Adapting and implementing a staff-led sleep intervention in an acute rehabilitation setting

Abstract

Objective

To adapt and modify the successful SIESTA (Sleep for Inpatients: Empowering Staff to Act) sleep-promoting hospital protocol to an acute stroke rehabilitation setting.

Design

This study utilized a mixed methods design, involving qualitative surveys and interviews. Needs assessment and staff interviews informed the development of the adapted protocol, SIESTA-Rehab.

Setting

Inpatient unit treating persons with neurological injury, primarily stroke, in an acute rehabilitation hospital.

Participants

Nursing staff on the inpatient unit where SIESTA-Rehab was implemented.

Intervention

After identifying needs, we adapted the SIESTA protocol with relevant modifications to SIESTA-Rehab. Protocol adaptations were guided by the Culture, Oversight, Systems Change, Training framework, with a focus on developing nursing education and sleep-enhancing tools. The protocol was implemented over a four-year period, sustained through periodic staff re-education, and nursing staff perceptions of the intervention were evaluated using fidelity interviews.

Main Measures

Qualitative assessments were conducted from a convenience sample of nurses to gauge understanding, recall, ease of implementation, and individual re-education needs for SIESTA-Rehab.

Results

Initial staff feedback indicated limited awareness of sleep disorder screening and sleep optimization practices, highlighting the absence of sleep-based assessments during standard care. Initial unit-wide training was conducted on SIESTA-Rehab for nursing staff (N = 29), with ongoing education for new staff and periodic re-education for existing staff over 4 years of implementation. Fidelity interviews revealed high understanding, recall, and ease of implementing the intervention over survey periods.

Conclusions

SIESTA-Rehab can be successfully implemented in an acute rehabilitation setting, as indicated through positive staff responses.

Keywords

Sleep quality stroke implementation science nurse intervention sleep intervention

Introduction

Sleep plays a crucial role in the recovery process of hospitalized patients post-stroke, yet inpatients face significant barriers towards achieving optimal sleep due to frequent nighttime disruptions.^1,2 Pain, noise, anxiety, staff interruptions, medication schedules, vital signs, and sleep-disordered breathing can often contribute to sleep disruptions in the hospital.^1,3,4 Although evidence suggests that sleep interventions can improve outcomes in patients with stroke,^5–8 these efforts have largely overlooked acute care environments, where reducing sleep disruptions or identifying risk of sleep-disordered breathing (e.g. obstructive sleep apnea [OSA]) is especially salient. Given that good sleep quality is linked to enhanced motor learning, cognitive repair, and other neurorehabilitation outcomes post-stroke,⁹ implementing targeted sleep interventions in acute rehabilitation settings is essential to optimize recovery and improve long-term quality of life.^10–12

Nurses play an integral role in creating optimal sleep environments in the hospital. Their medical training, close proximity, and frequent engagement with patients are ideal to support sleep optimization, including promoting sleep hygiene with patients and assessing sleep-disordered breathing risks early at the bedside.¹³ In particular, acute rehabilitation nurses attend to patients’ basic necessities on a longer-term basis,¹⁴ placing them in the unique position to advocate for inpatient sleep during crucial phases of recovery. However, sleep optimization is generally not considered part of standard care practices in acute rehabilitation settings. Therefore, we sought to design and implement a novel nursing intervention to improve sleep in this environment.

Previous work has demonstrated that nursing interventions focused on environmental modifications, such as providing eye masks, earplugs, and education, can significantly improve sleep quality and reduce nighttime disruptions in an acute care setting.⁵ We previously developed an intervention to reduce sleep disruptions during general hospitalization: the SIESTA (Sleep for Inpatients: Empowering Staff to Act) protocol.¹⁵ The SIESTA protocol integrated behavioral nudges designed to promote sleep-friendly practices among care staff and comprehensive nursing education on inpatient sleep hygiene, leading to reduced patient-reported and objectively measured sleep disruptions as well as improved patient experiences.

