Lightening the nights
Night-time on wards, like at home, can be relaxed and satisfying, or deeply fraught and disturbed. Many patients (especially elderly people) require high levels of care, there are many of the same tasks and challenges as earlier in the day and then there are the many other duties and dilemmas particular to the night. Sleep being the obvious one, but many patients (and staff) can have a very uncomfortable sense of darkness, isolation and what can feel like an eery stillness. Staff have to make complex mental and physical health risk assessments, balancing the risk of, for example, insufficient sleep with the need to prevent bed sores.
At least half of people over the age of 65 experience difficulty in sleeping with the additional time-shifts that dementia can cause, eg experiencing 40% of their bedtime hours awake and 14% of their daytime hours asleep. As well as tiredness or exhaustion being unpleasant for anyone, older people are at greater risk of difficulties thinking clearly, and of falls, when they aren’t getting sufficient good quality sleep.
The low attention given to patients and night staff teams is reflected in the research literature. There’s very very little. Happily, there is an excellent Joseph Rowntree Foundation report, Supporting older people in care homes at night. While the research was in a care home not a hospital and specifically with elderly people, much of the information in this Idea comes from there. (Including the time-shifts’ figures in the paragraph above.)
The references and resources section below has links to websites with loads and loads of other sleep-inducing ideas. But we’d like to pick out just one which seems particularly helpful. People really struggling to get to sleep, and perhaps very frustrated about this, should be encouraged to focus on relaxing, not on sleeping. We can’t fall asleep if we’re busy telling ourselves how infuriating it is we can’t get to sleep, how it’s going to mess up our next day, how our sleep problem is getting worse and worse, it’s wrecking our ability to work etc etc etc. Being reassured that relaxing in bed is also restorative can help to break through the anxiety onslaught. Once the anxious self-talk quietens and then stops, we’re in a much more relaxed state, which is restorative n itself – and also means we’re more likely then to fall asleep.
This would all suggest that night staff should be particularly strongly trained, supported and valued. Of course the reality is often that the ‘hidden’ nature of night is exacerbated by the apparent invisibility of those occupying it in hospital. Caring for patients at night requires all the ‘daytime’ skills plus expertise in sleep. Plus considerable confidence and courage given the levels of responsibility required and the absence of the daytime managerial and administrative supports. And seriously strong people skills as many patients are also aware of the lack of on-site back-up and need to trust the night team’s professionalism.
Compared to their colleagues on days, night shift health workers are at greater risk of:
- work-related injury
- insomnia leading to difficulties in concentration and memory
- Irregular working hours making it more difficult to maintain regular eating and exercise regimes, which contribute to gastric and cardiac problems
- Problems with digestive disorders, appetite changes and loss or gain in weight
- an increased level of relationship difficulties and divorces
- reduced life expectancy
Of course, for many people, working nights is a very positive preference. Patients really appreciate skilled, caring night staff and these nocturnal shifts allow (indeed require!) enormous professional autonomy. And for some staff, working nights fits in well with family and other commitments.
The ideas marked with an asterisk are examples from mental health wards. The others are a mix of things we’ve read, things we think are probably happening but which we can’t confirm and our own ideas.
- Personal CD players for relaxation music.
- Sessions on sleep hygiene delivered.
- OT assistant runs relaxation and sleep preparation group.
- Patients encouraged / supported to develop routine.
- The TV is turned off at 12pm to aid and encourage sleep.
- As a ‘night time’ cue, lights are turned down low at 11pm.
- Information is provided on sleep hygiene.
- Sleep diaries (for both patients and staff) are available
- Relaxation – learning techniques in afternoon then have relaxation session half hour before bed.
- Encouraging patients to use headphones with CD players, radios and TV. Many younger patients arrive with their MP3 players and this helps keep noise down.
- Eye Masks available.
- Staff that have set personal commitments and hobbies are able to work night shifts.
- Regular night staff attend ward time-out days.
- Regular management involvement in night shifts increases management understanding and awareness.
