NURS 6231 Week 11 Reflection Example

The Night Has a Schedule: Reattributing Our Quiet-at-Night Scores

Student Name

College of Nursing, Walden University

NURS 6231: Healthcare Systems and Quality Outcomes

Instructor Name

Month Day, Year

The Night Has a Schedule: Reattributing Our Quiet-at-Night Scores

The Explanation I Carried

For as long as I have worked on my medical-surgical unit, our lowest patient experience score has been the survey item asking how often the area around the room was quiet at night. For as long as I can remember, we have blamed it on staff talking at the nurses' station. The remedies followed from that explanation. We put up signs asking for quiet voices after 10 p.m., raised the topic at night huddles every few months, and installed a dimmer on the station lights so the unit would feel like night. Each remedy seemed reasonable, and I supported all of them. The score moved a few points after each one and then settled back.

What Changed My View

The change came from an exercise in this course, in which I mapped one typical night on our unit hour by hour for a patient in a room near the station. I used the order sets, the medication administration schedule, the laboratory draw list and a night's alarm log from our monitoring system. The map looked nothing like my explanation. Vital signs were ordered every four hours, so the patient was woken at midnight and 4 a.m. Scheduled intravenous antibiotics ran at 2 a.m. The standing morning laboratory draw came at 4:30, half an hour after vital signs, so the patient was woken twice in 30 minutes. The oral medication pass began at 5:30. Between those scheduled events, the alarm log for that one room recorded 11 pump and monitor alarms, most at the default volume set when the equipment was bought, and most for conditions that needed no action.

Staff conversation was on the map too, but it was one source among many, and the only one we had ever tried to fix. Laboratory research with recorded hospital sounds has found that electronic alarms were among the sounds most likely to wake sleepers, although voices woke them as well (Buxton et al., 2012). The sounds I had never questioned were designed into the night.

Reclassifying the Causes

The course's use of Donabedian (1988) gave me a way to name what I had seen. The quiet-at-night score is an outcome. I had treated it as a product of staff manners, but most of its causes sit in structure and process. The alarm defaults are structure, since they were set when equipment was installed and never reviewed. The every-four-hours vital signs, the 4:30 draw and the 5:30 medication pass are processes, each scheduled by a different department for its own convenience. None of the people carrying out those processes is being careless. The schedule wakes the patient.

The shift in my attribution is specific. I used to think the cause was behavior at the station. I now think the larger cause is schedules and defaults that the system sets and that no one on night shift can change alone. This is not a move from blaming staff to blaming leadership; it is a move from blaming people to examining design.

What I Would Measure and Change

A new belief needs a test, so I would start with two measures. The first is alarms per patient per night, from the monitoring system's log, for a sample of rooms each week. The second is scheduled interruptions between midnight and 5 a.m. per patient, counted from the orders and medication schedule. If my reattribution is right, those two counts should be high and should track the quiet score across months more closely than any measure of staff conversation.

The first changes I would propose are modest and within a nurse leader's reach. We could cluster overnight care so that vital signs, draws and medications happen in one visit rather than three. We could review alarm defaults with biomedical engineering and the unit's physicians. And we could ask whether every stable patient needs vital signs at 4 a.m.; a prospective study found that patients judged low risk by their evening vital signs rarely deteriorated overnight, suggesting that overnight checks could be matched to risk (Yoder et al., 2013). I would keep the signs asking for quiet voices, since conversation does matter. But I no longer expect them to fix a problem that the schedule creates.

References

Buxton, O. M., Ellenbogen, J. M., Wang, W., Carballeira, A., O'Connor, S., Cooper, D., Gordhandas, A. J., McKinney, S. M., & Solet, J. M. (2012). Sleep disruption due to hospital noises: A prospective evaluation. Annals of Internal Medicine, 157(3), 170-179. https://doi.org/10.7326/0003-4819-156-12-201208070-00472

Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260(12), 1743-1748. https://doi.org/10.1001/jama.1988.03410120089033

Yoder, J. C., Yuen, T. C., Churpek, M. M., Arora, V. M., & Edelson, D. P. (2013). A prospective study of nighttime vital sign monitoring frequency and risk of clinical deterioration. JAMA Internal Medicine, 173(16), 1554-1555. https://doi.org/10.1001/jamainternmed.2013.7791