Given the immersive, long-term nature of inpatient rehabilitation, the benefits of sleep during acute stroke recovery, and the close involvement of rehabilitation nurses over this extended period, it is imperative to incorporate sleep-promoting practices in these environments that can be led by nursing staff. In this article, we present our procedures for adapting and modifying the SIESTA protocol for an acute inpatient stroke rehabilitation setting and evaluate the modified protocol for its reception by nurses.

Materials and methods

Setting and context

This study was performed at the Shirley Ryan AbilityLab (Chicago, Illinois, USA), a translational rehabilitation hospital that provides both inpatient and outpatient care, between Fall 2020 and Spring 2024. Based on our internal hospital analytics data, ∼800 individuals with stroke are admitted annually to Shirley Ryan AbilityLab for inpatient rehabilitation, with an average length of stay of 20.6 days.¹⁶ While the intervention primarily was geared towards patients with stroke, it was implemented on a single unit within the hospital treating patients with different types of neurological injury. In the current study, we present the adaptation and modification of SIESTA to SIESTA-Rehab, and the implementation and evaluation of the new SIESTA-Rehab intervention. This is based on an ongoing clinical trial (ClinicalTrials.gov: NCT04254484) assessing the effectiveness of SIESTA-Rehab on patient outcomes post-stroke. For this study, we recruited nursing staff from the SIESTA-Rehab unit as participants.

The original SIESTA protocol

The original SIESTA protocol was developed using patient surveys and staff focus groups to detect barriers to inpatient sleep and was implemented on one “SIESTA-enhanced” general-medicine inpatient unit, while a second unit served as a control.

The protocol consisted of electronic health record changes, cueing reduced nocturnal vital sign assessments and laboratory orders, and physicians were educated about inpatient sleep deprivation and behavioral alterations for clinicians. Nurses in the SIESTA-enhanced unit received coaching on nurse-physician communication for the sleep-promoting orders. Badge cards with the SIESTA mnemonic (Screen patients for sleep disorders, Instruct patients on sleep hygiene, Eliminate disruptions, Shut doors, Treat pain, and Alarm and noise control) were provided to each nurse. Finally, SIESTA was incorporated into nurse daily huddles and shift handoffs by the identification of stable patients who would be eligible for sleep-friendly orders.¹⁵

Outline of study phases

Phases of the study included protocol (I) needs identification, (II) development, (III) implementation, and (IV) evaluation of protocol implementation (see Figure 1).

Protocol needs identification. To identify relevant areas for modification of the original SIESTA protocol to the acute inpatient rehabilitation setting, we first administered a needs assessment to examine existing staff knowledge about sleep-promoting practices and sleep disordered breathing (see Supplemental Material A). The needs assessment was administered to nurses and patient care technicians, who are healthcare professionals who provide care under the oversight of a nurse or physician. We administered a two-page manual survey assessing their knowledge of screening for sleep disorders, satisfaction with any previous training on sleep apnea risk detection, and level of perceived control of supporting inpatient sleep. The survey also assessed perceived sources of inpatient sleep disruptions and elicited ideas for sleep-promoting staff behaviors. We also conducted verbal staff interviews with nursing leadership, including three nurse managers and one nocturnist, a hospitalist primarily working during night shifts, to understand their perceptions of sleep disruptions for their patients.

Protocol development. After the needs assessment and staff interviews informed us what modifications should be made to the SIESTA protocol, we used the Culture, Oversight, Systems of Practice, and Training Framework for Value-Based Interventions to plan how to make our modifications. This framework consists of four key domains, which guided protocol modification in the following ways¹⁷: 1.

Culture: Cultivating a culture that values cost-consciousness and resource stewardship to encourage sleep-friendly nursing practices.

Oversight: Establishing robust oversight mechanisms by engaging leadership at all levels to maintain accountability in cost-effective decision-making and ensuring adherence to the protocol among nursing staff.

Systems of Practice: Protocol adaptation should incorporate evidence-based changes in nursing practices based on staff feedback.

Training: Comprehensive training is essential to prepare nurses for the adaptation of care delivery practices in alignment with the new protocol.