- Training for night staff is monitored, i.e. appropriate times and conditions for training is provided.
- Night staff receive regular supervision at an appropriate time.
- Night times are a set topic of community meeting agendas.
- A night-time key worker system and detailed night-time care plans.
- Strategies for consistent communication and support between manager and night staff are in place.
- Member of staff is sleep hygiene link nurse.
- The use of agency and bank at night staff is kept to a minimum. Staff with a familiarity of the patients and the setting are used where possible.
- Guidance is given to night staff on the impact of night working, i.e impact on health and wellbeing and advice on nutrition and hydration.
- Night staff are encouraged to do at least one day shift a month to aid team cohesion and decrease isolation.
- A night key worker system was introduced who completes night care plans.
Technology and resources
- Hygienic ear plugs.
- Staff are mindful about disruptive environmental factors such as noise and light.
- Utilisation of technology, i.e silent call systems.
- Hot water bottles.
- Light therapy boxes.
- ‘Nod Off’ pack are offered which contain items like, eyes masks, ear plugs, lavender-filled muslin bags.
- Night staff have been trained in aromatherapy massage techniques.
- Aromatherapy lavender oils and carrier massage oils.
- A budget for downloading restful music, self-help downloads and relaxation music.
- Patients make their own lavender wheat bags.
Time released for one-to-ones at night
- Importance of protected time at night understood.
- Staff have protected time with patients at night.
- Patients able to sit with staff for reassurance.
- Staff who spend time with patients at night not seen as “soft touch”.
Empathy and mindfulness
- Patients not made to go to bed.
- Patients can make phone calls to loved ones.
- Staff aware that night can be scary for patients.
- Patients appreciated as adults.
- Patients able to sit in lounge.
- Intrusive practices are done with minimal disruption and are carried out in response to individual needs, not part of a set routine.
- Staff are mindful about not speaking loudly at night or banging doors etc.
- Staff try to avoid wearing bunches of keys that can jangle as they walked down the corridors.
- Anti-snoring devices available.
Night activities made available
- Volunteers trained in massage utilised to aid sleep.
- Good range of books on the ward.
- Area closed off for those who want to stay awake.
- Basic activity resources like playing cards and dominoes are provided for those who cannot sleep.
- Exercise classes are provided to aid sleep.
- Simple activities, e.g. playing cards & dominoes
- Relaxation – learning techniques in afternoon then have relaxation session half hour before bed.
- OT assistant runs relaxation and sleep preparation group.
- Nightly relaxation sessions offered.
- Room made available for relaxation.
- Patients can take warm bath (bathroom not locked up).
- Reasonable time set and agreed to switch off TV.
- Attention is given to the light levels when checking or entering a patient’s room and the use of torches has been introduced.
- The night-time routine is explained to each patient (and relatives) upon their admission.
- Information sheets have been produced for relatives about night-time care. These aim to prevent relatives from feeling ‘in the dark’ about night-times.
The personal touch
- Patients bring in own duvet.
- Patients who wish to stay up at night times are asked to move away from bedrooms and dormitories.
- Each patient has a night-time key worker who takes responsibility for duties like night-time care plans, and the communication to other staff of the patient’s needs etc.
- Night staff complete a handover summary sheet every night. This details significant information and progress relating to each patient. The sheet is taken into each day time handover.
- Structured and inclusive morning handovers improve relationships between day and night staff, and lead to improved communication of patient’s care.
- Provision of extra staff in the period from 6am to 9am facilitates a smoother transition between the night and day shift.
Northamptonshire Trust won an award at the Star Wards’ Festival’s Dragons’ Den for their plans for an inspired, and deeply restful ‘Nod Off’ pack, including:
- Fabric eye masks.
- Ear plugs.
- MP3 players.
- Plug in or battery powered room diffusers with lavender refills.
- Aromatherapy lavender oils and carrier massage oils.
- Resources (dried French lavender and material) for making own lavender wheat bags.
- Lavender filled muslin bags.
- ‘Sleep stones’ infused with lavender oil.
