Abstract
Sleep is essential for health and well-being. The hospital is a challenging environment for sleeping and inpatients are at risk for insufficient and poor-quality sleep. Nurses have an important role to promote patients’ sleep and well-being. The quality of sleep should be assessed, and the activities taken should be documented accordingly. The aim of this study was to describe nursing activities of sleep promotion according to the nursing documentation. The data were collected from nursing documentations in electronic patient records of 50 + 50 patients in two central hospitals in Finland. The data were analysed using deductive content analysis. According to documentation, nurses promoted patients’ sleep in many ways. They treated sleep-disturbing symptoms, arranged a good sleeping environment and supported patients’ emotional well-being. Nurses also comprehensively observed patients’ sleep and documented it. Many sleep-promoting activities were not done intentionally to promote sleep but are known to be such according to previous studies. Nursing documentation gives a comprehensive picture of sleep promotion as part of nursing care. Sleep is assessed and various activities are in use, although not always intentionally. Nurse managers have an important role ensuring the use of evidence and that nurses have enough knowledge to promote patients’ sleep.
Introduction
Sleep is essential for many major physiologic processes such as the metabolic and sympathetic nervous system and the circadian rhythm. Sleep is crucial for health and wellbeing, and disrupted sleep has both short and long-term consequences for health. 1 In adults, the short-term consequences may include pain, anxiety, deficits in cognitive performance and an increased number of accidents. Possible long-term consequences may include hypertension, diabetes, heart disease, stroke, depression and increased risk of death. For optimal health, an adult should sleep at least 7 h per night, and sleep should be of good quality, adequate in both timing and regularity, and sleep disturbances should also be absent. 2
Hospitalized patients are at risk for low sleep quality and quantity. Many hospital environment-related reasons such as noise, light, nursing activities and an uncomfortable bed can disrupt patients’ sleep.3–6 Pain and other illness-related symptoms, anxiety, worries and feeling insecure can also disturb patients’ sleep.4–8 Disrupted sleep in hospitalized patients is associated with experiencing more complications and a longer stay in hospital. 9
Nurses have an important role to promote the hospitalized patients’ sleep. When promoting patients’ sleep, nurses also promote patients’ recovery and wellbeing.3,10,11 According to previous studies, nurses support patients’ sleep by providing a good sleeping environment, treating sleep-disturbing symptoms, reducing care-related disturbances and giving the patient psychological support.7,8,10,12 However, sleep promotion in acute care setting is often based on individual nurses’ observations rather than policy guidelines to manage patients’ sleep. 13 Nurse managers have an important role in supporting, following and evaluating evidence-based practice and enabling using evidence in everyday policy and practices. 14 Nursing documentation should accurately describe all the nursing activities performed. Nursing documentation reflects the complete nursing process, which sets requirements for its quality. High-quality nursing documentation enables safe nursing practice and evaluation of the nursing process.15,16 High -quality nursing documentation is required to make visible the nursing activities performed for a patient. 17
Nursing documentation is evidence of the decisions made and the care provided. 18 Nurses’ decision-making is influenced by a range of factors such as nurse's experience, education, organizational culture, nurse's understanding of the patient's status, situation awareness and autonomy. Experience supports decision-making and is associated with intuition and confidence. 19 Intuition can be defined as an understanding without a rationale. Intuition comes from experience and is based on recognizing similarities between situations and knowledge formed over time. 20 Intuition is the base for decision-making, and it guides nurses throughout the nursing process. 21
Nursing documentation has many purposes. Continuity of care, communication between healthcare professionals, improving the standards of care, data collection for evaluation, contribution to research and education, visibility of the work done, demonstration of professional accountability and legal record, and adducing the patient's experience are all consequences of documentation. 18 Nursing documentation is a diverse phenomenon that provides a better understanding of nursing care. 16 Nurses experience documentation as being essential and part of their core tasks. However, in some situations, nurses feel that documentation is a burden that takes too much of their time. Nurses value documentation when they feel that it benefits the patient or helps their colleagues. 22
The aim of this study was to describe nursing activities of sleep promotion according to the nursing documentations. Nursing documentation is evidence of the work done and makes visible the actions that nurses do to promote their patients’ sleep. 18 There is a gap of knowledge on how sleep promotion appears in nursing documentations.
Methods
This is a qualitative, descriptive study. The Standards for Reporting Qualitative Research (SRQR) were used for reporting this study. 23
Setting and sample
The study was conducted in two central hospitals in Finland. Nursing documentations from electronic patient records were collected from 50 patients from each hospital (n = 100). The data were collected in autumn 2022. The patients were adults and from surgical, neurological, internal medicine and cardiac wards. Ten patients were selected from each ward. The inclusion criterion was that the patients had spent at least two nights in hospital. The patients were chosen randomly. 24 Every third patient's record from all records on a specific day was selected. If the selected record was such that the patient had not slept for two nights at the hospital, the next patient record was selected. All 100 selected records had writing in them.