Protocol implementation. After protocol development, protocol implementation was planned using insights gained from phases I and II. To promote sustained, consistent implementation of the protocol, we created re-education sessions to be administered to nursing staff every 3 months beginning one year post-implementation. Re-education was characterized by pre-test questions to be verbally administered to nursing staff on the SIESTA-Rehab unit about their overall understanding and recall of the intervention (see Supplemental Material B). We also created an educational handout to be distributed to nurses highlighting SIESTA-Rehab components, reminders for sleep-promoting practices, and background on existing literature supporting the importance of inpatient sleep for stroke recovery (see Supplemental Material C).

Evaluation of protocol implementation. To evaluate protocol implementation procedures, we developed semi-structured fidelity interviews (see Supplemental Material D) using the consolidated framework for implementation research.¹⁸ We conducted the interviews based on two domains of this framework—characteristics of individuals and intervention characteristics—to capture nurses’ individual beliefs and knowledge about our interventional reach and the protocol's development, feasibility, and adaptability for a new setting.¹⁹ Fidelity interviews, based on this framework, were planned for administration one month after protocol implementation, followed by one year of uninterrupted implementation. We then conducted fidelity interviews every three months until the study's completion in Spring 2024. See Figure 2 for the protocol implementation timeline.

Pre-test and fidelity interview responses were recorded and transcribed using the automated transcription service Sonix²⁰ and manually categorized by two raters into pre-determined measures of feasibility, which included protocol understanding, positive nurse feedback, ease of implementation, recall of protocol components, need for re-education, and incorporation of behavioral changes into nursing staff routines. These measures represented the main implementation outcomes for this current study, investigating implementation success and protocol adherence among nursing staff.

Results

I. Protocol needs identification

The needs assessment was conducted with 36 nursing staff members, including N = 18 stationed on the control unit (47.4% nurses, 47.4% patient care technicians [36.8% night shift]) and N = 18 on the SIESTA-Rehab unit (73.7% nurses, 21.1% patient care technicians [42.1% night shift]). Staff confidence in screening patients for obstructive sleep apnea and correct identification of a sleep apnea screening tool (snoring, tired, observed apnea, (blood) pressure, body mass index, age, neck circumference, and gender)²¹ was low at 38.9% (N = 14) across both units, with only 33.3% (N = 12) of nurses exhibiting proficiency in identifying risk factors for obstructive sleep apnea. While all nurses recognized the significance of sleep, only 58% (N = 21) felt adequately empowered to address it across both units. Nurses’ perceptions of the primary patient-related sleep disruptors included pain, anxiety, and gastrointestinal upset, while their perception of hospital-related disturbances included noise, bed comfort, monitors, doors, and light.

The overarching theme that emerged from staff interviews was an emphasis on nurturing a supportive organizational culture conducive to inpatient sleep among nursing staff. This included requests to appoint peer champions, provide coaching support, cluster nursing care, add sleep-related reminders for nurses during shift handoff, and post signage defining “quiet hours” from 9 p.m. until 7 a.m.

II. Protocol development

Using the Culture, Oversight, Systems of Practice, and Training Framework to incorporate these stakeholder-driven suggestions into the original SIESTA protocol resulted in the modifications summarized in Table 1.

Table 1.

Utilization of the Culture, Oversight, Systems of Practice, and Training framework for high-value care interventions¹⁷ in development of Sleep for Inpatients: Empowering Staff to Act (SIESTA)-Rehab.

	Culture	Oversight	Systems of practice	Training
Description	Valuing cost-consciousness and resource stewardship at individual and team levels	Requiring accountability for cost-conscious decision-making from peers and organization	Creating systems to make cost-conscious decisions using institutional policy or support tools	Providing knowledge and skills clinicians need to make cost-conscious decisions
SIESTA Protocol Component General Medicine Inpatient Unit	• SIESTA nurse badge cards	• Incorporation of SIESTA into nurse daily huddles	• Modification of nursing shift handoffs • Signage • Coaching on staff communication • Electronic health record nudges	• Physician education: presentation on inpatient sleep deprivation and behavioral modification
Identified Protocol Needs	Robust leadership and integrative job aids	Enhanced staff engagement and assessment of protocol adherence and implementation	Improved staff communication and mitigation of external disruptors	Tailored nursing education to address gaps in knowledge on inpatient sleep
SIESTA-Rehab Protocol Component Acute Inpatient Rehabilitation Unit	• SIESTA nurse badge cards • Protocol handouts	• Reports on sleep promotion orders • Establishment of nurse champion • Fidelity Surveys	• Modification of nursing shift handoffs • Signage • Eye masks	• Nurse education: “MicroCME” learning modules on sleep health and disruptions • Re-education

