NURS 4300 Week 9 Project Manuscript Example

Protecting Sleep for Older Adults on a Medical Unit: An Evidence-Based Proposal for Clustered Overnight Care

Student Name

College of Nursing, Walden University

NURS 4300: BSN Capstone

Instructor Name

Month Day, Year

Protecting Sleep for Older Adults on a Medical Unit: An Evidence-Based Proposal for Clustered Overnight Care

Abstract

Problem: older adults on general medical wards are woken repeatedly overnight, mostly for routine care that could be scheduled differently. Question: for inpatients aged 65 and older, would gathering routine night care into scheduled rounds, instead of doing each task at its own time, improve the sleep quality patients report during their first three nights? Evidence: nine sources survived a search of two nursing and medical databases, which show that planned care is a major source of disruption, that bundles reducing interruptions improve measured sleep, mostly in intensive care, and that links between sleep and delirium remain associations. Proposed change: a protected window from midnight to 0500 with grouped rounds, later nonurgent blood draws and a quieter unit, with clinically required care unchanged. Evaluation: an eight-week trial on one wing will compare morning sleep questionnaire scores with a baseline period, track whether planned rounds occur, and watch for overnight deterioration.

Problem and Significance

On a composite 32-bed medical unit, the night of an older patient is broken up by care. Vital signs are taken near midnight, scheduled doses fall in the early hours, phlebotomy arrives before four for morning laboratory work, and baths begin before five so the day shift inherits a finished task list. Most of this timing reflects habit rather than any individual patient's needs.

Hospitalization is a period of acute sleep loss for older adults, and sleep loss in hospital has been associated with cardiometabolic problems and with delirium (Stewart & Arora, 2018). On Dutch general wards, patients slept well over an hour less than at home and woke more often, and more than a third said hospital staff had woken them (Wesselius et al., 2018). The relationship between poor sleep and falls in older adults is less clear, with conflicting findings overall but some sleep problems, such as very short sleep, related to falls (Min & Slattum, 2018). Because nursing staff control most planned overnight care, this is a problem nursing can address directly.

The problem is also a matter of patient experience and dignity. Older patients and their families often describe hospital nights as the hardest part of a stay, and a routine that wakes a frail patient for a bath before dawn, for no clinical reason, sits uneasily with person-centered care.

Clinical Question

The project asks: for inpatients aged 65 or over on a general medical ward (P), will grouping routine overnight care into two planned rounds (I), when compared with the present practice of completing each task as it falls due (C), lead to better sleep quality as reported by patients (O) over their first three nights in hospital (T)? It is an intervention question, and it is referred to below by its elements.

Search Methods

CINAHL Complete and PubMed were searched with subject headings and free-text terms for hospitalized adults, sleep and sleep quality, and sleep-promoting interventions such as clustered care, noise reduction and earplugs. Limits were English language, adults and publication from 2000 onward. Adults of all ages were included because a trial search limited to older adults found too few intervention studies. Once duplicate records were set aside, screening moved from titles and abstracts to full texts and ended with nine sources, following the reporting stages of the PRISMA statement (Page et al., 2021). Every source received a Johns Hopkins level and grade (Dang et al., 2022); the full evidence table appears in Appendix A.

Review of the Literature

Sources of disruption. Nursing and other planned care emerged as a major cause of overnight waking. A record review of intensive care nights counted more than 40 care contacts a night on average and very few uninterrupted stretches long enough for a full sleep cycle (Tamburri et al., 2004), and ward patients in the Netherlands named staff, noise and devices among the causes of broken sleep (Wesselius et al., 2018).

Interventions. Bundles that lowered noise, light and care-related awakenings in intensive care raised sleep efficiency (Patel et al., 2014), and on general medicine units a program combining provider prompts with nurse coaching cut nighttime room entries by 44% on the coached unit (Arora et al., 2019). Earplug trials disagreed: one found less confusion and better perceived sleep (Van Rompaey et al., 2012), while in another the main sleep measure fell short of significance and a third of patients did not tolerate the devices (Demoule et al., 2017). A Cochrane review judged the evidence for earplugs and eye masks to be of low quality (Hu et al., 2015).

Measurement. A five-item morning questionnaire has been tested against polysomnography in critically ill patients (Richards et al., 2000), making it practical for a unit project, while actigraphy and polysomnography need equipment the unit lacks.

