The importance of sleep for both comfort and the physical recovery of hospitalized patients is self-evident. However, hospital environments are typically noisy, with noise produced by a variety of sources, including alarms, paging systems, ancillary equipment, delivery carts, and conversations of care teams and visitors.1, 2 As a result, patients rarely have sound sleep. Research has shown that sleep interruptions adversely affect hospital patients' comfort, care experience, and perception of care.3 At a 120-bed community hospital in suburban northern California, patient dissatisfaction with excessive noise had been a long-standing challenge. Moreover, despite stakeholders' recognition of the problem at all organizational levels—from direct care nursing staff to hospital administrators—staff members' efforts to maintain a quiet environment on the hospital's 20-bed telemetry unit had been ineffective. The unit's clinical nurse leader (CNL) observed underlying contributors to excessive noise at night, including a lack of organizational focus on the problem and staff members' resistance to change. Following this observation, the hospital's quality improvement (QI) team introduced a holistic, evidence-based “sleep menu” intervention to reduce noise and improve both patient and organizational outcomes. (For the sleep menu that was given to patients, see Figure 1.)
Background and significance. In recent years, multiple studies have examined hospital noise and its detrimental effects on patients' health and health care workers' performance.4 For example, Hedges and colleagues and Fillary and colleagues have reported that noise is the primary cause of patients' sleep deprivation and disruption.1, 5 Sleep deprivation has been implicated in diminished cognitive performance and increased incidence of falls.6, 7 Sleep disruption has been shown to have affective consequences as well, including deficits of positive mood and increases in negative mood and comorbid depression.8 Moreover, the ability to remember emotionally positive experiences has been found to decline after sleep deprivation, while the ability to remember emotionally negative experiences remained relatively unaffected.9 Therefore, it's clear that a patient's condition with regard to sleep—whether rested or fatigued—can affect the patient's perception of the care experience. Well-rested patients are more likely to be satisfied with their care.
Along with these studies on the effects of noise and sleep disruption, researchers have also explored strategies for reducing noise. Applebaum and colleagues and McGough and colleagues have reported that simple changes in practice (for example, dimming hallway lights and announcing quiet time) can lead to increased patient satisfaction and improved patient outcomes.3, 10 However, in the abundant research on noise reduction strategies, few studies have focused on corrective interventions directly related to acute care patients.11 More important, although some studies have usefully examined noise reduction from an environmental perspective, prior to the QI project described in this article, no study had employed a quiet-at-night intervention that could be tailored to individual patient needs and preferences. Moreover, no study had explored the disparity between staff assumptions regarding patients' experience of nighttime noise and patients' actual self-reported experience—an exploration that, in the present QI project, proved both startling and illuminating. Finally, while previous studies have provided valuable recommendations for involving individual key stakeholders in QI efforts,1 the present project builds on those studies by comprehensively engaging all key stakeholders, including patients and professionals at all levels of the organization, from staff nurses to the hospital's senior leadership.
Relevance to organizational priorities. In addition to adverse effects on patients, excessive noise in a hospital can have negative ramifications for the hospital itself. In today's health care system, hospitals' reimbursements are linked to patient satisfaction, among other outcomes, which is measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Hospitals are rewarded (or penalized, as the case may be) by the Centers for Medicare and Medicaid Services' Hospital Value-Based Purchasing Program, in which reimbursement rates are based on performance and quality of care.11 In developing the sleep menu initiative, the telemetry unit's QI team anticipated that it could potentially improve the unit's quality of care, patient outcomes, and HCAHPS scores.
Problem description and aims. Two important data sources informed the aims of this QI project. First, in a 2018 HCAHPS survey conducted at the hospital, the telemetry unit scored the lowest, 1 out of 5 points, on the question pertaining to the quiet-at-night measure. Second, prior to the QI project's implementation, the telemetry unit's CNL had interviewed 59 patients during morning shifts about their sleep experience. Data from these interviews indicated that patients' average self-reported hours of uninterrupted sleep were only 3.6 hours. Given these data, the QI project's two specific aims were achievement of an HCAHPS quiet-at-night score higher than 1 and improvement of patients' self-reported hours of uninterrupted sleep.
