Vol. 5 Issue 26
The Power of One Idea
UW nurse creates sweet dreams for geriatric patients without medication
Early in her career on the night shift at University of Wisconsin Hospital and Clinics, Madison, Fawn Havarangsi-Nawaphan, BSN, RN, encountered a patient who, on the eve of her surgery, kept telling the staff to "look at her bling." Everyone admired the 2-carat diamond ring. As a matter of course, the nurse on duty removed the ring and other jewelry at night for preparation.
Havarangsi-Nawaphan was making her rounds and noticed the patient was tossing and turning and having some difficulty falling asleep. She approached the bedside and asked the woman how she could help. The two reviewed the patient's typical bedtime routine and discovered the act of twisting the ring, an anniversary present from the woman's husband, lulled her to sleep at night. Havarangsi-Nawaphan immediately retrieved the bauble and the patient was dozing off within minutes.
"This was one of my most important cases," she recalled. "When we spend time with the patient, she will tell you what it takes for her to fall asleep."
This is just one illustration of Havarangsi-Nawaphan's hands-on approach to patient relations. In 2005, she utilized her skills in communicating with patients for a nurse residency research project, which has since been adopted as an evidence-based practice in the facility's medical geriatrics unit.
While brainstorming for a research topic, Havarangsi-Nawaphan approached Linda Walton, MSN, RN, clinical nurse manager of the unit, for advice on a topic.
"Fawn was already working nights as part of her nurse residency, so she had interaction with patients and other nurses. Instead of just making a poster, we wanted to create a reference tool nurses would be able to use in their practice," Walton said.
As sleep is frequently a problem for elderly patients, the two hypothesized that improving the quality of sleep for elderly patients could lead to faster healing. The team recognized patients functioning on an efficient night's sleep were able to bring more energy to learn about their prognosis and recovery. In addition, fatigued patients are more likely to cancel X-rays or other necessary procedures because of their tired state and are always at a greater risk of taking a fall. Given her easy rapport with elderly patients, Havarangsi-Nawaphan was excited to discover nonmedicated interactions would induce a good night's sleep for her patients.
The Natural Path to Slumberland
One of the most important elements of the project was the idea of providing quality rest without the assistance of sleep enhancement pills. Maria Brenny-Fitzpatrick, MSN, FNP,C, APNP, explained the background of this idea.
"When elderly patients complained about not getting enough sleep, the nursing staff usually prescribed Ambien as a matter of course. The problem is that sleeping pills tend to cause memory loss in a patient population already having memory problems. There has never been a lot of assessment about sleep in the elderly and Fawn wanted to find a nondrug solution," she said.
Additionally, many of the medications the elderly population may be taking for other health problems can contribute to disturbed sleep. Antidepressents such as bupropion, selective serotonin reuptake inhibitors and venlafaxine; beta-blockers; bronchodilators; corticosteroids; neurologic drugs like phenytonin; CNS stimulants such as caffeine, cocaine and theophylline; decongestants like pseudoephedrine; cimetidine; and cardiovascular drugs such as furosemide, methyldopa and propranolol can act as barriers to a healthy night's sleep.
The irony of this is that the elderly patient population with the most obstacles to sleep is the population needing it the most. A cross-sectional survey of 1,526 adults ages 64Ð99 conducted by the Journal of the American Geriatrics Society in 2000 found insomnia, not psychoactive medication, was associated the most with falls. Havarangsi-Nawaphan realized she had to find alternative ways to facilitate rest for her geriatric patients.
Simulating Home Sweet Home
When Havarangsi-Nawaphan set out to change the notion it's impossible to get a good night's sleep in a hospital, her first step was to record vital signs and learn about each patient's sleep history.