Data collection
The documentations were collected from a 24-h-period. A matrix from an earlier made sleep promotion protocol was used to help with the data collection. The sleep promoting protocol had been created based on findings from earlier research, interviews with patients and workshops with nurses. 25 The nursing activities that are based on previous research known to promote patients’ sleep were collected to the matrix from the nursing documentations. The matrix assisted also in recognizing the sleep promoting interventions that were not necessarily done with the intention of promoting sleep. Demographic data were not collected from the patients for whom documentation was analysed because the purpose of this study was to examine the nursing documentations, not the patients.
Data analysis
The data were analysed using deductive content analysis.26,27 A categorization matrix was formed based on the categories of a sleep promoting protocol that was implemented earlier in one of the hospitals. Two members of the research team EP and MK performed the analysis. The data were read through several times before the analysis. Meaning units that described sleep promoting activities were then clustered into the matrix categories. Meaning units were coded and they formed subcategories under the main category. In addition, the meaning units that did not fit in the categorization matrix were gathered and analysed using inductive content analysis. In inductive content analysis the meaning units were coded at first. The codes formed subcategories and subcategories formed a main category.26,27 Examples of the analysis are presented in Tables 1 and 2.
An example of deductive analysis in the category of symptom management.
An example of inductive analysis in the category of comprehensively observing sleep.
Ethical considerations
This study was conducted according to the principles of the Declaration of Helsinki. 28 Confidentiality and anonymity were ensured throughout the study process.29,30 The study received ethical approval from the local ethics committee on 10 January 2022, and organizational approvals from both participating hospitals (Decisions: Hospital District of Central Finland 7.2.2022, Satakunta Hospital District 2.2.2022). The study coordinators collected the data from the patient record systems. The patient record systems used were similar in both organizations. No direct personal information was collected from the patient records. Thus, individual participants cannot be identified in the reporting. Nurses who had written the documentation could also not be identified from the material. The data were stored in a secure environment provided by the hospital, which was only accessible by members of the research group.
Results
The nursing documentations on sleep promoting activities were categorized into six categories. The categories were symptom management, minimizing disturbance related to nursing interventions and round-the-clock activity in the ward, providing a good sleeping environment, paying attention to fear, worry, uncertainty and confusion, supporting the maintenance of healthy circadian rhythm, and comprehensively observing sleep. Each category had two to four subcategories. The categories are presented in Table 3.
Documented nursing activities supporting sleep promotion.
Symptom management
The documentations indicated that the nurses tried to predict and prevent the patients’ symptoms to promote sleep. According to the nursing documentations, the nurses actively treated pain. They used pain scales to evaluate the patients’ pain. The nurses also described verbally the patients’ condition at the same time as they evaluated pain. The numbers in parentheses after the quotes points at the original patient record. Quotes 100–150 are from one participating hospital's patient records and quotes 200–250 are from the other.
The documentations showed that the nurses took care of adequate pain medication. They ensured that the patients received enough regular analgesic medication as prescribed. They also asked the patients if they needed additional analgesic medication. The nurses attempted to treat pain non-pharmacologically as well; for example, by helping the patient to find a pain-relieving posture.
The nursing documentations revealed that in addition to treating pain the nurses also treated other symptoms to promote the patients’ sleep. They administered medication for fever, nausea, and other symptoms. The nurses tried to ease patients’ breathing by oxygen administration, airway suctioning, administering medication to help breathing and trying to find a posture where breathing would be easy. They also verbally evaluated the patients’ breathing: At the moment without nasal cannula, speaks full sentences smoothly. Still, wants to have the nasal cannula for the night. (248)
According to the documentations nurses tried to predict and prevent different symptoms and gave medication before the night. They also tried to predict discomfort that could disrupt sleep.
Minimizing disturbance related to nursing interventions and round-the-clock activities in the ward
The documentations showed that the nurses aimed to reduce and predict nursing care-related disturbance. The nurses tried to avoid unnecessary wake-ups. When it was necessary to wake up a patient at night, the nurses attempted to cluster all the care needed at the same time to minimize the number of wake-ups. The nurses also aimed to avoid unnecessary nursing procedures at night to reduce wake-ups. If possible, some procedures were performed proactively in the evening so that they would not have to be done at night. The nurses were also aware that they sometimes woke patients unintentionally during routine checks and documented it if it happened. Tells that the i.v. cannula leaked at some point and the sleeve had got wet. At the moment it doesn’t seem to be leaking. However, the anaesthetist was called to replace the i.v. cannula. (214) (documented in the evening shift)
According to the documentations, the nurses tried to perform appropriate procedures to support nutrition and hydration at night. If certain procedures were not necessary at night, the nurses tried to avoid them. On the other hand, the nurses calculated the patients’ fluid balances and helped to maintain the balance when needed.