Context. The community hospital in which the QI project was conducted is part of an integrated delivery system and managed care organization. The telemetry unit's CNL performed a microsystem assessment using the five P's (purpose, patients, professionals, processes, and patterns) to identify the unit's aggregate characteristics.12
On the telemetry unit, both the patient population and the staff have been multigenerational and demographically diverse. The primary ethnicities of the unit's staff have been Filipino (constituting approximately three-quarters of nursing staff), Asian American, white, and Latinx. When the QI project was being developed and implemented, the majority of the nursing staff were members of generation X (then 38 to 53 years old); the baby boom generation was also represented (then 54 to 72 years old), as was generation Y (then 22 to 37 years old). At the time of the project, 95% of the staff nurses had a BSN; 5% had an associate's degree and were studying for their bachelor's degree. The number of years of employment in nursing ranged from a half year to more than 30 years among participating nursing staff. QI project participants were selected because they worked on the telemetry unit. Most of the nurses worked full time.
The telemetry unit's patients have typically been admitted with a variety of diagnoses (for example, stroke, sepsis, congestive heart failure, fall, syncope), and many have comorbidities such as coronary artery disease, chronic obstructive pulmonary disease, cancer, and diabetes. Most patients admitted to the telemetry unit arrive in stable condition from the hospital's ED, a step-down unit, or the medical–surgical unit. For these stable, monitored patients, vital signs are checked every four hours. The vital signs of patients who arrive or become unstable after admission are checked more frequently (for example, every two hours). All unstable patients are transferred to a step-down unit or the ICU. The average length of hospital stay is two to four days. The majority of the unit's patients are Asian and Asian American, Latinx, white, and Black; the patients' ages range from the mid-20s to over 100 years; the approximate average age is 62 years. For the purposes of the project, patients who presented with confusion or delirium or who were nonverbal were excluded from participation.
In the initial planning phase, institutional review board exemption was obtained after a determination that the project would have a QI focus and, therefore, be part of routine organizational activities to improve quality of care and the patient care experience.
The telemetry unit's CNL also performed a return-on-investment analysis. The analysis suggested that the holistic sleep menu initiative would result in patients' sleeping more soundly at night—a benefit that would be likely to lead to faster recovery, reduced length of stay, and decreased hospital costs. A satisfied patient is more inclined to respond to HCAHPS survey items more favorably (and thereby give a higher HCAHPS score) and to refer the hospital to other patients.
Conceptual framework. Three models informed the design and implementation of the sleep menu initiative and shaped the associated resulting culture change. Two of the three models address change management: Kotter's 8-Step Process for Leading Change and the Institute for Healthcare Improvement's model for improvement through rapid testing using multiple plan–do–study–act cycles.13, 14 Watson's theory of human caring and 10 caritas processes informed the staff education component.15
Intervention development. The telemetry unit's CNL initiated the QI project in discussion with the QI team, focusing on how to improve the unit's low score on the HCAHPS survey's quiet-at-night item. The team members, who met monthly, included the patient care service director, the patient care experience director, the unit manager, the environmental services director, the telemetry unit's CNL, and staff nurses from each shift. The team's objectives were to articulate the problem, compose an aims statement, propose solutions, and create and implement an intervention. After the team discussion, the patient care director appointed the unit's CNL to lead the initiative.
The CNL then informally interviewed a variety of team members (including staff nurses, nursing assistants, and unit secretaries from all shifts) as well as patients and family caregivers to ascertain their perception of factors that contributed to the unit's excessive noise at night.
Patients and staff members have different perceptions of these factors. In interviews, the unit's CNL asked patients to describe a quiet night, specify the causes of sleep disruptions, report the number of hours of uninterrupted sleep, and suggest ways to decrease noise at night. Patients perceived being awakened for vital signs, blood draws, and medication administration as the most frequently occurring factors that contributed to noise at night. On the other hand, staff members perceived that noise at night came from staff conversations, equipment with alarms, announcements on the paging system, and delivery carts, among other sources. Interestingly, patients' perceptions of a lack of quiet at night were primarily related to being awakened from a restful sleep rather than to actual noise on the unit.