- Large quantities of herbal teabags for restful sleep.
- 4 night staff per ward to be trained in aromatherapy massage techniques.
- Downloading restful music, self-help downloads and relaxation music.
- Service user information project
Thanks to the dynamic OT Sarah Wilson, Northamptonshire have kindly shared their incredibly helpful sleep resources. These are below in the Resources section.
- The TV got turned off at midnight but if there was a film on that finished after this time staff let us watch it.
- My post dinner chats with other patients are my fondest memories of being on the ward.
- I often felt misunderstood so at the end of each day the staff would ask me if I felt like there was anything we needed to talk about and go back over. It meant I could go to sleep without worrying about everything.
- I was admitted at three AM so the first night wasn’t all that good. When I woke up in the morning I expected the worst. Instead I was greeted by a nice student nurse, who spent a lot of time with me.
- A cup of hot chocolate before bedtime was my favourite thing. I would drink it slowly and savour every mouthful. It would set me up for a good night’s sleep – as well as the medication of course!
- Evening chats on the sofa about our dreams, goals, ideas & aspirations keep them alive. It is always a sparkling, special time.
- I found a lot of people just needed a few nights sleep. Seems to be a thing with mental health. You get to a point where you’re either in overdrive or at rock-bottom because you haven’t slept for weeks or months. The ward gave me a place to rest, relax and sleep. That was a huge part of my recovery. Like respite.
A little note from Marion
Still on the bed linens’ theme, during those admissions when I was in for more than a week, a friend would bring over my duvet cover from home. This (along with photos, cuddly toys (see Idea #70 Comfort Objectsf), books etc) makes her ward bedroom feel more familiar and homely. Some people also ask relatives to bring in their favourite pillow as well as the more obvious nightclothes.
1. Keeping the ward quiet and gently lit at night
Your ward’s particular layout, design and features (and age!) make a huge difference to night-time disruptions. (See Idea #69 Therapeutic ward environment.) A good relationship with the estates’ department usually helps with swift repairs to noisy ﬂoorboards, plumbing and doors.
The problem of noise levels is exacerbated for people with dementia, who have a decreased ability to ﬁlter out unwanted noise (Jacques and Jackson) and this can lead to increased anxiety and agitation.
- Noise made by staff walking, talking and using equipment (eg trolleys, phones, printers – and of course alarms). Even a quiet voice or sound can wake a light sleeper, especially if it’s right outside their door! There really does need to be a ‘night-time voice volume’.
- Noise made by patients. Music, mobiles, chatting, calling, crying are all continuous features of ward life, but unless a patient is very disturbed or cognitively impaired, most are very amenable to keeping the noise down in order not to disrupt others’ sleep.
Again there is a trade-off between creating an environment conducive both to sleep and to safety, and the balance of these are strongly determined by patients’ age, disabilities and the specific lay-out and features of the ward. On elderly wards, in particular, it’s a tricky compromise between making it safe, comfortable, easy and appealing for patients to make their way to the toilet vs the wakefulness of bright lights. Appropriate lighting is even more important for people with dementia who need very strong environmental clues to help them differentiate between night and day. The following can help:
- dim lights in communal spaces before bedtime, as a signal that it’s a good time for people to start getting ready for bedtime and sleep.
- using a gentler or more limited light when checking on patients – eg torches or offering patient the choice of a having a low-key night-light on.
- movement-sensitive lighting systems produce dimmed lights til someone is ‘in the zone’ when they brighten so the person can see where they’re going and what they’re doing.
- New hospitals mainly have en-suite bathrooms, which greatly help not only with privacy and comfort (and it feeling pleasantly hotel-like) but with having an individualised level of lighting.
There is an undoubted art to checking that a patient is safe and comfortable at night in a way that minimises the intrusion and the risk of waking the person, and provides a reassuring presence if the patient is woken up. This is especially important with incontinent patients and night-staff should lead the care planning about the balance between keeping the patient being dry and their need to sleep. For example, night staff should contribute to the assessment of patients’ night-time needs as part of their individualised night-time care plan, which informs how often and how best to carry out night checks for each person.
