43, Number 6, pp 342-347Copyright B 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

How Do Clinicians Assess, CommunicateAbout, and Manage Patient Sleepin the Hospital?

Lichuan Ye, PhD, RN

Kathleen Keane, MS, BSN, CNL, CCRN

Stacy Hutton Johnson, MS/MBA, RN, NE-BC

Patricia C. Dykes, DNSc, RN

OBJECTIVE: The objective of this study was to char-acterize how clinicians assess, communicate about,and manage patient sleep, with the focus on identify-ing existing barriers and facilitators to sleep promo-tion in clinical practice.BACKGROUND: Sleep is a critical need for im-proving for hospitalized patients.METHODS: Content analysis was used to interpretdescriptive data from 4 group interviews with a totalof 62 clinicians.RESULTS: Clinicians reported they did not formallyassess for patient sleep, which led to largely unman-aged sleep disruption during hospitalization. Majorbarriers to effective sleep management were limitedunderstanding of the importance of sleep, lack of astandardized tool for assessment, and inadequatecommunication. Facilitators included collaborativecommunication with patients and the healthcareteam and customized patient-centered interventions.CONCLUSIONS: It is critical to inform clinicians onthe importance of sleep, to standardize sleep assess-ment, and to facilitate collaboration among caregiversto promote sleep for hospitalized patients.

Sleep is a fundamental human need for survival,health, and well-being.1 The importance of a goodsleep does not diminish when hospitalized. One ofthe most prevalent concerns of the hospitalized pa-tient is the inability to get restorative sleep while inthe hospital setting.2 Often unrecognized and un-managed during hospitalization, sleep disruption af-fects recovery from illness and can lead to chroniclack of restorative sleep, resulting in numerous phys-ical and psychological consequences.3 Sleep depriva-tion is a contributing factor to decreased posturalcontrol and falls.4 Lack of restorative sleep can be amodifiable risk factor for the development of delir-ium, a prevalent serious source of morbidity and mor-tality in the hospital.5,6 In an effort to improve sleepfor hospitalized patients, an important 1st step is toexamine the current practice regarding the manage-ment of patients’ sleep. The purpose of this studywasto characterize how clinicians assess, communicateabout, and manage sleep in hospitalized patients. Theexisting barriers and facilitators to sleep promotionare identified, which inform the development of prac-tical strategies to promote patient sleep and to refineorganization-wide systems of sleep management.

Methods

Site and Participants

This study utilized a qualitative descriptive designand took place at a large metropolitan teaching hos-pital located in the northeastern United States. Thestudy received institutional review board approval.We conducted 4 focus-style group interviews with atotal of 62 clinicians (13-17 clinicians per group),including 52 nurses, 8 physicians, 1 pharmacist, and

342 JONA � Vol. 43, No. 6 � June 2013

Author Affiliations: Assistant Professor (Dr Ye), DoctoralStudents (Ms Keane and Ms Hutton Johnson), William F. ConnellSchool of Nursing, Boston College, Chestnut Hill; and Senior NurseScientist and Program Director (Dr Dykes), Nursing Research,Center for Nursing Excellence, Brigham and Women’s Hospital,Boston, Massachusetts.

This work is supported by the Haley Research Fund from theBrigham and Women’s Hospital and Aging Research IncentiveGrant from Boston College.

The authors declare no conflicts of interest.Correspondence: Dr Ye,William F. Connell School ofNursing,

Cushing Hall 423, Boston College, 140 Commonwealth Ave,Chestnut Hill, MA 02467 ([email protected]).

DOI: 10.1097/NNA.0b013e3182942c8a

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

1 respiratory therapist. Purposive sampling was per-formed to ensure that the participants consisted of avariety of clinicians with differing areas of clinicalexpertise. Participants were recruited via the invita-tion from the principal investigator and providedinformed consent. The majority of the participantssampled were nurses (83.9%; n = 52) because nursesadminister the highest amount of direct patient careand play a pivotal role in sleep promotion in the hos-pital. The participants were predominantly women(85.5%, n = 53) and white (77.4%, n = 48) and had 2to 43 years’ experience (median, 17 years’ experience)with a median of 11 years of practice in the partic-ipating hospital. The majority of the nurse partici-pants (94.2%, n = 49) had at minimum a bachelor’sdegree in nursing. The 1st 3 group interviews wereconducted with staff nurses who served on existingnursing committees in the hospital. Each of the com-mittees consisted of staff nurses from a variety of acuteclinical settings. To enrich the participant perspective,the 4th group interview was conducted with a multi-disciplinary clinical team (n = 17), primarily consistingof clinicians who practiced in intensive care units.