Next, the CNL convened a new telemetry unit council that met weekly to oversee the project and included a unit manager, three assistant nurse managers, and six staff nurses who collectively represented all shifts; the CNL also served both as the telemetry unit council's team leader and as a liaison between the council and the QI team. The members of the unit council acted as unit champions for staff education, introduction, and instruction regarding the sleep menu; implemented the sleep menu intervention and monitored its effectiveness; and ensured that the focus of the intervention was patient-centered care.
In addition to performing telemetry unit functions, the CNL reviewed baseline data from quarterly HCAHPS reports and from interviews with the 59 patients; these data included self-reported hours of uninterrupted sleep and revealed common causes of sleep disruption. The CNL then presented to the unit council a sleep menu of best practices that could potentially reduce a patient's exposure to noise. The proposed sleep menu was similar to the dietary menus that are provided to patients. This novel patient-centered approach to reducing noise was proposed as a small test of change, and the council supported the proposal.
Intervention. The intervention had three evidence-based components: staff education,3, 11 a checklist menu of best practices,16, 17 and purposeful hourly rounding. Potentially, each of these components could reduce environmental noise and improve patients' care experience. Staff education consisted of targeted education on the sleep menu initiative to five unit champions and all of the direct care staff nurses on the unit. The checklist menu of choices was packaged in a plastic ziplock bag (this was called “the kit”). During the three-month intervention, the kit was offered to each new patient on admission. Each patient selected her or his preferences for reducing noise at night from a list of five evidence-based practices (keeping the door closed, turning off the lights at night, providing earplugs and eye masks, and hanging a “Do Not Disturb” sign).1, 17 In addition, staff nurses and other health care team members tried to avoid interruptions during the 9 PM to 6 AM quiet time. If clinically feasible and there was no change in the patient's condition, nonessential care activities, such as the routine taking of vital signs and equipment adjustment, were rescheduled to promote a restful sleep.17 Examples of essential care activities for which patients could be awakened at night included medication administration and serial blood draws.
Nurses and physicians collaboratively determined whether an activity was essential or nonessential during quiet time, based on an assessment of each patient's stability. Whenever clinically feasible, nonessential activities were omitted to promote restful sleep during quiet time. A sudden change in a patient's condition (for example, the onset of dysrhythmia or oxygen desaturation) would trigger an assessment of vital signs and necessary intervention during quiet time. During the QI project time frame, no adverse events occurred.
The third interventional component, purposeful hourly rounding, occurred between 7 AM and 9 PM. In conversation with patients, unit champions and assistant nurse managers stimulated patients' interest in using the sleep menu. Staff nurses used an assessment tool developed for the QI project to query patients about their previous night's sleep, including the number of hours of uninterrupted sleep they had, any sleep disruptions that occurred, and suggestions they might have on how to decrease noise at night. The unit champions and the CNL documented and monitored this information daily on morning rounds.
Measures. Using the assessment tool developed for the QI project, staff nurses collected patient feedback daily during purposeful hourly rounding to evaluate the intervention's effectiveness and monitor its ongoing progress. Two measures were derived from the assessment tool: self-reported hours of uninterrupted sleep and perceptions of causes of sleep disruption.
Statistical analysis. Fifty-nine patients who did not engage in the sleep menu intervention completed a baseline assessment; the data from these patients became the project's baseline group data. In the three-month QI project, 174 patients (none of whom had been in the baseline group) completed the assessment while participating in the intervention; the data from these patients were considered the intervention group data. The average number of hours of uninterrupted sleep per night reported by the intervention group participants was compared with that of the baseline group using an independent samples t test. Chi-square tests were used to compare the baseline and intervention groups regarding the following types of sleep disruption: vital sign measurement, blood draw, staff conversation, pain or physical discomfort, bathroom needs, medication administration, and checkups.