Components of the original SIESTA protocol¹⁵ and identified needs from the preliminary needs assessment and staff interviews informed the new SIESTA-Rehab protocol, with relevant modifications for the acute rehabilitation setting. Retained components from the adaptation of SIESTA to SIESTA-Rehab are bolded.

Based on the results of the needs assessment in phase I, we determined that components of the new protocol should include training nurses on the relevance of their role in sleep promotion, adding sleep to shift handoffs, and delivering eye masks to all incoming patients on the SIESTA-Rehab unit. Based on the feedback from the staff interviews, bedside shift report guidelines were adjusted to include sleep within the existing report structure—that is, Diagnosis, Diet, Bowel & Bladder movements, Safety concerns, Skin & Lines, Sleep, and “Up & Ready”—encouraging nurses to consider patient sleep during shift handoffs. Additionally, cluster care was reinforced in standard care protocols to reduce unnecessary nocturnal disruptions such as repeated overnight vital sign checks and daily labs on medically stable patients. Lastly, SIESTA-Rehab eye masks were provided at the unit nursing stations, allowing staff to address concerns with nighttime sleep disruptions due to light. The National Institutes of Health (NIH) sleep brochure²² and quiet signs for patients’ room doors were also available for handout by nursing staff (see Figure 3).

Clinician education was the main SIESTA component retained to emphasize the importance of staff education to support patient sleep needs in the rehabilitation setting, with the focus shifted from physicians to nursing staff. A 20-minute web-based educational module was designed to address the consequences of sleep deprivation during hospitalization,²³ the role of sleep in post-stroke recovery,²⁴ the importance of sleep disorder screening,²⁵ and the effectiveness of sleep aids.⁸ This module was disseminated to all staff on the SIESTA-Rehab unit upon the intervention's launch. Any nursing staff who were hired on the SIESTA-Rehab unit after implementation were required to view the module as part of their onboarding. Re-education was conducted for all SIESTA-Rehab nursing staff in three-month intervals, including a pre-test assessment with seven questions and distribution of an educational handout (see Supplemental Materials B and C).

Cultural adaptations in the inpatient rehabilitation setting were facilitated by preparing badge cards featuring the mnemonic SIESTA (see Figure 4) to serve as a daily reminder of protocol components, aid adherence to intervention guidelines, and foster cultural and system-level changes. For continuous oversight, we appointed one nurse champion for the SIESTA-Rehab unit to promote protocol adherence, solicit feedback on protocol implementation, and act as a liaison between the study research team and nursing staff.

III. Protocol implementation

Following phase II (protocol development), we began implementation under the supervision of the established nurse champion by disseminating the nurse educational module, sleep-support tools, and having nurses attach their SIESTA badge cards to existing lanyards with their hospital badges.

During initial protocol rollout in 2021, 93% of nurses (N = 27 of 29) completed the SIESTA-Rehab training module. The first re-education session in early 2023 revealed that 77% of nurses (N = 23 of 30) demonstrated a comprehensive understanding of the intervention, improving during the second re-education phase to 88% of nurses (N = 7 of 8), with 63% (N = 5 of 8) recalling protocol components such as cluster care, eye masks, and sleep signage. Additionally, 75% of nurses (N = 6 of 8) successfully articulated the implications of obstructive sleep apnea for patients with stroke, and 88% (N = 7 of 8) were aware of the eye mask locations on the unit. Nurses who gave incorrect responses were further re-educated on these guidelines.