Data Collection and Analysis

In all 4 group interviews, participants were askedpreplanned questions, such as ‘‘What is your expe-rience of taking care of patients with sleep complaintsin the hospital?’’ ‘‘How do you usually assess patients’sleep?’’ ‘‘How do you communicate about patientsleep in your practice?’’ and ‘‘What interventions, ifany, do you use to manage patients’ sleep problems?’’Probes (eg, ‘‘help me understand,’’ ‘‘tell me more aboutit’’) were used to facilitate discussion and clarify par-ticipant responses. Themoderator elicited answers fromindividual participants and promoted group discus-sion. Clarification was requested concerning infor-mation learned in earlier interview(s). For example,‘‘we have heard some things from other groups regard-ing the lack of assessment of patient sleep; I would liketo ask your opinion about it.’’ The 3 interviews withnurses were audiotaped, and the interview with themultidisciplinary clinical team was recorded by meansof note taking by a research assistant. Each interviewranged in length from 30 minutes to 1 hour.

Raw data from interviews were transcribed intoa text document, identifiable characteristics removed,and reviewed and corrected for transcription accuracy.Data were then analyzed utilizing HyperRESEARCH3.07 software program (ResearchWare, Inc, Randolph,Massachusetts). Highly referential open codes werereviewedandgrouped into similar categories and themesusing a 2-person consensus approach. Conventionalcontent analysis was followed to interpret these de-scriptive data.8 Credibility and validity were further

ensured by referential adequacy (eg, checking pre-liminary findings against raw data), debriefings oncoding approaches, and internal audits of coding bymembers of the research team.

Results

Across the 4 interviews in this study, thematic contentemerged naturally under each of the research topics inthe study: assessment of sleep, communication aboutsleep, and management of sleep in hospitalized pa-tients. We report the major findings of each of the 3topical areas individually and summarize the findingsacross the 3 domains in terms of existing facilitatorsand barriers to sleep promotion in the hospital setting.

Assessment of Sleep

Overall, sleep was not formally assessed for patientsduring their hospital stay. Across clinician groups,the only formal standardized assessment of sleep thatwas reported took place during the nursing admissionassessment. Clinicians reported they felt concerned thatthe importance of sleep was not prioritized during thehospital stay and noted that after the admission as-sessment there was a lack of systematic follow-up as-sessments to detect new onset or exacerbation of sleepproblems while the patient was in hospital. As 1 nursecommented:

II don’t really recall if a patient speaks to meabout sleep. I probably didn’t really make an assess-ment and address that issue because it’s in a lumpwith all other issues that I’m worrying aboutImostpatients complain about sleep, and I have to saymaybe I’m a bad nurse, but I never really followedthrough and said ‘‘Let me see what I can do aboutitI’’

When clinicians discussed sleep with theirpatients as a 1st question in the morning, it wasnoted as a means of rapport building rather than asinformation that could be used to develop a plan ofcare for the patient:

It’s sort of a conversation starter though [ie, askinga patient how they slept], like ‘‘How was yournight last night?’’ So it’s easy to ask, but I don’tthink you try to glean too much information fromit except, oh my, last night was horrible.

Clinicians noted that a trigger for a healthcareteamYfocused assessment of patient sleep was thedevelopment of an acute patient problem, particu-larly the onset of delirium in critically ill patients:

[Sleep is an] important part of patient assessment,especially with delirious or disoriented [patients],but we don’t ask all patients as a standard of care.

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One major challenge of sleep assessment identi-fied by clinicians was that no tool was available toassess for sleep disturbance in hospitalized patients.Clinicians reported utilizing informal approaches toperform patient sleep assessments, but these approacheswere seen to be highly subjective constructs.

I am unaware of a standard tool for measuringquality and quantity of sleep, something we couldput on the flow sheet and track over time.

