Sign Up For Email Updates   Submit

Individualizing Night Time Routines

Tip Sheet


WHAT IT IS:
Individualizing night time routines means following residents' individual customary routines for how they spend their evening and the time they are naturally ready to go to sleep, and then providing night time care in a way that minimizes sleep interruption and maximizes deep sleep time. For residents who are naturally up at night this means providing support through the night, including preferred snacks and activities, perhaps a whirlpool to sooth them to sleep, and then following any daytime sleep routines.

Institutionalized night time routines mean that residents are expected to fit into the established routine of the nursing home. Early to bed and early to rise is the norm in many homes regardless of the lifetime patterns and routines of residents. In addition to a sleep schedule that is "one size fits all," institutionalized night time routines mean that staff routinely interrupt sleep to perform tasks or provide supports according to a set staff schedule for changing a resident's position, monitoring toileting needs, administering medications or treatments, taking vital signs, taking out the trash, refreshing water pitchers, and the numerous other tasks accomplished by night staff. These routine interruptions and noise levels make it difficult to get a good night's sleep.

Homes that individualize night time routines reduce noise and sleep interruptions by providing care according to each person's rhythms and individualized care needs rather than on the homes schedule. For example, for a resident at risk for a pressure ulcer who cannot turn herself, CNAs quietly come in at regular intervals to help shift the person without waking her. For another resident who does not have skin risks and has full bed mobility, the CNAs come in according to the person's normal times for needing assistance to the bathroom. Nurses coordinate treatments and medications with times when CNAs are giving assistance, so night care interruptions are minimized.

WHY IT IS IMPORTANT
Sleep is essential for human life. A human body can actually go longer without food than without sleep. Sleep is restorative; it is the time our bodies heal and our minds are refreshed. To get the benefits of sleep a four-hour period of deep sleep, often referred to as a REM (Rapid Eye Movement) cycle, is needed.

When we do not get enough deep sleep it affects mood, balance, appetite, our body's healing process, and our ability to think sharply. When the nursing home's care system routinely disrupts sleep there is no way to get a true base line for residents' mood or abilities because when residents routinely do not get good rest, they are always in a sleep deprived state.

Homes that honor residents' natural night time patterns, and reduce noise and interruptions, have seen residents thrive, their "behaviors" diminish and their moods, appetites, engagement, and overall functional ability improve. By contrast, if residents with dementia who are naturally up at night are routinely "redirected" back to bed, they will likely react negatively, in a way that quickly escalates into a "behavior" that is then "treated" with antipsychotic medication.

Maximizing sleep also affects falls. Sleep deprivation affects balance and coordination. Noise that interrupts sleep contributes to falls as residents, awakened and groggy, try to get up to go to the bathroom.

This interconnection between customary routines and quality outcomes is identified in the Nursing Home Reform Law's requirement that homes provide care and services to "attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident."

The federal nursing home regulations state under self-determination and participation, that:
"The resident has the right to—
  1. Choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care;
  2. Interact with members of the community both inside and outside the facility; and
  3. Make choices about aspects of his or her life in the facility that are significant to the resident."

The CMS Quality of Life surveyor guidelines explain that "Choices over schedules include: waking, eating, bathing, and going to bed at night, as well as health care schedules," and state that the facility must:
  • Actively seek information
  • Be "pro-active" in assisting residents to fulfill their choices
  • Make residents' choices known to caregivers

Surveyors ask residents whether they are able to follow their own night time routines including bathing, eating, and going to bed according to their customary routines. The CMS Partnership to Improve Dementia Care references these customary routines as surveyors explore the root cause of use of antipsychotics in response to a resident's distressed and self-protective behaviors.

HOW TO DO IT
The four foundational organizational practices provide the support staff need to individualize night time routines. Consistently assigned CNAs and nurses know and follow their residents' routines. As consistent co-workers, they coordinate their care to minimize interruptions. Through huddles, they note and make a game plan for how to plan care through the night and pass along to the next shift any variations in how the resident's night time went. With collaboration from other departments through the care plan process and in QI huddles, CNAs are able to provide the food, activities, and supports residents need according to their individual sleeping and waking schedules.