Sleep and delirium. Sleep disruption has been associated with delirium in older surgical patients, more strongly for disruption at home than in hospital (Todd et al., 2017), and bundle and earplug studies in intensive care reported less delirium or confusion. None of these studies tested whether better sleep prevents delirium in older medical patients.

Synthesis

Taken as a body, the sources give good, consistent support to two claims, that planned care breaks sleep and that cutting interruptions improves sleep measures, although most of that support comes from intensive care. They give insufficient support to a third claim, that such changes prevent delirium in older patients on medical units. The project therefore proposes a pilot of clustered overnight care with patient-reported sleep as its outcome, and it makes no claim about delirium. Earplugs will be offered to patients who want them rather than made part of the core change, and night staff will help design the change, since the one general medicine study found its best result where nurses shaped the program themselves.

Proposed Practice Change

The change will protect a window from 0000 to 0500 for eligible patients. Routine vital signs, repositioning and continence care will be gathered into two rounds, one late in the evening and one at the end of the window. Nonurgent morning blood draws will move to 0530 or later, with provider and laboratory agreement. Lights will be dimmed and noise reduced during the window, and earplugs and eye masks will be offered. Nursing can adjust repositioning, lighting and noise on its own authority; the timing of protocol vital signs requires the medical director's approval, and blood draw and medication times require laboratory and pharmacy agreement.

The window will be a default, not a rule. Patients will remain on their usual schedule if they are newly admitted from the emergency department or transferred from a higher level of care within 24 hours, have vital signs ordered more often than four-hourly, are on titrated infusions or transfusions, have a rising early warning score, need two-hourly turns for pressure injury risk, or if any member of the team or the patient raises a concern.

Implementation

The trial will use the east wing, half the unit's beds, while the west wing continues its current routine. A role-change table (Appendix C) sets out what nurses, nursing assistants, phlebotomy, providers, the charge nurse and pharmacy will do differently and what each group needs to switch. A force-field analysis (Appendix B), based on Lewin (1951), weighs drivers such as patient complaints and staff interest against restraints such as laboratory batch schedules, habit and concern about missed deterioration. The plan will strengthen staff interest by involving night nurses and assistants in finalizing the workflow, and it will weaken the fear of missed deterioration through the exceptions list and a safety watch.

Four weeks of preparation will cover approvals, the workflow sheet and short education sessions held on night shifts. The eight-week trial will follow, with the design group meeting every two weeks. At week 13 the manager and night staff will decide whether to continue, adjust, stop or extend. Communication will run through start-of-shift huddles, a one-page handout and door signs, and families will be told about the window at admission.

Resources will be modest: door signs, a huddle script, revised workflow and assignment sheets, earplugs and eye masks, and staff time for education. The nurse manager will sponsor the trial, the medical director and laboratory manager will approve the changes that need their consent, and a night-shift design group of three nurses and two nursing assistants will own the workflow. The capstone author will coordinate data collection with the manager's support.

Evaluation

Three measures will be defined before data collection begins (Appendix D). The outcome will be the Richards-Campbell questionnaire score reported each morning for nights one to three by patients able and willing to answer. The process measure will be the share of window-patient nights on which routine care was documented only at round times or with a clinical reason. The safety measure will count overnight rapid response calls and unplanned transfers on the east wing, with each event reviewed within a week.

Four baseline weeks will precede the trial. Scores from each period will be reported as a median and its interquartile range. The unit will continue if the median trial score is at least 10 points above baseline, planned rounds hold on four nights in five or better and safety events do not rise; it will adjust if delivery falls short; and it will stop early if any safety event is linked on review to a delayed check. All data will be de-identified.

Implications for Nursing Practice

If the trial supports the change, its main lesson will be that sleep is a nursing outcome that nurses can influence through how they organize their own work. The change asks for no new equipment and little money, but it asks night staff to rethink routines that have been handed down from shift to shift. Even if sleep scores do not improve, the project will show the unit how many of its overnight interruptions are planned and how many of those have a clinical reason, information that can guide later work on the patient experience at night.

The project also illustrates a wider point about evidence-based practice at the bedside. Much of the published evidence comes from intensive care, research settings and bundles tested by specialist teams. Bringing it to a general medical unit means translating it into routines that night staff can sustain without extra staff or equipment, and testing it honestly on a small scale before asking anyone to adopt it. A trial that shows modest benefit, or none, would still leave the unit better informed than a change adopted on enthusiasm alone.

