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  1. Smith, Lisa A. MHI, RN
  2. Larsen, Charles A. BSN, RN
  3. Johnson, Karen L. PhD, RN

Article Content

PATIENT SATISFACTION scores have been in the national spotlight since 2007 when Medicare began to link hospital reimbursement with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. Patients are asked to respond to this question: "During this hospital stay, how often was the area around your room quiet at night?" (Answer choices: Never, sometimes, usually, and always).1 Many hospitals, including ours, have worked diligently to improve patient satisfaction with quiet-at-night initiatives.


This article describes our quiet-at-night initiatives and concerns that these initiatives were impairing our night-shift staff's alertness. We addressed these concerns by conducting a survey; its results led us to change our initiatives to improve staff wakefulness while maintaining patient satisfaction.


Setting the scene

Our hospital is a Magnet(R)-designated 685-bed urban tertiary care academic medical center in Phoenix, Ariz. The nursing units are circular, with 15 beds around a centralized nurses' station.


In 2007, a committee of night-shift nursing and ancillary employees was formed to identify opportunities to improve patient satisfaction with quietness at night. One of this committee's first recommendations was to dim all nursing unit lights at 2100 hours and offer patients the option of having their room doors closed. Lights were turned back up at 0600. These initiatives, along with an overall awareness of noise at night, were primarily responsible for a dramatic increase in patient satisfaction.


Additionally, we implemented 4-hour quiet times (2300 to 0300 or 0000 to 0400) in each nursing unit. Nursing care and interventions were clustered before and after these times so that patients would have minimal interruptions and an opportunity for increased rest and healing.


In 2012, a concern was brought to the CNO: Nurses may be sleeping during night shift outside of their scheduled break times. During the CNO's rounds during night shifts, several clinical staff, including nurses and unlicensed assistive personnel, commented that they felt that the darkened units created an environment that promoted sleepiness and impaired staff alertness. Was it possible that our interventions to promote patient satisfaction with quietness at night were actually promoting sleepiness in the nurses, potentially causing them to be less alert and creating a patient-safety issue?


Assessing the situation

To answer this question, we conducted a survey using convenience sampling; we sent surveys to specific departments and responses were anonymous. Of the 89 respondents who took the preintervention survey:


* 45% (N = 40) reported they'd witnessed a coworker sleeping while on duty and not on a break in the past month.


* 70% (N = 63) sometimes found it difficult to stay awake and alert at night.


* 70% (N = 63) reported the most difficult time to stay alert and awake was between 0200 and 0600.



These results revealed that we did have a problem with nurses' alertness during night shift and that interventions were needed.


Literature review

Sleep disorder is one of the most important issues affecting nurses who work the night shift. Results of two studies conducted with night-shift nurses indicate that more than half of the nurses sampled reported sleep deprivation.2,3 A recent study by Johnson and colleagues found an inverse relationship between hours slept and patient-care error.3 Nurses who experience impairments due to fatigue, loss of sleep, and inability to recover between shifts are also more likely than unimpaired nurses to report decision regret.4 Scott and colleagues define decision regret as a negative-outcome emotion that occurs when the actual outcome and the desired or expected outcome differ and reflects concerns that the wrong decision had been made.


Melatonin released from the pineal gland lowers alertness and readies the body for sleep. Production of melatonin is impacted by both natural and artificial light. Melatonin is released in the dark and suppressed in light at night.5 A study of night-shift nurses revealed an inverse relationship between light intensity and eye fatigue; an increase in light intensity was associated with a decrease in eye fatigue. Some have suggested that inadequate sleep and disordered sleep in night-shift workers are due to inappropriate light intensity in the work environment.5


Hansen and Stevens demonstrated that improving the light intensity of night nurses' workplace improved their consciousness, performance, and comfort.6 Appropriate light intensity is essential and important when performing work activities.


Body temperature, alertness, and performance reach a low point between 0400 and 0600, and this low point persists even if a night-shift worker gets enough sleep during the day.7 Night-shift nurses should "phase shift" their circadian clock by using the following interventions:


* Use bright lights during the night shift.


