CardiologyClinical TopicsCritical CareEditorialFeatures

Shhhhhh! Quiet zone


Would you ignore the symptoms of a hospital patient with an elevated heart rate and blood pressure, increased sensitivity to pain, and anxiety? Of course not. You’d perform an assessment and provide appropriate treatment, or seek guidance from other care team members. Would you purposefully ignore or withhold interventions that promote healing? Not likely.

Yet, every day we may be compromising our patients’ recovery by contributing to sleep deprivation. Denying patients meaningful sleep is hardly patient-centered care and is known to lead to a poor patient experience. Some sleep experts consider it a public health hazard.

Nightingale believed sleep and rest are critical to healing. In Notes on Nursing: What It Is and What It Is Not, she cautioned nurses about the hurtful nature of noise. From whispered conversation to a loud sudden jarring noise, she believed unnecessary noise not only harms sleep but inflicts suffering. Almost a decade ago, nurses participating in Transforming Care at the Bedside, an initiative of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement, implemented such care innovations as quiet time during daytime hours and midnight rounding with physicians to identify and minimize potential nighttime interruptions that would threaten patients’ rest. Yet patients continue to report lack of sleep as a problem, and environmental noise is a significant contributing factor.

On the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, the lowest-scoring item is the question, “During this hospital stay, how often was the area around your room quiet at night?” Hospital executives realize this measure contributes to the assessment of value-based purchasing incentive payments. Nurses, for their part, should be concerned about the noise level because of the negative impact of noise on sleep and the effects of sleep deprivation.

Studies of patients in intensive care units revealed that repeated periods of nocturnal sleep measuring 5 hours or less caused harmful physiologic changes. Such partial sleep loss has been linked to such conditions as insulin resistance, decreased insulin response, reduced ability to respond to hypoxia and hypercapnia, increased sensitivity to pain, hyperactive gag reflexes, slurred speech, sluggish corneal reflexes, and delayed healing.

Delirium is another dangerous side effect of sleep deprivation and puts patients at risk, especially elderly patients. Other minor changes, such as elevations in blood pressure, heart and respiratory rates, anxiety, and irritability, also occur.

Many effective suggestions have been offered to reduce noise and create quiet times for patients to promote rest and sleep. If we’ve implemented any of them, are we sticking with the plan? Or have we caved to pressures that support the age-old traditions of routinized vital signs, phlebotomy, and medication administration schedules done for the convenience of hospital personnel, even though they ignore patients’ needs?

We can make a difference by taking charge of the environment, which is already ours to command. It will mean tackling ingrained behaviors and negotiating with colleagues to make changes that challenge conventional wisdom. Consider using a sleep protocol that calls for a prescribed period of sleep, as well as declaring quiet times. Identify factors that prevent sleep, such as noise, light, pain, interruptions, and medications. Noises typically include alarms, monitors, pagers, phones, chatter, squeaking equipment, visitors, roommates, closing doors, and televisions. Hospital noise levels often exceed twice the levels recommended by the Environmental Protection Agency. You may want to use noise-monitoring devices that light up when ambient noise exceeds desired levels. Implement noise controls, such as preventing alarms by ensuring proper settings, avoiding I.V. sites that occlude infusions, and anticipating I.V. solution changes. Offer patients ear plugs, eye masks, and headsets for televisions; close their doors. Eliminate overhead paging; most of it isn’t necessary. For instance, emergency response teams can be contacted by cell phone or pager instead of overhead paging. Adopt a strict practice of no hallway conversations for staff and visitors during quiet times.

Turn off lights wherever possible. At night, group required care and reschedule interventions for patient convenience. Stretch vital-signs intervals. Work out q.i.d. medication schedules rather than giving meds every 6 hours; there will be a few exceptions. Avoid giving transfusions at night. Rely on lab samples done just before sleep; do we really need labs drawn at 4 AM? Treat pain before the patient goes to sleep. Be aware of medications that cause sleep interruptions or disrupt sleep cycles, and stay alert for insomnia and the need for sleep aids.

It’s a rare patient who reports feeling rested when leaving the hospital. Let’s make sure we own the environment and help patients get their Zs.

Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN



    December 31, 2019 7:39 pm

    Are there any examples of gunfire disrupting sleep – duck hunting??

  • My elderly father was recently hospitalized for pneumonia. The noise level on the unit was one of his complaints he commented several times that it sounded like they were having a party outside his room which was across futon the stockroom/nutrition kitchen. This situation was not limited to daytime hours and significantly impaired his sleep. Thank you for bringing this problem to nurses attention. I think I will share this article with the manager of the unit to share with her staff.

  • How are other’s handling the barcoding of patients and medications at night? We find that a significant disruptor to sleep is the need to wake the patient to scan their wrist band to hang a new bag of fluid of antibiotic. Appreciate the need to verify identity for med safety, but find that this is technology is a huge sleep disruptor, especially in our most ill patients who’s meds are not amenable to rescheduling.

  • This is an excellent article which many nurses and other caregivers must read. It offers great suggestions to assist noise reduction in the hospital

  • The caregiver is better able to care for their patients when they have had enough sleep. Explore current laws, etc that protect the nurse from working 16 plus hours in a row. There may be only one or two states that address this with enforceable laws.

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