The QI project's sleep menu intervention had several key outcomes. First, the average number of hours of uninterrupted sleep per night was 3.6 (SD, 1.60) in the baseline group, compared with a significantly higher average of 5.7 (SD, 1.63) in the intervention group (P < 0.001). Five or more hours of uninterrupted sleep per night were reported by 31% of patients in the baseline group, compared with 80% of patients in the intervention group, a significant improvement (c2 = 50.36; P < 0.001). Second, the number of intervention group patients who self-reported sleep disruption was lower than the number of baseline group patients for all causes of sleep disruption. Thus, 22% of patients in the baseline group reported that sleep disruptions were caused by vital sign monitoring, compared with 7% in the intervention group (c2 = 10.54; P < 0.001). Similarly, 12% of patients in the baseline group reported blood draws and other laboratory tests as the cause of sleep disruptions, compared with 2% in the intervention group (χ2 = 11.02; P < 0.001). Likewise, 14% of patients in the baseline group reported staff conversations as the cause of disruptions, compared with 5% in the intervention group (χ2 = 6.75; P < 0.01). Although 12% of patients in the baseline group reported that incidents of sleep disruption were caused by factors such as pain and physical discomfort compared with 6% in the intervention group, this difference was not significant (χ2 = 2.43; P = 0.118). Similarly, 5% of patients in the baseline group reported disruptions necessitated by bathroom needs related to diuretics compared with 3% in the intervention group, but this difference was also not significant (χ2 = 0.31; P = 0.572). Finally, the percentage of patients reporting sleep disruptions from other causes (for example, medication administration and checkups) was significantly higher in the baseline group than in the intervention group (22% versus 1%; χ2 = 31.90; P < 0.001). The two groups' self-reported hours of uninterrupted sleep and causes of sleep disruption are shown in Figures 2 and 3.
Third, for the 174 patients in the intervention group, the number of uninterrupted hours of sleep and sleep disruption caused by staff conversation (r = −0.177; P = 0.04) and pain or physical discomfort (r = −0.198; P = 0.02) were negatively correlated to a statistically significant degree. Correlations between uninterrupted hours of sleep and sleep disruption caused by blood draw (r = −0.148; P = 0.09), vital signs (r = −0.054; P = 0.54), bathroom needs related to diuretics (r = −0.047; P = 0.59), and other factors, such as medication administration and checkups (r = −0.050; P = 0.57), were not statistically significant.
In terms of the interventions, menu option choices selected by patients included keeping the door closed (the most popular choice), followed by use of earplugs, use of an eye mask, hanging a “Do Not Disturb” sign on the door handle, and turning the lights off. The correlation between keeping the door closed and the reported uninterrupted sleep hours was statistically positive (r = 0.192; P = 0.01). No statistically significant correlation was found between using earplugs (r = −0.115; P = 0.13), dimming of lights (r = 0.054; P = 0.47), using an eye mask (r = −0.111; P = 0.14), or hanging a “Do Not Disturb” sign (r = 0.123; P = 0.10) and the numbers of self-reported hours of uninterrupted sleep.
Usefulness of the sleep menu initiative. The sleep menu initiative had three levels of impact. On the surface, the QI project provided a structured system for resolving the causes of sleep disruption and increasing patients' uninterrupted hours of sleep. As a result, patients' sleep disruption decreased, and hours of uninterrupted sleep increased. Both patients and staff responded positively to the initiative, and the telemetry unit's subsequent quarterly HCAHPS quiet-at-night score rose markedly, from 1 to 4. Taken together, these improvements demonstrated the vital connection between staff engagement, patient care experience, and patient outcomes.18
At a deeper level, the sleep menu initiative supported a practical approach for implementing a short-term intervention that produced long-term improvements in quality of care—as manifested by improved HCAHPS patient care experience scores. At its deepest level of impact, the sleep menu initiative was transformative for the telemetry unit's staff and unit culture. By engaging all stakeholders—including patients and hospital personnel from bedside staff to senior leadership—the initiative created positive quality feedback loops that linked all stakeholders and introduced a culture of continuous improvement and patient-centered care.
Sustainability and potential for spread. After completion of the QI project, the sleep menu intervention continued on the telemetry unit with strong support from all stakeholders. To promote the QI project's sustainability and to plan for the intervention's spread to other units, the unit council recommended that
- senior leadership should support hospital-wide use of the intervention.