There are two key aspects to ensuring that residents get a good night sleep:
  • Honoring each resident's customary routines, preferences, and body rhythms
  • Creating a restful environment so that deep sleep is easily achieved

For honoring each resident's customary night time routines:
  • For new residents, learn their customary routines in time for the first night. Honoring each resident's internal body clock and their stated preference for sleep time is easier done with new residents. As the consistently assigned CNA helps a new resident settle in, ask about the person's normal night time routines. If the resident is unable to share this information, ask the family members. Share this information in the shift huddle so that staff know and can follow the schedule from the first night. Pass the information to other departments so that meals, medications, treatments, and appointments can be set accordingly. The resident assessment guides us to ask questions about residents' customary routine. However, if the MDS Section F on Customary Routines isn't completed for a couple of days and then is done by the Activities staff instead of the staff closest to the resident, the CNAs providing care may not get or use this information.
  • Ask "What do you need for a good night's sleep?" In asking about night time routines, also ask "What do you need for a good night's sleep?" We all have our own patterns. Some of us like it cooler or warmer, with or without extra blankets and pillows, total darkness or night-lights, quiet or quiet music. Our preferences vary for what we do to wind down and ready for sleep. By asking residents what they need for a good night's sleep early enough in the first day, staff can make the necessary preparations and accommodations in time for the first night. Encourage families and residents to bring familiar bedding and their favorite chair. Know and honor residents' preferences for sleeping in a bed or a chair. Having CNAs who care for the resident ask this information in time for the first night and then pass it along ensures the information is known and can be used in time for a good first night's sleep and a good start to the person's nursing home stay.
  • Give long-time residents time to return to their natural rhythms. Some residents may be able to tell us what they would like, and other residents may have family who can share what the resident's lifetime patterns had been. For residents who have lived in your home for a long time and have adapted to your schedule, more diligence is needed. People adjust their sleep patterns as the need arises, and residents become institutionalized to the homes routine. So if you have been waking residents early for breakfast even though they were night owls at home, they are likely tired by the end of the day from the early rising and comply with the home's timing for going to bed. It will take time for them to revert to their natural rhythm. When you ask about their sleeping and waking times, they will likely answer in relation to the current schedule, choosing not to miss breakfast, an appointment, or an activity that they have learned is only offered at a set time. They will need to know that you will adjust the schedule according to their natural patterns so that opting to stay up late and sleep in won't make them miss out. Consistently assigned CNAs accommodate residents' patterns as best they can within the existing schedule. With more support for flexibility, CNAs can work with residents to determine and support their natural night time routines.
  • Chart patterns and look at cues when residents can't verbalize. For residents who have lived a long time in your home and are not able to verbalize their routines and who may not have family who can share information, it will take time and careful observation to determine their natural patterns. Consistently assigned CNAs recognize cues about a resident's level of tiredness or wakefulness, hunger, or other needs. To discover residents' true sleep routines, don't wake them in the morning; let them wake according to their own need for sleep, keeping quiet so noise doesn't wake them unnaturally, and check every 15 minutes in the morning until they awaken on their own. Note during the evening whether residents seem to tire or continue to be awake. Offer food, engagement, or a whirlpool. Engage residents in preferred activities. Through trial and error, learn each resident's pattern. Chart a person's sleep patterns by doing 15 minute checks for a couple of days to see when they naturally awaken in the night, and set the schedule for assistance accordingly. By paying attention at bedtime to their need for rest, we will be able to let their body clock start operating.
  • Address the impact on other systems. Respecting residents' sleep patterns has an impact on many other care delivery systems. For instance, if we know a resident is a night owl and a late riser we will need to schedule therapies and appointments for later in the day. People up at night may well be hungry and need access to their preferred night time snacks. You may have to rethink when rooms are cleaned if they are typically cleaned on the assumption that residents are up for a set breakfast time. Night time treatments and medication routines will have to follow the resident's routines as will morning treatments and appointments. If living in a double room, the compatibility of the resident's night time patterns with that of their roommate need to be considered. It will take thinking through with all of the affected departments.
  • Facilitate communication and documentation. Share information about residents' routines through huddles, communication books, and assignment sheets. Use this information in care planning and in QI to see if adjustments to accommodate residents' sleep patterns can aid in addressing clinical issues such as mobility, mood, appetite, behaviors, etc.


