Sleep - Who Needs It?

Healthcare administration is, for the most part, a very arduous job. Visualize an Aggravation game board and you've seen a leader's daily schedule. Generally, senior executives and directors are more visible during first shift. They can be seen rounding on staff or huddled around improvement boards; bound up for hours in conference rooms, staff meetings and one-on-ones with key stakeholders. Their work day is frequently bookended with pre-dawn or dinner events; but as evening falls, most of management, ancillary and support services trickle away from the hospital campus. It is in the dusky hours that patient care is transitioned from one group of workers to another. As family members step away for a brief respite, a very special team of night time caregivers take up the vigil to protect and respond to the needs of those patients entrusted to their care. They see it all and understand the despair that darkness can bring.

"The best bridge between despair and hope is a good night's sleep." ~E.J. Cossman

We know the vicious cycle of pain and it doesn't matter whether the suffering is physical, psychological or emotional. Pain impairs sleep quality which magnifies discomfort; discomfort dulls mental acuity which elevates stress; heightened tension exacerbates pain. Patients complain that too many interruptions (often perceived as medically unnecessary) keep them from getting the sleep they need to heal. Nurses and doctors complain that too many interruptions (often perceived as medically unnecessary) make it impossible to complete important tasks. Our clinical teams and support staff are reminded, "It's not about you."

Over the past few years, some organizations have implemented quiet-at-night protocols designed to facilitate uninterrupted sleep for patients. Quiet times are designated hours on inpatient units where activity and conversation is minimized to allow patients to rest.  A common model designates a 2-hour period in the afternoon and a 4-hour period during the night when quiet hours are observed. During quiet hours, lights are lowered across the unit and in patient rooms; overhead paging is minimized; conversations in nursing stations and other areas are conducted in a hushed manner; visitors are encouraged to take breaks so that loved ones can rest; TV’s and music require headphones for listening; phone conversations are moved to designated areas away from patient rooms; clinical interventions (vital signs, blood draws, etc.) are deferred and comfort rounds are scheduled before/after quiet times.

There's not much empirical data to validate the clinical effectiveness of quiet time protocols, but we may be hearing more about an unintended consequence. At least one study (Smith, Nursing 2017) suggests that the darkened units and prolonged hours away from the bedside may adversely impact vigilance, the very essence of nursing. As we have learned, appropriate light intensity is essential and important when performing work activities. Studies suggest that bright light might actually facilitate circadian rhythm adaptation for night shift workers. These insights are important given research from Berger & Hobbs (CJON 2006) as well as Caruso (RNJ 2013) wherein 26-50% of night-shift workers already report severely reduced alertness, decreased sleep, excessive fatigue, or long-term insomnia. Additionally, 32-36% of night-shift nurses have reported falling asleep during their shift at least once per week (Rogers NCBI 2008).

It would seem that sleep deprivation, regardless of the cause, is an equal opportunity offender - one that challenges us to identify solutions that benefit not only patients, but caregivers as well. As a prerequisite to launching quiet time or any patient experience initiative, leaders should carefully evaluate potential quality, safety, productivity and experiential implications. Paramount in importance is the endurance and fortitude of our nurses and doctors. When it comes to protecting patients from harm, we must remember to...

Speaking of airline safety, in 2010 Congress mandated a Fatigue Risk Management Plan (FRMP) for all airlines, and the carriers have since developed these plans based on FAA guidance materials. An FRMP provides education for pilots and airlines to help address the effects of fatigue brought on by a variety of factors. Pilots are provided training that includes fatigue mitigation measures and the fundamentals of sleep's impact on performance. The program addresses the influence of lifestyle (nutrition, exercise, family life) on fatigue and offers resources to evaluate and treat sleep disorders. We might learn something by looking over the fence at what other industries are doing.

A compassionate and competent workforce is a differentiator in healthcare. For some organizations, it is their greatest strategic advantage; for others, their greatest vulnerability. The vitality of caregivers is foundational to the delivery of safe, quality healthcare. Without adequate self-care, healthcare workers, regardless of when they clock in or out, will lack the stamina required to do their jobs. There are actions that leaders can take to create a work environment conducive to self-care. By doing so, we are promoting culture, values and behavior standards in four key areas: accountability , compliance, situational awareness and ownership.