Reducing care-related discomfort to promote sleep was one on the nurses’ targets according to the documentations. Nurses tried to support the patients’ sleep by alleviating care-related irritation. Likewise, the nurses attempted to relieve dry mouth related discomfort: Says that hasn’t been able to sleep at all so far. Changes posture in bed by himself. Urinary catheter has been irritating, xylocaine is administered around urethra. (212)
The documentations showed that the nurses supported the patients’ sleep by trying to enable normal elimination. The nurses assisted the patients with urination, sometimes several times a night. Sometimes, support was also needed with normal defecation.
Providing a good sleeping environment
According to the documentations, the nurses supported the patients’ sleep by providing a good sleeping environment. The documentations showed that the nurses were aware that some patients caused disturbance to other patients. When possible, the nurses tried to reduce disturbance from other patients and moved the disturbing patient away from the patient room so that the other patients could sleep better: Moved the patient to a single room because of restlessness. (209)
The documentations indicated that the nurses tried to take care of cleanliness to provide better sleeping conditions. The nurses saw to it that the patient's bed was clean. When needed, they helped the patients to change into clean clothes. Moreover, when there was unclean dressing, the nurses changed them for clean ones: Leaking around the drain. Changed bedsheets. Changed shirt and all drain dressings. (231)
According to the documentations, the nurses tried to promote the patients’ sleep by providing sleep supporting postural care. The nurses helped the patients to find a good posture for sleeping. Additionally, they also assisted the patients to change their posture during the night.
Paying attention to fear, worry, uncertainty and confusion
The documentations indicated that the nurses aimed to ensure that the patients got adequate information. The nurses aspired to give the patients enough information and made sure that the patient understood it. The nurses also informed the patient's family. When needed, the nurses organized a possibility to talk with a physician.
According to the documentations, the nurses took care that the patients got support. The nurses had conversations with the patients and sometimes they just listened when the patients wanted to talk about something that was worrying them. The nurses discussed with the patients’ families and supported them as well. Sometimes, the nurses attempted to support the connection between the patient and his family. In addition, if there were other things troubling the patient, the nurses attempted to help them. If the patient needed more support than the nurses could give, the nurses arranged counselling. Has been telling a lot about his life, at times becomes emotional while talking. (150)
The documentations showed that the nurses paid attention to patients’ confusion. They tried to calm and guide confused patients. The nurses also tried to ensure that a confused patient had safe and appropriate care: The patient took off his nasal cannula and tried also to take off his i.v. cannula. Said that he is going out and any extra tubing will be thrown down on the ground. Walked the patient to the toilet and after that back to bed. He agreed to take the nasal cannula back and leave the i.v. cannula alone. (233)
Supporting the maintenance of healthy circadian rhythm
The documentations indicated that the nurses strive to support the patients’ sleep by maintaining a normal circadian rhythm. The nurses gave the patients sleep supporting medication to promote sleep during the night. They paid attention to lighting and turned off the lights for the night. The nurses also supported the patients in daytime activity. They motivated and encouraged the patients to be active. The nurses assisted and helped the patients to move and be active. When needed, the nurses brought the patients mobility aids to facilitate their movement. Started Dexdor® infusion so the patient could sleep properly and through that, would be better able to maintain circadian rhythm (head would clear up). (241)
Comprehensively observing sleep
The nurses systematically documented patients’ sleep. They observed the patient and documented if the patient had been asleep. They also documented how the patient had been sleeping from their point of view. Along with this, the nurses documented the patients’ own experience of how they had slept.
The documentations revealed that nurses strove to comprehensively respond to the patients’ needs to support their sleep. They gave patients an opportunity to talk about their wishes and needs concerning sleeping. In the documentations, the nurses expressed that they had an overall view on the patients’ well-being. Doesn’t express any worries towards the night. No changes in condition. (134)
Discussion
According to the results of the present study, the nurses’ sleep promoting activities were versatile based on their documentations. Some nursing activities such as taking care on lighting and providing a peaceful sleeping environment were done intentionally to support patient's sleep. However, many nursing activities, such as giving information, were perhaps not performed with the intention to support sleep and they were not documented as such. With the use of the sleep promotion protocol that was formed based on previous studies as a categorization matrix, we were able to view all the nursing activities that have been identified to support patients’ sleep.4,7,10,11 This ensured a comprehensive view on the documented nursing activities that promote sleep.
According to previous studies, nurses tend to have positive attitudes towards sleep and sleep promotion although they have a knowledge deficit in sleep and sleep promotion. 11 This may also partially explain why many sleep supporting activities are not perceived as such. This also indicates that sleep promotion is mostly based on individual nurses’ observations instead of policy guidelines, which is a similar finding with Gellerstedt et al. 13 Nurse managers are in an important role ensuring the use of evidence in daily practice. 14 Effective sleep promotion requires purposeful nursing management with clear guidelines and policies, in addition to ensuring that nurses have enough knowledge on promoting patients’ sleep.