I don’t think we quantify how a patient slept verywell, nor do we communicate it very well. You’llsee on a flow sheet, ‘‘slept well,’’ ‘‘slept poorly,’’‘‘slept in naps,’’ but we don’t have any measure likea pain scale to really quantify the quality or length ofa patient’s sleep, and it’s very subjectiveI

In addition to the lack of a standardized instru-ment to assess for sleep, another challenge identifiedwas the need for clinician education on sleep assess-ment. One physician working in the ICU commented:

[There is a] need to clarify sedation versus sleep formany clinicians.

Communication About Sleep

Clinicians noted that communication with patients isvital in planning care promoting patient sleep.Clinicians verbalized the need to engage patients ina dialog about sleep, explaining the plan of care aswell as engaging them as active participants whenproblem-solving patient sleep disturbances. Throughdiscussion with patients, nurses were able to tailorinterventions to meet specific patient needs.

As we asked the patient what helps them sleep; weare often surprised by the answers; sometimes, it’swarm milk or a warm blanket or fewer blankets,music; find out what they want.

Additionally, nurses found it important to clearlyarticulate to the patient what sleep interruption mightbe necessary during the night as a means of settingexpectations, explaining the importance of the carebeing provided, and showing the patient respect as anactive participant in their care.

Icommunicating with the patient: ‘‘We’re goingto have to wake you up at midnight because youhave medicines, you have nebulizers, I have to dochest PT. It’s not always that we can let you sleep.You may need interventions at specified times. Wecan let you sleep between those interventionsI

Communication with patients was facilitated byclinician understanding of the importance of sleepand the role in healing as well as the experience levelof the clinician. In addition to the importance of

clinician communication with the individual patient,clinicians reported a complex network of communi-cations in the healthcare team (eg, between nurses[RN], RN to certified nursing assistant [CNA], RNto physician), which can enhance or detract fromeffective care. Report between RNs at the change ofshift and coordination in planning care between theRN and CNA were identified as essential points ofcommunication that facilitated continuity in the plan-ning of patient care. Interdisciplinary rounds wereidentified as a venue that can enhance team commu-nication around planning sleep promotion for pa-tients. This was seen as an opportunity for any teammember to raise the issue of poor sleep quality duringmorning rounds, and a plan could be developed andimplemented. Particular challenges in interdisciplin-ary communication between nurses and physicianswere identified. A nurse said:

Ione hurdle that I come across all of the time isthat the doctors don’t want to be ordering, eventhough they take lorazepam (Ativan) at home, theydon’t want to order itI. I had 1 doctor, it was2 weeks ago, you click on the pager, and his picturepops up, and it says, ‘‘By the way, I can’t order anysleep medications, so don’t even bother asking.’’ It’sso frustratingVhim saying don’t even botherI

Despite acknowledgement that communicationamong care team members is essential, lack of effec-tive communication in the healthcare team led clini-cians to experience frustration when trying to promotepatient sleep. This is particularly challenging whenpatients require complex care from multiple depart-ments and caregivers. A nurse stated:

Even the best-laid nursing plans can go awry.When phlebotomy unexpectedly goes into theroom at 1 AMI How did that happen? You knowsomebody just ordered a test, and you weren’taware of it when they put it in. Or you havephysicians coming in to check the groin site. OrIsurgery will come in at 3 AM to consent somebody.And it makes the patients angryI

Management of Patient Sleep

Clinicians described strategies that they were activelyusing to promote patient sleep. Strategies reported tocreate a better environment for patient sleep includeregulating visiting hours, unit quiet time, curtailingnoise, and limiting light in the environment. The utili-zation of these strategies was variable, depending onthe clinical unit involved. A variety of individualizedtailored interventions were also mentioned, includ-ing promotion of comfort and relaxation (eg, music,Reiki, family presence), sleep hygiene (eg, nighttimeritual, back rub,washing up), and patient care activities

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(eg, clustering patient care activities, uninterruptedsleep time, consideration of the roommate assignment,deferring vital signs as indicated by patient acuity).

Across the groups, it was clear that cliniciansembraced the value of creating an individualized planof care with each patient. There was recognition thatwhat helps one person sleep will differ greatly frominterventions that help others. Clinicians voiced a lackof effective management strategies to offer patientsand a need for improved expertise to promote sleep.Some clinicians also reported that they chose to dis-regard patients’ sleep complaints and left sleep dis-ruption unmanaged, which could reflect clinicians notknowing how to begin to manage sleep problems inthe hospital environment.