The Rowntrees’ report included the following: One man made a distinction between staff opening the door to check and coming into his room, which he experienced as an invasion of his space.
There are increasing technological solutions that can make checking on patients’ well-being at night less disruptive, such as bedside motion detectors.
3. A good night’s sleep
4. Patients who are awake
How to respond to patients who are awake is an ongoing dilemma for night staff. The top of the list of recommendations in the Rowntree’s report is not uncontroversial! “While sleep is an obvious objective of good care at night, this can also be a time when a range of beneﬁcial and effective care practices can be carried out.” This is a view we strongly endorse. The reality is that a significant percentage of patients are awake much of the night. For some patients, it’s best to stay in bed trying to relax and get to sleep. But for others, this is either simply impossible or creates excessive frustration and perhaps agitation and gentle activities from a game of Scrabble to some companionable TV watching can be a constructive option. It’s very common for patients to wait til the evening, when the ward is quieter, before they open up about how they’re feeling and these night-time conversations can be particularly valued by both patients and staff.
5. Friends and family
It’s common for friends and family to be very uncertain and therefore anxious about what happens to their loved one at night, especially if the person has particular needs at this time eg because they are manic or have dementia. The Rowntree’s report describes relatives feeling they were ‘in the dark’ about night-times, reflecting how unsettlingly hidden nights can feel. This is of course compounded by usually not being able to visit and see for themselves at night. The report makes these useful recommendations:
- Provide relatives with an information sheet about basic expectations relating to night-time care.
- Include up-to-date photographs of night staff as part of the information.
- Inform relatives of the resident’s night-time key worker and encourage some form of regular communication between them.
- Have regular meetings for relatives to improve communication and information sharing.
Because sleeping patterns and problems are so individual, the real experts in what helps and what hinders someone’s sleep is that person. They’ve had decades of discovery and experimentation. Partners and relatives are also an invaluable source of information and advice, especially if they live with the person. And of course night staff themselves have developed many effective techniques to help people have as restful a night as possible. But all of us benefit from new suggestions so here’s a bunch, some of which we hope will be of some help.
Going to bed and getting up at roughly the same time every day will programme your body to sleep better. Choose a time when you’re most likely to feel sleepy.
2. Create a restful sleeping environment
Your bedroom should be kept for rest and sleep. Keep it as quiet and dark as possible. It should be neither too hot nor too cold. Temperature, lighting and noise should be controlled so that the bedroom environment helps you to fall (and stay) asleep.
3. Make sure that your bed is comfortable
It’s difficult to get restful sleep on a mattress that’s too soft or too hard, or a bed that’s too small or old. If you have a pet that sleeps in the room with you, consider moving it somewhere else if it often makes noise in the night.
4. Exercise regularly
Moderate exercise on a regular basis, such as swimming or walking, can help to relieve some of the tension built up over the day. But don’t do vigorous exercise too close to bedtime as it may keep you awake.
5. Less caffeine
Cut down on stimulants such as caffeine in tea or coffee, especially in the evening. They interfere with the process of falling asleep, and they prevent deep sleep. The effects of caffeine can last a long time (up to 24 hours) so the chances of it affecting sleep are significant. Have a warm, milky drink or herbal tea instead.
6. Don’t over-indulge
Too much food or alcohol, especially late at night, can interrupt your sleep patterns. Alcohol may help you to fall asleep initially, but it will disrupt your sleep later on in the night.
7. Don’t smoke
It’s bad for sleep. Smokers take longer to fall asleep, they wake up more frequently, and they often have a more disrupted sleep.
8. Try to relax before going to bed
Have a warm bath, listen to quiet music or do some gentle yoga to relax the mind and body. Your doctor may be able to recommend a helpful relaxation CD.
9. Write away your worries
Deal with worries or a heavy workload by making lists of things to be tackled the next day. If you tend to lie in bed thinking about tomorrow’s tasks, set aside time before bedtime to review the day and make plans for the next day. The goal is to avoid doing these things when you’re in bed, trying to sleep.