According to previous studies, earplugs are useful to some patients in reducing noise and supporting sleep.3,11 Patients also say that nurses support their sleep by giving them earplugs and more blankets and pillows. 8 However, in this study, we did not find any documentations that would indicate that the nurses gave the patients earplugs, blankets, or pillows. These may be considered such small gestures that the nurses do not document them. Also, giving earplugs, blankets and pillows are not measures to treat the patient's illness. This may be why they are not perceived as something that should be documented. Sometimes, nursing documentation is also seen as a pointless burden that takes too much time. Nurses do several tasks, and they feel that it takes too much time to document everything. 22 This is another possible explanation explaining why these little gestures were not found in nursing documentations.
Nurses have an obligation to truthfully document the provided care and patients’ situation. 16 The results of this study show that the nurses have an overall understanding on their patients’ situation, which is seen in the documentations. The nurses observed the patients and tried comprehensively to respond to their needs concerning sleep. In the documentations the nurses used extensive expressions like ‘everything all right’ and ‘no needs’. Even if the expressions may be simple, they contain a lot of information. These documentations show nurses experience and knowledge on what is needed for a good night's sleep in hospital. The documentations also reveal nurses’ intuition. Intuition is an element in nurses’ decision making and how they provide care. However, intuition in practice is difficult for nurses to explain and document. 21 When a nurse records in the documentation that everything is all right for the night with the patient, it includes the nurse's observations and understanding on the patient's condition and knowledge of what is required for sleeping. Intuition is difficult to document, but it is simple just to comprehensively summarize: that everything is all right. The documentations show the nurses’ intuition and that they understand their patients’ situation without a rationale.20,21 On the other hand, it can also mean that the analytic process of decision-making lacks and some details in patient's condition are missed.
Nursing documentations make visible the decisions nurses make and the work they do. 18 In this study, the nurses’ decision-making is shown in the documentations especially when documenting issues concerning minimizing disturbance related to nursing interventions and round-the-clock activity in the ward. Some documentations indicated that the nurses made a decision not to wake up the patients at night. Not to wake up the patient for a control or check-up is a decision based on nurses’ expertise and experience. In these decisions, the nurses prioritize sleep over controls or check-ups. When prioritizing sleep over controls and check-ups, nurses must be aware of the risk it might include; for example, in cases where patient's condition significantly changes during the night. However, nursing documentations are also a legal document and, when nurses make their decisions, they must be documented with justification. 18 Also, documentations about performing appropriate procedures to support nutrition and fluid balance often included a decision where sleep was prioritized, and only necessary procedures were carried out during the night to minimize the effect on sleep. On the other hand, the documentations indicated that when the patient's condition required it, nurses decided to prioritize some other procedures over sleep.
Strengths and limitations
Qualitative approach is a strength of this study. It provides a rich description of the topic. Nurses’ original expressions from the documentations give an insight to the reality of nursing in promoting patients’ sleep and how it manifests in nursing documentation.
The data were analysed by two researchers and the results were discussed together with the research group, which increases the trustworthiness of the analysis. Using quotes indicates the connection between original expressions and analysis and increases credibility of the research. 31 SRQR were used when reporting this study. This improves the quality and transparency of the research. 23
The data were collected from two acute care hospitals and from certain types of wards. This limits the transferability of the results, especially to different medical specialty wards and non-acute care facilities. 31 The data collection and analysis were based on the matrix from earlier developed sleep promotion protocol. This approach gives the researchers certain expectations on the data and may have affected on the data analysis. However, thorough inductive analysis was performed on the meaning units that did not fit the matrix categories.
Conclusions
According to this study, nurses perform various activities to promote patients’ sleep. Nursing documentations make visible the work nurses do to promote sleep. Reviewing nurses’ sleep-promoting activities through documentations enables to see the activities that are done intentionally to support sleep, and the activities that are not performed with an intention to support sleep but can be identified as such based on previous studies. In addition to sleep promoting nursing activities, nursing documentations also reveal nurses’ experience, knowledge, and intuition on sleep promotion. Sleep promotion is not only single nursing activities, but also a comprehensive understanding of patients’ needs and situation, which is made visible in nursing documentations.
Footnotes
Author contributions
MK, HLL, SS and MR designed the study. HL and HT collected the data. EP and MK analysed the data EP, MK, HL, HT, MR, HLL and SS wrote and revised the manuscript.
Data availability statement
Data are available on request due to privacy/ethical restrictions.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The study was financially supported by The Satakunta Hospital District (Government Research Financing, Decisions 301/2021, 128/2022, 169/2023).