We don’t have a good answer for sleep problems.We joke that you don’t come to the hospital for agood night’s sleep!

Clinicians commented that the management ofpatient sleep takes place in a complex clinical envi-ronment, and current culture and hospital systemswere not supportive of promoting sleep for patients.One nurse articulated her frustration in trying toeffectively manage patient sleep:

I get frustrated when I think about how [to promotepatient sleep]I we have so many systems that arebuilt on what’s convenient for the physicians and thenurses and the housekeeping and everybody else, and

the patient was the last one considered about whatschedule was going to work.

Facilitators and Barriers to Sleep Promotion

Based on the clinicians’ descriptions of how they as-sess, communicate about, and manage patient sleep inthe hospital, we summarized the major barriers andfacilitators to sleep promotion for hospitalized pa-tients (Figure 1). Major barriers to the effective man-agement of sleep were limited understanding of theimportance of sleep during hospital stay, the lack of astandardized assessment tool for sleep, lack of educa-tion in sleep evaluation, inadequate interdisciplinarycommunication, and lack of supportive hospital infra-structure. Major facilitators of sleep promotion in-cluded collaborative communication with patients andin the healthcare team, and tailored, patient-centeredinterventions.

Discussion

In examining the current practice regarding themanagement of patient’s sleep in the hospital, wehave gained insight into overcoming barriers andenhancing facilitators of sleep promotion in acutecare hospitals. It is essential to educate cliniciansregarding the importance of sleep and to facilitateinterdisciplinary collaboration among caregivers topromote sleep for hospitalized patients.

Figure 1. Sleep promotion in hospitalized patients: facilitators and barriers.

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Critical to optimizing recovery from illness, sleepshould be considered a vital sign and be a routinepart of clinical evaluation for every hospitalized pa-tient.3 Unfortunately, as suggested by our findings,sleep is not formally or adequately assessed, whichcan lead to largely unmanaged sleep disruption dur-ing hospitalization. Although clinicians describe somecreative individualized interventions that are activelyimplemented to promote sleep in hospitalized patients,a systematic approach is needed to support care qualityimprovements across disciplines and departments. Be-cause of the complexity of the clinical environmentin hospital, the infrastructure (ie, basic services andfacilities) of the hospital need to be aligned with thegoal of patient sleep promotion. One potential strat-egy for alignment would be integration of a patientsleep assessment instrument, to be used from admis-sion and throughout the hospital stay, via interdisci-plinary rounds and in the electronic hospital record,to promote continual assessment and reevaluation ofpatient sleep quality.

Applying our findings to the model of the nurs-ing process, we have proposed a conceptual model ofsleep promotion practice in the hospital (Figure 2).The nursing process, also referred to as scientific prob-

lem solving method, is a dynamic method of scientificinquiry consisting of the following processes: assess-ment, diagnosis, outcome identification, planning,implementation, and evaluation. Barriers to clinicalassessment of, communication about, and manage-ment of sleep promotion in hospital can be viewed asimpediments to the nursing process, while facilitatorsenhance the process.

A clear research priority for nurse leaders is thedevelopment of a reliable and valid instrument tosupport assessment of sleep quality and quantity inhospitalized patients. Two of the 5 national prior-ities outlined by the Patient-Centered Outcomes Re-search Institute (PCORI)9 have direct implicationsfor the work of this study and future research en-deavors in this area: improving healthcare systemsand communication/dissemination research. Integratedin the PCORI research agenda is the explicit expec-tation of patient involvement and engagement withimproving healthcare quality. The design and testingof assessment tools and interventions to address pa-tient sleep efficacy in the acute care setting should bea collaborative effort with patients. Patient empow-erment and shared decision making are occurring inpractice to some extent based on our interviews with

Figure 2. Application of the dynamic model of nursing process to sleep promotion practice.

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clinicians. This was evidenced by clinicians dialogu-ing with patients about sleep strategies, bundlingcare, and collaborating with other team membersto decrease the frequency of vital signs at night, ifclinically appropriate. These practices should bediscussed in a more strategic way by the interdis-ciplinary team as a care priority while affording the

patient a more predominate voice in the decision-making process.

Acknowledgment

The authors thank the Sleep InterestGroup and all otherclinicians from the Brigham and Women’s Hospitalfor their great input and participation in this study.

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