ACCOUNTABILITY - There are many accountabilities in healthcare, but it is a well-measured truth that patient safety is Job One. In it's 2015 publication Patient Safety: Fatigue, Sleep, and Work Schedule Effects, AANA offers these considerations to promote self-care, which I've annotated a bit:

? Provide a comfortable rest space for employees; somewhere that offers modest privacy if they wish to conduct personal business during breaks. BTW, the break room shouldn't be a homeless shelter for castoff furniture. Your people deserve nice stuff - it reminds them of their value to the organization.

? Create and educate staff on a non-judgemental process for addressing scheduling concerns. Solicit feedback on policies that affect work/life balance. Nursing management should monitor nurses’ hours worked, including hours worked in second jobs and work closely with leadership to demonstrate respect for time-off and prompt departure after shift. Above all, there should never be a fear of retribution when a nurse refuses overtime or extended shifts.

? Always consider fatigue as a potential factor when reviewing adverse events. The exercise will facilitate the development of self-care policies and procedures going forward. In the words of a nationally renowned sleep medicine expert, “An overwhelming number of studies keep saying the same thing – once you pass a certain point, the risk of mistakes increases significantly. We have been slow to accept that we have physical limits and biologically we are not built to do the things we are trying to do.” (Rogers, JC Alert, 2011)

? Encourage collaborative teamwork particularly as a means of supporting extended-hours staff and bolstering the safety of both patients and caregivers. The journey to effective teaming may be fraught with issues like time constraints, perceptions of lost autonomy, distrust in the decision-making of others - even a general lack of understanding as to what teamwork really is. But the benefit to patients is immense. To paraphrase Deming, "teamwork is endemic to a system in which all employees are working for the good of a goal, who have a common aim, and who work together to achieve that aim."(A great article on collaborative teamwork: https://journalofethics.ama-assn.org/2016/09/stas2-1609.html)

? Monitor updated resources and safety recommendations from organizations such as the AANA, Agency for Healthcare Research and Quality (AHRQ), Institute for Healthcare Improvement (IHI), and Institute of Medicine (IOM).

? Through your leadership role, demonstrate compassion and understanding of the behavioral implications of fatigue and deficiencies in self-care. We cannot, either through word or deed, impart the perception that the safety and well-being of our caregivers is somehow less important than top box scores or the bottom line.

"Self care is not selfish. You can not serve from an empty vessel. ~ Eleanor Brownn

COMPLIANCE - Yes, somehow you must establish a dedicated time on that Aggravation game board to periodically round on the night and weekend shifts. (Please don't be that teacher that only calls home when your kid has done something wrong.) Approach the discovery process as a recognition opportunity, focusing initially on those desired behaviors that are being performed correctly and consistently. Once you have a sense of how things are being done, sit down and have a real conversation with night/weekend supervisors and clinical leads. Listen first. You must measure the gap between a supervisor's expectations for staff performance and organizational behavior standards, policies and processes. Be transparent in sharing your first impressions with them. More than anything else, they must believe that you are there to enhance their effectiveness - not to blame or criticize. Over time, with authentic dialogue, a mutual trust will develop, laying the foundation for service excellence going forward.

"Trust, but verify." ~Ronald Reagan

SITUATIONAL AWARENESS - Situational awareness (SA) may have taken off in military/aviation training, but the practice of SA has also proven very effectively in the delivery of patient care. Gary Sculli, a nurse and co-author of the book Soaring to Success: Taking Crew Resource Management from the Cockpit to the Nursing Unit, talks about how nurses handle mental load, task load, and other external pressures. According to Sculli, nurses with poor SA demonstrate limited communication with others, often fixating on past events or lacking clarity in explaining the details of a situation. These characteristics bear a striking similarity to behaviors observed in sleep-deprived nurses and doctors. Fatigue and sleepiness compromise one's ability to perceive what is happening; understand why it is happening, and evaluate the consequence of actions taken.

"Knowing is not enough. We must apply. Willing is not enough. We must do. ~ Bruce Lee 

OWNERSHIP - Generally, people take jobs that offer them some measure of personal and professional gratification. That said, it is not uncommon for night, evening and weekend staffers to distance themselves from organizational improvement initiatives. They may project resentments of being marginalized and forgotten, and honestly, part of this perceived disenfranchisement is on us as leaders. Many night owls have grown comfortable flying under the radar and may require persistence in establishing more open communication. In light of the growing evidence of health risks associated with night shift work, we must make a concerted effort to engage with this vital segment of the workforce. We can't do the work without them. Something to sleep on, for sure.

"If you wish to persuade me, you must think my thoughts, feel my feelings and speak my words. ~Cicero