"Since elderly people almost always have sleeping problems, we needed to do everything we could to parallel their sleep patterns at home. So, I'd always ask their typical sleep and rise time, medications taken for sleep, time taken to fall asleep, the number and duration of nighttime awakenings, daytime naps and tiredness, and then take a subjective assessment of sleep quality. One of the best things is to learn bedtime routines by asking if they normally drink tea before bedtime and if noise bothers them," she explained. Family members are included in these discussions, as people who share sleeping space often can provide valuable information on the patient's sleep habits.
Benefits of these sleep assessment conversations were twofold, said Havarangsi-Nawaphan. Obviously, the discussions helped nurses increase awareness of the normal bedtime routines so they could take steps to maintain normalcy during the hospital stay. Nurses also were pleasantly surprised to discover how appreciative patients were of the extra personalized attention.
In simple terms, she said, "I found out early that, if I show them respect, patients respect the nurses more and are more cooperative."
Tailoring Hospital Stays
Armed with patient sleep history data, Havarangsi-Nawaphan manipulated the unit's environment to parallel patient sleep patterns. Her research showed the need for noise reduction was widespread. Patients reported the few "common-sense" measures Havarangsi-Nawaphan applied yielded hours of additional shut-eye.
It didn't require special noise cancellation technology to reduce sound in the unit. Rather, she posted signs to remind staff and visitors to speak quietly, especially between the hours of 11 p.m.-7 a.m.; closed doors to patient rooms; placed phones and IV pump machines on lower volumes; turned off equipment that wasn't being used; placed pagers on vibration mode, offered earplugs to patients; and moved group conferences to a staff meeting room.
During one study on noise reduction, Havarangsi-Nawaphan was shocked to find staff conversations in the hall had the noise equivalent of running a vacuum cleaner for the elderly patients. "In our unit, when staff members see a co-worker for the first time in a week or so, they're excited in their speech," Walton said. "Fawn presented an educational seminar and used the vacuum example. It really drove home the message much easier than if she'd said 'we're talking too loud.'"
Havarangsi-Nawaphan also found the staff itself was interrupting patients' sleep. After hearing numerous patients complain about such interruptions, she tried to streamline their care by formulating nursing care plans to provide longer uninterrupted sleep periods, delaying or eliminating unnecessary nursing procedures when the patient is sleeping and using her best nursing judgment to determine if it's necessary to wake a patient to take vital signs. Of course, it's not always possible to abstain from waking patients for some element of care, so Havarangsi-Nawaphan communicated the plan of care to patients before bedtime to avoid upsetting them when they're awakened.
Fixing what was wrong in the hospital atmosphere was only half of what it would take to ensure a solid 8-hour rest for elderly patients. The second part of the equation involved developing an aura of relaxation. To that end, Havarangsi-Nawaphan borrowed some practices common to any luxury day spa.
For instance, aromatherapy has proved to induce sleep, so she dotted tissues with lavender and placed them near a patient's pillow. Other popular nonpharmacological interventions include providing warm blankets, back rubs and decaffeinated tea or warm milk. Nurses offer eye masks to patients and adjust the room's lighting to each individual's preference. Finally, Havarangsi-Nawaphan frequently turned on the university's classical music station to let patients drift off to soothing sounds.
Involved Nurses = Rested Patients
Though the medical staff was enthusiastic to implement the shift away from medicating patients complaining of insomnia, the patients themselves were another story. Nurses encountered hundreds of patients who would say the only thing that would work for them is medication.
Havarangsi-Nawaphan discovered the best response is to listen to the patient's reasoning for wanting medication and then ask them to try her way. If the nonmedicated interventions do not work within a few hours, she'd promise to get them medicine. Within the 3-4 hour trial period, every single patient had fallen asleep.
With a laugh, Havarangsi-Nawaphan recalled the number of patients who protested her methodology. Many times, she'd leave the room to get blankets or tea and return moments later to find the patient asleep.
"This has taught me geriatric patients are a lot like little kids. If they feel like you care about them, they'll want to sleep," she said.
Robin Hocevar is a regional editor at ADVANCE.