Limitations

The proposal rests mainly on evidence from intensive care, and no retained study tested clustered care alone on a general medical unit. The questionnaire can be completed only by alert patients, so the results will not describe older patients with confusion, who may be the most affected by poor sleep. A before-and-after trial on one wing leaves room for other changes in those weeks to explain any difference, although the west wing provides a partial check. The project will not be able to say which part of the bundle, if any, is responsible for a change.

Appendices

Appendix A: Evidence table for the nine sources, including their level and grade (from Week 4). Appendix B: Force-field analysis (from Week 7). Appendix C: Role-change table (from Week 7). Appendix D: Measurement table (from Week 8). Each is reproduced in the submitted manuscript as prepared in the earlier weeks.

References

Arora, V. M., Machado, N., Anderson, S. L., Desai, N., Marsack, W., Blossomgame, S., Tuvilleja, A., Ramos, J., Francisco, M. A., LaFond, C., Leung, E. K., Valencia, A., Martin, S. K., Meltzer, D. O., Farnan, J. M., Balachandran, J., Knutson, K. L., & Mokhlesi, B. (2019). Effectiveness of SIESTA on objective and subjective metrics of nighttime hospital sleep disruptors. Journal of Hospital Medicine, 14(1), 38-41. https://doi.org/10.12788/jhm.3091

Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.

Demoule, A., Carreira, S., Lavault, S., Pallanca, O., Morawiec, E., Mayaux, J., Arnulf, I., & Similowski, T. (2017). Impact of earplugs and eye mask on sleep in critically ill patients: A prospective randomized study. Critical Care, 21(1), Article 284. https://doi.org/10.1186/s13054-017-1865-0

Hu, R.-F., Jiang, X.-Y., Chen, J., Zeng, Z., Chen, X. Y., Li, Y., Huining, X., Evans, D. J., & Wang, S. (2015). Non-pharmacological interventions for sleep promotion in the intensive care unit. Cochrane Database of Systematic Reviews, (10), Article CD008808. https://doi.org/10.1002/14651858.CD008808.pub2

Lewin, K. (1951). Field theory in social science: Selected theoretical papers (D. Cartwright, Ed.). Harper & Row.

Min, Y., & Slattum, P. W. (2018). Poor sleep and risk of falls in community-dwelling older adults: A systematic review. Journal of Applied Gerontology, 37(9), 1059-1084. https://doi.org/10.1177/0733464816681149

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., ... Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, Article n71. https://doi.org/10.1136/bmj.n71

Patel, J., Baldwin, J., Bunting, P., & Laha, S. (2014). The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia, 69(6), 540-549. https://doi.org/10.1111/anae.12638

Richards, K. C., O'Sullivan, P. S., & Phillips, R. L. (2000). Measurement of sleep in critically ill patients. Journal of Nursing Measurement, 8(2), 131-144. https://doi.org/10.1891/1061-3749.8.2.131

Stewart, N. H., & Arora, V. M. (2018). Sleep in hospitalized older adults. Sleep Medicine Clinics, 13(1), 127-135. https://doi.org/10.1016/j.jsmc.2017.09.012

Tamburri, L. M., DiBrienza, R., Zozula, R., & Redeker, N. S. (2004). Nocturnal care interactions with patients in critical care units. American Journal of Critical Care, 13(2), 102-112. https://doi.org/10.4037/ajcc2004.13.2.102

Todd, O. M., Gelrich, L., MacLullich, A. M., Driessen, M., Thomas, C., & Kreisel, S. H. (2017). Sleep disruption at home as an independent risk factor for postoperative delirium. Journal of the American Geriatrics Society, 65(5), 949-957. https://doi.org/10.1111/jgs.14685

Van Rompaey, B., Elseviers, M. M., Van Drom, W., Fromont, V., & Jorens, P. G. (2012). The effect of earplugs during the night on the onset of delirium and sleep perception: A randomized controlled trial in intensive care patients. Critical Care, 16(3), Article R73. https://doi.org/10.1186/cc11330

Wesselius, H. M., van den Ende, E. S., Alsma, J., ter Maaten, J. C., Schuit, S. C. E., Stassen, P. M., de Vries, O. J., Kaasjager, K. H. A. H., Haak, H. R., van Doormaal, F. F., Hoogerwerf, J. J., Terwee, C. B., van de Ven, P. M., Bosch, F. H., van Someren, E. J. W., & Nanayakkara, P. W. B. (2018). Quality and quantity of sleep and factors associated with sleep disturbance in hospitalized patients. JAMA Internal Medicine, 178(9), 1201-1208. https://doi.org/10.1001/jamainternmed.2018.2669