Postponing Morning Rounds for Nurses May Lead to Sleep Improvement for Patients

Prabath W. B. Nanayakkara, MD, PhD

Nonpharmacologic interventions may be effective in improving sleep hygiene with medical and surgical patients, a recent study suggests.

Patients in hospital settings often report sleep difficulties, with many negative side effects associated. In addition to poor cognitive functioning and mental health, sleep inadequacies can affect fall risk, delayed healing from wounds, increased resistance to insulin, and immunosuppression.

Enhancement of sleep for hospital patients, consequently, was seen as necessary and relevant as a topic of research by this study’s investigators led by Eva S. van den Ende, MD, and Prabath W. B. Nanayakkara, MD, PhD, of Amsterdam UMC’s Department of Internal Medicine Section of Acute Medicine.

“Popular pharmacologic interventions to improve sleep are use of benzodiazepines and melatonin,” van den Ende and colleagues wrote. “However, there is insufficient evidence for the success of these medications in hospitalized patients. A systematic review and meta-analysis reported that the benefits often do not outweigh the risks of medication.”

As a result of these risks and the potential for negative outcomes, nonpharmacologic intervention was seen as an important subject of interest.

Research and Methods

The investigators recruited 374 total patients for the nonrandomized trial, each included if they had been admitted to 1 of the 3 participating hospital wards, had spent one night in the hospital, and were 18 years or older.

The research team developed a sleep folder which contained an overview of sleep hygiene tips and tricks, as well as such tools as tea without caffeine, earplugs, aromatherapy oil, and response codes for soothing music, mindfulness, and audiotape-guided imagery. The researchers also provided training sessions for nurses on the importance of sleep and  quizzes were designed to test for knowledge post-session.

They also changed medication and vital sign checks to slightly later times. Patients were given a sleep registration bracelet, detecting motion in order to measure sleep. The patients would fill out questionnaires regarding their previous nights’ sleep, questioning prior to 11 a.m. to allow for maximum recall bias minimization.

The investigators measured participants’ sleep through actigraphy as well as the Dutch-Flemish Patient-Reported Outcomes Measurement Information System. In addition, further patient outcomes that were assessed were patient-reported sleep disturbance factors and their use of the provided sleep-enhancing tools.

Study Results

The intervention group was 152 patients and the control was 222, with the median age being 65 years. In total, 331 participants were included in the overall assessment. For the intervention group, total sleep time was 40 minutes longer than that of the control group due to 30-minute wake time delays. However, sleep quality was not substantially different with either group.

The final wake time delays and postponement of nursing rounds in the morning were positively received by those working in the hospital, and they were maintained even following the study’s completion. The investigators found no significant differences in the nurses’ distribution of potential sleep-enhancing or sleep-disturbing medications.They recommend this change in time, citing its benefits to inpatient sleep and general simplicity.

The investigators also found that the primary factors disturbing sleep were reported as pain, ambient light and noise, bathroom visits, and staff waking the patients. They also found that of the sleep tools given, sleep masks and earplugs were the ones implemented the most (16% and 12%, respectively). Significant decreases in nightly vital sign checks were observed (intervention: 11%; control: 54%; P < .001).

“Future research could focus on whether more comfortable sleeping masks and earplugs would increase popularity and whether there are alternatives to attenuate external stimuli at the patient level without completely shutting the patient off from the outside world (such as a dome designed to reduce exposure to sound and light),” they wrote.

This article, “Evaluation of Nonpharmacologic Interventions and Sleep Outcomes in Hospitalized Medical and Surgical Patients/ A Nonrandomized Controlled Trial,” was published online in JAMA Network Open.