10. Don’t worry in bed
If you can’t sleep, don’t lie there worrying about it. Get up and do something you find relaxing until you feel sleepy again, then return to bed.
Why Do Sleep Disturbances Occur?
Researchers are not exactly sure why individuals with Alzheimer’s disease have sleep disruptions. Some researchers theorize that the sleep disturbances have to do with breathing problems, a common condition in individuals with Alzheimer’s disease. Studies have reported that 30% to 70% of patients with Alzheimer’s disease have sleep-disordered breathing.
What Can Alleviate Sleep Disruptions?
Before heading to the medicine cabinet, caregivers can try some of the following techniques:
- If sleep-disordered breathing is suspected, consider continuous positive airway therapy. This therapy involves the use of a machine that supplies the patient with a continuous stream of air. Studies have shown this therapy to be successful among Alzheimer’s disease patients.
- Stick to a daily schedule, setting regular times for waking in the morning and sleeping at night.
- Support a daily exercise routine, but reserve the four hours before bedtime for more quiet activities.
- Keep TV exposure to a minimum, especially within the four-hour period before bedtime.
- Set up a nightlight and provide a “transitional object,” which helps the individual transition from day to night. This object can be a blanket, item of clothing or even a stuffed animal, but use it only at nighttime.
- Limit use of cigarettes, caffeinated beverages and alcohol.
- Encourage daytime exposure to sunlight.
- Some medications can increase wakefulness, so talk to a physician or pharmacist about which medications might be disrupting sleep. Consider changing medications or the medication schedule, to avoid giving the drug in the evening.
Can Medication Help Treat Sleep Disorders?
The list of medications that treat sleep disorders is lengthy, and includes drugs ranging from tricyclic antidepressants, such as Pamelor or Aventyl (nortiptyline), to traditional sleeping pills like Ativan (lorazepam). Aricept (donepezil), a medication already approved to temporarily limit the progression of Alzheimer’s disease, has also been shown to increase oxygen saturation in patients with Alzheimer’s-related sleep disordered breathing.
Each medication has possible side effects that should be discussed with a physician prior to beginning treatment.
According to the Alzheimer’s Association, the use of medications to induce sleep should be avoided. Sleep medications are associated with an “increased risk of falls and fractures, confusion and a decline in the ability to care for oneself.” Experts advise that if such medications are used, to start out with the minimal amount of medication needed.
As many sleep medications can be habit-forming, experts also recommend phasing out the drugs after attaining a healthy sleep schedule.
Time spent in bed at night by care-home residents: choice or compromise?
The findings indicate that residents spent, on average, nearly 11 hours in bed at night, significantly more time than was spent sleeping. There was greater variance in the amount of time residents who needed assistance spent in bed than there was for independent residents. Detailed investigation of six care homes, each with 8 pm to 8 am night shifts, showed that bedtimes and getting-up times for dependent residents were influenced by staff shift patterns. Analysis of qualitative interviews with 38 residents highlighted a lack of resident choice about bedtimes and many compromises by the residents to fit in with the care home shift and staffing patterns.
The social norm of early bedtimes in care homes also influenced the independent residents. It is argued that the current system in care homes of approximately 12-hour night shifts, during which staff ratios are far lower than in the daytime, promotes an overly long ‘night-time’ and curbs residents’ choices about the times at which they go to bed and get up, particularly for the most dependent residents.
In discussing sleep in institutional contexts, Williams and Bendelow (1998) noted the importance of understanding the spatial and temporal organisation of sleep, the monitoring of sleep, and issues of power, surveillance and control of sleep. In addition, sleep should be considered as a social act that is negotiated with others (Meadows 2005), particularly with partners, family members or others in a household. In the communal environment, sleep ‘negotiation’ occurs with not only other ‘sleepers’ but also staff and is constrained or influenced by a care home’s policies and customary practices.