- staff should be dynamically involved in implementing the intervention.
- training should be provided to sustain the use of the intervention.
Because the initiative mirrors the hospital's strategic aim of providing high-quality care, continuous QI, and innovation in the delivery of care, the CNL recommended that the initiative be formally aligned with it. All these recommendations were well received and put into practice, and senior leadership is moving forward to operationalize the sleep menu initiative throughout the hospital.
Implications for practice. In all health care systems, improving the patient care experience must be a priority for all stakeholders. To support the provision of patient-centered care, the QI team should discuss with nurses the importance of a project such as the sleep menu initiative. For example, bedside nurses have the opportunity to engage in continuous QI and manage practice changes when they participate in regular shift huddles, rounding, team meetings, hospital committees, and interprofessional collaboration. Hospital-wide orientations provide another opportunity for nurses to present their ideas and successful QI project outcomes. Because nurses are primary caregivers, they have a unique perspective on creating a culture of improvement and advocating for new approaches to optimize quality and care delivery.
Physicians and senior leaders are also key team members who can support and operationalize performance improvement projects. According to Wilson and colleagues and Grossman and colleagues, physician engagement and senior leadership support increase the likelihood of adherence and commitment to a QI intervention11, 19; such engagement and support were important in the successful implementation of this QI initiative. Clearly, practice change projects require nursing input, interprofessional collaboration, and the support of senior leadership to improve both the patient care experience and team engagement.
Lessons learned. In conducting the QI project, we learned four main lessons. First, the success of the intervention in achieving its aims—significantly decreased sleep disruption and increased duration of uninterrupted sleep—suggests that similar interventions can be applied in other acute care settings. Second, using a patient-centered approach, the QI project's quiet-at-night intervention was tailored to individual patient needs and preferences, and throughout the project patients were proactively asked for their recommendations for improving the intervention. Third, the QI project was novel in exploring the disparity between staff members' assumptions regarding patients' experience of nighttime noise and patients' actual self-reported experience. While past noise reduction efforts have focused on staff members' understanding of the problem,20 in this QI project, patients were queried to better understand their perceptions of sleep disruption. Patients provided valuable insights that surprised all their providers and the QI team members and caused the team to rethink prior assumptions. Subsequently, to optimize the intervention's effectiveness, patients' stated preferences regarding which sleep menu items to use were combined with staff observations related to the phenomenon of sleep disruption. Fourth, before implementation, the team heeded the recommendations of previous researchers who reported on contributions of individual stakeholders in the success of a study. In this QI project, rather than limiting engagement to one or two stakeholders, the unit council strategically and systematically involved all key stakeholders—including the patient and all levels of the organization, from staff nurses to the hospital's senior leadership. Understanding these lessons learned within the context of designing and executing the QI project led to cultural transformation and development of a unit-based team whose dynamics were characterized by effective communication, collaboration, and coordination.
Limitations. The QI project was subject to limitations related to reporting, project length, and generalizability. The patients' stated hours of uninterrupted sleep were potentially subject to self-report bias. Also, differences in patients' age, sex, type of room, and proximity to the nursing station may have also influenced their responses. In addition, as previously discussed, the brevity of patients' stays in the hospital necessitated the completion of the baseline assessment survey by one group of patients and completion of the intervention survey by another group of patients. Another project limitation related to the intentional lack of measurement of specific noise levels in decibels. Finally, considering that the sleep menu QI project was implemented on a single unit of a community hospital, the project's findings and conclusions are not necessarily generalizable to other nursing units or hospitals.
Although completely eliminating noise in hospital environments is impossible, minimizing noise at night is essential for promoting positive patient care experiences. During the QI project, staff members came to appreciate the need to prevent excessive noise in the work environment. Patients who experienced more hours of uninterrupted sleep expressed gratitude for their care team's efforts to improve their hospitalization and promote restful sleep. The enthusiastic response from patients and staff also suggests that a holistic sleep menu initiative can confer multiple benefits that optimize both patient and organizational outcomes.