For creating a restful environment so that deep sleep is easily achieved:

  • Analyze the current situation, listing all the current causes of sleep interruption. Creating a restful environment requires us to pay attention to it. What are all the causes of sleep disturbance under current practices? What is the current noise level? Are alarms going off? Are staff more in tune to the home being their work space or are they aware and paying attention to this being sleep time? Some times there are noises that we are unaware of. Pill crushing machines, garbage cans on wheels that squeak, loud doors that staff use at change of shift, alarms, and hallway conversations are just a few of the routine nighttime noise in many homes. Additionally there are built in interruptions. Repositioning, checks for wetness, medications, vitals, and many other care routines interrupt sleep. Do staff turn on overhead lights when they enter a room? Do they wake residents and roommates?
  • Measure the degree of sleep interruption and its impact. A simple measure is to ask residents every morning, "How did you sleep?" and then to use information to guide changes in practice. You can chart the amount of uninterrupted sleep each resident gets each night and look for ways to increase this sleep time. Other possible indicators include residents' mood on rising and during the day, appetite, medications, receptivity to morning care, and functional ability.
  • Start small and adjust as you go. As with any major change it is best to start small, and learn as you go. Have the staff make the list of the current sleep interruptions and then choose a starting place that is easy to accomplish and will have a significant effect on noise levels or sleep interruptions. Look for simple steps that require no extra resources, such as timing nurses' vitals with CNAs' assistance to the bathroom, or using overnight briefs as appropriate. Start with staff who are most eager and able. Expect to adjust continually as you learn more. Have regular check-ins as you go. Monitor all vital clinical areas.
  • Make changes in routines and care practices to minimize sleep interruptions. Instead of routinely going from resident to resident for regular two hour checks, follow each resident's normal pattern. Do turning and/or changing positions for residents at risk of skin break down in accordance with their natural sleep and waking patterns so as to support better sleep and better skin. Remember that sleep is essential for healing so waking people to turn them is counterproductive. Time bathroom assistance according to each resident's pattern rather than the home's schedule. Eliminate alarms – try sleeping with an alarm yourself and you'll see how it inhibits deep sleep. It also awakens everyone else within earshot. Change the pattern for taking out the garbage so that it doesn't awaken residents. As the environment gets quieter, it will be easier to identify other sources of noise and sleep interruption and address them. Keep track of measures and share results with staff.
RESOURCES
Pioneer Network
  • Pioneer Network's website provides links to many affiliate organizations with resources to support homes in individualizing the night time routine.
  • The National Learning Collaborative's Webinar 7 features a team of staff from a nursing home, sharing information about how to operationalize individual night time routines, and Webinar 11 shares how to individualize night time pressure ulcer prevention. Webinars are available for a fee for five on-demand viewings of each webinar. All 12 webinars are also available for purchase as a set of discs, at a discounted rate. To purchase viewings of one or more of the webinars, or the entire package of 12 webinars, go to Pioneer Network store.
  • This tip sheet is from the Pioneer Network Starter Toolkit: Engaging Staff in Individualizing Care. The entire toolkit, with additional tip sheets, starter exercise and resources, is available at www.pioneernetwork.net/Providers/StarterToolkit
Advancing Excellence in America's Nursing Homes www.nhqualitycampaign.org
Data collection can help determine whether the changes being made are working, and continue to work. The Advancing Excellence in America's Nursing Homes campaign has the tools and excel sheets for collecting data on consistent assignment (are we REALLY doing this?) and on Person Centered Care (are the wishes and preferences of the residents actually being delivered, and are the direct care workers attending and participating in the care plan meetings?), as well as other organizational and clinical goals. www.nhqualitycampaign.org

B&F Consulting www.BandFConsultingInc.com
Short videos available under free resources at www.BandFConsultingInc.com


Download Individualizing Night Time Routines Tip Sheet (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.
All webinars in this series are available as archived recordings at
http://eo2.commpartners.com/users/pioneerlive/all_series.php.
In addition, the full series is available as packaged DVD set in the Pioneer Network store.