This paper focuses on one aspect of 24-hour care for older people living in care homes, namely their going to bed and getting-up times and the time they spend in bed at night. We make explicit the distinction between ‘time in bed’ and ‘time sleeping in bed’, and argue that residents’ night-time routine is not necessarily a ‘sleep’ routine, but rather based around the organisation of care. The activities of going to bed and getting up not only mark the intersection between night and day for residents, but also embody a potential conflict between a resident’s preferences and personal routines and the care home’s routines and institutional practices. Following a review of the pertinent literature, the paper examines both quantitatively and qualitatively the amount of time care-home residents spend in bed at night. Four main research questions are addressed:
- How much time do care-home residents spend in bed and how does this relate to likely time spent sleeping?
- How does a resident’s level of dependence relate to bed-times and getting-up times and therefore to time spent in bed?
- How does the organisational routine of staff shift patterns and the related staffing levels influence bedtimes and getting-up times?
- What is the meaning of resident ‘choice’ regarding bedtimes and getting-up times given their dependency and the routines commonly adopted in care homes?
Care-home routines are based upon organisational factors and resources, and differ from the distinctive routines chosen by individuals. A ‘routine’ is not necessarily a negative thing: most people develop and follow routines, but these are freely adopted and can be altered if circumstances change. The critical question is whether care-home residents are able to choose their own routines about when they go to bed and get up, and how this is influenced by care-home practices and national policy.
Care staff are part of an organisational structure, often based around 12-hour night shifts, that is taken for granted in the social care system. One result is that many of the most dependent residents have to make compromises regarding the timing of their care and support. Such compromises may play a part in maintaining a positive relationship with care staff (Brown Wilson, Davies and Nolan 2009), and residents may choose to adjust their night-time routines as part of a reciprocal arrangement, for many residents appreciate that the staff have no more control over their shift patterns than they do.
From Psychologies Magazine, January 2012
What can you do?
Prepare your evening
- ‘A good night’s sleep is prepared for in advance,’ says sleep specialist Professor Damien Leger. ‘It’s about giving your brain a signal to sleep by gently lowering its activity levels and reducing the noise, light and temperature.’
Setting the scene is key
- ‘It’s about telling your body that night-time is coming,’ says Dr Guy Meadows from The Sleep School in London. ‘So don’t check your emails or Facebook while getting ready for bed.’ This preparation should even start earlier in the day. ‘Tiredness is often seen as a sign of weakness, so we try to override it,’ he says. ‘If you feel tired, you’re likely to reach for a coffee or tea to keep you awake. Drinking either after 4pm isn’t a good idea.’
Recognise the signs of fatigue
- ‘Listen more to your body so that you don’t miss the chance to get to sleep,’ says sophrologist Catherine Aliotta. ‘In order to do that, you have to learn to recognise signs of fatigue such as tingling eyes and difficulty concentrating.
Adopt a wind-down session
- ‘If you’re short of personal time then you probably need a break between work and home,’ says psychiatrist Georges Alcaraz. ‘Go to the cinema, play sport, or set aside 10 minutes to try something new. Allocate a space for recreation during the day so that you don’t feel cheated in the evening. Avoid upsetting your biological rhythm. For example, be consistent with your eating patterns. If you eat early, you’ll go to bed earlier, too.’
References and resources
Supporting older people in care homes at night Diana Kerr, Heather Wilkinson and Colm Cunningham
A fantastic range of resources from Northamptonshire FT.
Sleep Disorders and Alzheimer’s Disease
Time spent in bed at night by care-home residents: choice or compromise? Rebekah Luff , Theresa Ellmers, Ingrid Eyers, Emma Young and Sara Arber. Ageing and Society, 2011, vol 33
Rehabilitation for older people with dementia. Dewing, J. (2003) Nursing Standard; 18: 6, 42-48.
This is an excellent article, full of practical ideas
How to Sleep Better – Tips for Getting a Good Night’s Sleep
The Sleep Foundation has a cracking strapline: Waking America to the importance of sleep. And some really great information.