Date Presented 04/05/19
Primary Author and Speaker: Siri Dusek
Additional Authors and Speakers: Alissa Hynes, Brenda Frie
Contributing Authors: Janet Benz, Cynthia Graham, Katherine Campbell, Laura Bonsell, Lecia Heinen, Mary Mehelich, Mary Kelvie
PURPOSE: The purpose of this study was to determine the feasibility and effectiveness of a multi-component environmental toolkit intervention on resident sleep quality in a long-term care setting. Most research in this setting has yielded marginal results and has focused on a single sleep intervention. Martin and Ancoli-Israel (2008) argue that improvement is at the facility level is often overlooked stating it is important “to change staff training, policies and caregiving practices that impact resident sleep.” Our research focused on two primary questions, 1.) What effect does an environmental sleep toolkit have on resident sleep quality? 2.) How feasible is the implementation of an environmental toolkit for long-term care staff?
DESIGN: This study used a quasi-experimental design to assess the effects of toolkit implementation. The study was conducted by an interprofessional team represented by nursing, physical therapy, occupational therapy and library science using the TeamSTEPPS framework (AHRQ, 2006). The study was conducted on a 24 bed residential unit, divided into equal north and south wings.
METHOD: The study used the well-established Rapid Cycle Change process employing a Plan-Do-Study-Act loop aimed at improving resident sleep quality through experimenting with evidence-based solutions (Johnson, K., Gustafson, D., Ewigman, B., Provost, L., & Roper, R., 2015). The first cycle, needs assessment, determined evidence-based interventions that were feasible for the setting. The second cycle, staff education, was aimed at improving staff understanding of elder sleep, the rationale for the intervention, and the study protocol. The third cycle was a 26-day implementation of the environmental toolkit and the fourth cycle was the pre-post assessment of the results. Pre-post measures included administration of the Pittsburgh Sleep Quality Index (PSQI), unit sound logger data, unit checklists and a staff post-implementation feasibility and effectiveness survey. The PSQI (Monk, Berman, Kupfer 1989) assessment generates a sleep quality global score through nineteen individual questions that cover sleep quality, latency, duration, efficiency, disturbances, medication, and daytime dysfunction. A global PSQI >5 is indicative of poor sleep quality. Sound logger data and compliance checklists from the north and south units were compared pre and post-study implementation. Post implementation the staff ranked the feasibility and effectiveness of 17 interventions on a 4 point Likert scale.
RESULTS: Sixteen male veteran residents (average age 76.6) participated in the study. Although paired t-test calculations did not find PSQI global score result (p .45) significant at p < .05. the number of residents with a PSQI global score >5 decreased 50% from eight to four residents. Pre-post calculations show improvement in mean sleep quality (pre .88, post .50), sleep latency (pre 1.27, post .87) sleep duration (pre .67, post .53) and medication (pre .56, post .18). There was no change in pre-post measures for sleep disturbances or daytime dysfunction and scores for sleep efficiency increased. Sixteen staff (76%) completed the post-intervention staff questionnaire with average Likert scale score of 3.65/4.00 for feasibility and 3.56/4.00 for effectiveness. The checklist completion rate was 85 % on the south unit and 69% on the north unit. The sound logger data confirmed sound reduction during quiet time hours on the south unit.
CONCLUSION: The preliminary finding suggest environmental interventions to promote sleep in long-term care can increase resident sleep quality and are feasible for staff to implement. These findings support population based occupational therapy interventions to enhance the occupation of sleep, further study is recommended.
References
AHRQ-Agency for Healthcare Research and Quality (2017). TeamSTEPPS 2.0. Rockville, MD. Retrieved from http://www.ahrq.gov/teamstepps
Johnson, K., Gustafson, D., Ewigman, B., Provost, L., & Roper, R. (2015). Using Rapid-Cycle Research to Reach Goals: Awareness, Assessment, Adaptation, Acceleration. Agency for Healthcare Research and Quality. Retrieved from https://pbrn.ahrq.gov/sites/default/files/docs/page/AHRQPBRNFinalRapidCycleResearchGuidanceDocument.pdf
Martin, J. L., & Ancoli-Israel, S. (2008). Sleep disturbances in long-term care. Clinics in geriatric medicine, 24(1), 39-50.
Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Journal of Psychiatric Research, 28(2), 193-213