IV. Evaluation of protocol implementation

The initial fidelity interview (one month post-implementation) indicated that 91% of nurses (N = 10 of 11) recalled intervention components, understood the protocol, and considered it easy to implement as a “standard of practice.” After one year of uninterrupted implementation, nurse feedback (N = 12) from fidelity interviews revealed that rigid lab and medication orders were deterrents to clustering care, and patients’ cognitive deficits posed the greatest difficulty for sleep-disorder screening. The third fidelity interview showed that 78% of nurses (N = 7 of 9) found the protocol easy to implement, and they recalled components such as eye masks and cluster care. Protocol understanding was 100% by the end of the study period (N = 7), with nurses considering it as “part of the workflow.” Nurses’ ease of implementation also increased to 86% (N = 6 of 7), with responses noting the intervention was “not complicated,” “simple,” and “well organized.” Nurses also highlighted the positive impact of SIESTA-Rehab on their perceptions of inpatient sleep quality, with one remarking, “I know the sleep masks have been helping the patients.” During the final two fidelity interviews (N = 7), 100% of nurses noted that they regularly emphasized to patients the importance of sleep for stroke recovery, educated them on sleep hygiene, and actively improved sleep environments. As one nurse mentioned, they “started [these practices] after being educated on the sleep study and the importance of sleep hygiene,” recognizing “how [they] affect that in [their] roles.” During this period, nurses identified additional positive aspects of the intervention, including the team dynamic, which was “very apparent on [the SIESTA-Rehab] floor,” efficient communication, and the use of eye masks. Following their “bedside assessment,” some nurses believed that the efficacy of these intervention components was dependent on the patient's circumstances.

Discussion

The primary aim of this article was to present our modifications of the SIESTA protocol, originally developed for a general medicine inpatient unit, to an acute inpatient rehabilitation setting (SIESTA-Rehab), with the goal of minimizing sleep disruptions among inpatients recovering from stroke. The needs identification process revealed that sleep is not always prioritized in the standard care protocols for the rehabilitation setting, as evidenced by nurses’ low confidence about the relevance of sleep and sleep disorder screening. These results align with existing literature demonstrating that hospital environments are often not conducive to patient sleep,²⁶ and formal sleep-friendly practices for hospital staff remain limited.²⁷

In tailoring SIESTA to an acute inpatient rehabilitation setting, we integrated components from the original protocol with relevant modifications. To preserve SIESTA's evidence-based focus on limiting disruptions through behavioral changes and cluster care,²⁸ we retained previous components such as staff education on inpatient sleep, adjustments to shift handoffs, SIESTA signage, and nurse badge cards to facilitate staff engagement. SIESTA-Rehab was designed to support post-stroke inpatient sleep needs and aid rehabilitation nurses, who play an integral role in the transition from acute hospitalization to long-term inpatient rehabilitation care, in promoting early stages of neurological recovery and improved patient experience. Moreover, establishing a conducive sleep-friendly environment often relies on the proactive efforts of unit-based nurses^5,15 to serve as champions to facilitate intervention success.²⁹ Strategic modifications were made to address the needs of a new rehabilitation setting, including providing nurse-centered education on post-stroke sleep concerns and sleep disorder screening, a nurse champion, and fidelity interviews, reinforcing existing evidence on effective sleep protocols. These modifications were included in SIESTA-Rehab, given that our results from staff feedback and previous nursing interventions³⁰ emphasize the importance of staff education and environmental improvements (quiet hours,³¹ eye masks,³² and light control³³) for improved sleep quality.

Existing quality improvement studies highlight the value of theoretical frameworks to evaluate interventional needs for sleep protocols in inpatient settings, including the Consolidated Framework for Implementation Research and Human-Centered Design methodologies.²⁶ Our use of the former framework to create the initial staff interviews and fidelity interviews was imperative to assess potential barriers and facilitators to SIESTA-Rehab's implementation throughout its progression. Previous sleep interventions for older adults, particularly those with cognitive impairments, highlight limitations to time, financial resources, and staff motivation as key barriers to implementation success.³⁴ Therefore, the Culture, Oversight, Systems of Practice, and Training Framework served as a critical tool to support the holistic, value-driven design of SIESTA-Rehab through cost-effective job aids, enhancing usability and nurse buy-in. These frameworks were essential to strengthen the feasibility of SIESTA-Rehab and foster a culture that prioritizes inpatient sleep after stroke.