* Wear dark sunglasses on the commute home because bright lights would suppress melatonin release.


* Have a regular dark and daytime sleep period.7



Pilot project

We launched a pilot project on several nursing units: two medical-surgical units, one progressive care unit, four postpartum units, and four ICUs. The goal was to improve nurse alertness without impacting patient satisfaction with quiet-at-night initiatives. We specifically selected the postpartum units because they had consistently high patient satisfaction scores with quiet at night; consequently, we believed any intervention that impacted patient satisfaction would be easily detected there.


We conducted a 5-week pilot project that included having the nursing units' lights dimmed at 2100 and turned back up at 0200. We selected 0200 because our survey revealed that this is when most staff reported difficulty staying awake. To evaluate our intervention, we conducted a postpilot project survey of 63 staff members who worked nights on these units and evaluated the HCAHPS item for patient satisfaction scores with quiet-at-night initiatives.


Project results

Most of the staff who completed the pre- and postpilot intervention surveys were female nurses (80%; N = 137). Ages were fairly evenly distributed in the prepilot survey, but most of those who responded to the postpilot survey were ages 20 to 30.


Length of time as a night-shift employee was widely distributed. No significant differences between those who responded to pre- and postpilot surveys were found (P = 0.223).


The postpilot survey showed an increase in the number of nurses who reported they never had difficulty staying awake and alert at night (prepilot, 20% versus postpilot, 30%) and a decrease in the number of nurses who reported that they sometimes had difficulty staying awake at night (prepilot, 71% versus postpilot, 59%), but these results weren't statistically significant (P = 0.363). However, when asked directly if turning up the lights at 0200 helped them stay more alert, 67% said it didn't. Fewer nurses in the postpilot survey reported that they had witnessed colleagues sleeping at night (prepilot, 45% versus postpilot, 37%; P = 0.174).


No changes were noted in postpilot patient satisfaction scores related to quiet at night (prepilot, 57% responded it was always quiet at night versus 58% postpilot).


Future direction

Although our results didn't reach statistical significance, we think that this pilot project sets the stage for further research. If we were to expand the research, we would identify surveys by specific areas of specialty so we could work on additional ways to improve the work environments.


Putting issues to bed

Quiet-at-night initiatives in nursing units typically consist of dimming the lights and clustering care. Although these initiatives are directed at improving patient satisfaction, the impact of these initiatives on nurse alertness should also be considered.


We found that dimming the lights at night as a component of quiet-at-night initiatives to promote patient satisfaction may have adversely impacted nurse alertness. In our pilot project, we demonstrated dimming the lights for a shorter period at night improved nurse alertness, decreased reports of colleagues sleeping, and didn't negatively impact patient satisfaction with quiet-at-night initiatives. We also believe that awareness of the change in lighting has made an impact.




1. HCAHPS Survey. 2016. http://www.hcahpsonline.org/files/March%202016_Survey%20Instruments_English_Mail.pdf. [Context Link]


2. Johnson AL, Brown K, Weaver MT. Sleep deprivation and psychomotor performance among night-shift nurses. AAOHN J. 2010;58(4):147-154. [Context Link]


3. Johnson AL, Jung L, Song Y, Brown KC, Weaver MT, Richards KC. Sleep deprivation and error in nurses who work the night shift. J Nurs Adm. 2014;44(1):17-22. [Context Link]


4. Scott LD, Arslanian-Engoren C, Engoren MC. Association of sleep and fatigue with decision regret among critical care nurses. Am J Crit Care. 2014;23(1):13-23. [Context Link]


5. Azmoon H, Dehghan H, Akbari J, Souri S. The relationship between thermal comfort and light intensity with sleep quality and eye tiredness in shift work nurses. J Environ Public Health. 2013;2013:639184. [Context Link]


6. Hansen J, Stevens RG. Case-control study of shift-work and breast cancer risk in Danish nurses: impact of shift systems. Eur J Cancer. 2012;48(11):1722-1729. [Context Link]


7. Eastman CI. Practical circadian interventions for night shift work. 2009. http://www.cdc.gov/niosh/nioshtic-2/20045415.html. [Context Link]