Other literature and nursing care models also indicate that implementation fidelity is critical for replicability, relevance to target populations, and improved interventional design.^35,36 In our study, we found protocol understanding and adherence improved over time, with nurses expressing a strong commitment to promoting patient sleep, utilizing intervention components, and applying SIESTA-Rehab in daily practice. For example, staff awareness of the impact and screening of obstructive sleep apnea improved up to 42% from the needs assessment to the final nurse re-education period. These results highlight the importance of soliciting input from nurses for continuous protocol implementation and evaluation.

There are several limitations that should be acknowledged. First, the implementation of SIESTA-Rehab relied heavily on the engagement of nursing staff. Nursing and research staff turnover, changes in leadership, and competing priorities within the healthcare system could pose challenges to sustainability. Second, due to our method of convenience sampling, we were unable to include all nurses in our protocol implementation measures due to time constraints and nurse availability. Lastly, our research was conducted at a single institution across two inpatient units, which may limit the generalizability of our findings to other settings. Future work is needed to evaluate the effect of SIESTA-Rehab on subjective and objective inpatient sleep quality in the acute rehabilitation setting, as assessed in our ongoing clinical trial. Subsequent findings may inform protocol refinements to optimize its effectiveness for widespread implementation.

In conclusion, we found that our procedures for adapting and modifying the SIESTA protocol were feasible to implement in an acute rehabilitation setting, resulting in a comprehensive, staff-led sleep intervention (SIESTA-Rehab). As an actionable model for future care interventions, SIESTA-Rehab was sustainable to implement among nurses and effective in promoting a supportive sleep environment in a specialized inpatient setting. These findings point to the implementation potential of organizational hospital sleep policies to enhance clinical practice and the patient experience in a variety of inpatient settings, including sleep in standard care protocols. Our study highlights the value and merits of incorporating a cost-effective, low-burden intervention targeted to empower nurses to champion high-quality patient care without adding strain to their roles. By leveraging the insights gained from our protocol adaptation and adopting a collaborative approach to its implementation through the application of evidence-based frameworks, healthcare organizations can effectively address the critical issue of sleep disruption among inpatients with stroke.

Clinical messages

The adaptation and modification of the Sleep for Inpatients: Empowering Staff to Act (SIESTA) protocol for an acute stroke rehabilitation setting demonstrates the feasibility of implementing tailored nursing interventions, encompassing staff education and sleep-support tools, to establish clinical practices conducive to inpatient sleep.

Implementation science frameworks, including the Culture, Oversight, Systems of Practice, and Training Framework and Consolidated Framework for Implementation Research, can be integral to designing nurse-focused sleep protocols with strong staff buy-in, cost-effective job aids, and supportive resources to promote long-term retention with continuous improvements.

Supplemental Material

sj-docx-1-cre-10.1177_02692155251375369 - Supplemental material for Adapting and implementing a staff-led sleep intervention in an acute rehabilitation setting

Supplemental material, sj-docx-1-cre-10.1177_02692155251375369 for Adapting and implementing a staff-led sleep intervention in an acute rehabilitation setting by Bianca A Ramos, Kavita Ram, Maylyn Martinez, Aashna Sunderrajan, Jacob Sindorf, Megan K O’Brien, Sara Prokup, Sehar Siddiqui, Linda L Morris, Kristen L Knutson, Babak Mokhlesi, Shyam Prabhakaran, Lisa F Wolfe, Phyllis C Zee, Arun Jayaraman and Vineet M Arora in Clinical Rehabilitation

Footnotes

ORCID iDs

Bianca A Ramos

Jacob Sindorf

Megan K O’Brien

Kristen L Knutson

Babak Mokhlesi

Arun Jayaraman

Ethical approval and informed consent statement

This study received ethical approval from the IRB (CIRB20-2132) on March 8, 2021. All participants provided written informed consent prior to enrollment in the study. This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work has been supported by the Foundation for the National Institutes of Health (grant number 5R01HD097786-05).

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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