Good Night Good Morning Routines

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Sue Ellen Clark
Guide, 2022 Pioneering a New Culture of Aging Conference

A good night’s sleep is fundamental to health and being human.  However, lack of quality sleep is the number one problem that no one is talking about in long-term care.  If you are not convinced, just ask yourself how important sleep is to you.  It is really important!  Poor sleep patterns are among the most common difficulties elders experience and are associated with many negative outcomes.  We carefully review the quality measures of falls, infections, pressure areas, and the like, but do little if anything in assessing the sleep that elders receive.  There are many things that happen in a traditional nursing home that create bad sleep including age related changes, environmental factors, behavioral issues, care practices, diagnoses, polypharmacy, inactivity, and the unbending institutional structure.

Sue Ellen Clark

Prior to moving in to a care community, an elder had expressed night time and morning routines, but shortly after their arrival those preferences get squeezed out for the sake of efficiency.  The elder becomes lost in the regimented routines, and falls prey to the tasks that need to be done.  Just think about the schedules that typically exist in traditional long-term care settings.  The day is akin to a one size fits all, assembly line approach.

If you have never stayed overnight in a long-term care bedroom, please consider doing so. No, not for your own self-glorification but for the sake of upending the institutional regime.  It will serve as a disturbing motivator for change.  One time, I stayed overnight at a community where I worked as winter weather was bearing down on the region.  Upon entering my assigned room, it was unusually cold and smelled like my grandmother’s old chest freezer, the one found in her basement.  There was no shower to bathe myself, only a shallow sink that overflowed if the water ran for more than 30 seconds.  I crawled into bed and experienced sleeping among the tentacles of bedrails for the first time.  The pillow was a crunchy, plastic substance, and the mattress made squeaky noises each time I flinched.  A badly stained chair, whose expiration date was long overdue, wafted an undetectable stench.  Throughout my five-hour existence in the room, I could hear team members chatting in the hall, and elders on all sides of my room with their televisions at full volume.  I thought to myself that if a CNA came in to reposition me every two hours on top of all this, I would surely go out of my mind.  I raced to get out of bed and out of that room as early as possible the next morning to end the misery.

Throughout that ordeal, my mind kept turning to the fact that this is the environment in which so many elders live.  It did not represent anything close to what I experience at home every night.  I felt guilty as I could easily walk away, go home, tell a good story about it, and chalk it up to ‘taking one for the team.’  But the elders could not do that.  This is their daily life and existence.  Everyone has preferences and styles that vary enormously related to sleep.  Everyone needs productive, meaningful sleep.  That does not change as one gets older but only becomes more essential.  Elders in long-term care have the very basic right to sleep and wake in a way that is needful for them.  For elders in traditionally run nursing homes, achieving that can be much more challenging and elusive.

Part of the theme for this year’s conference is shaping the future.  That means creating sleep and wake routines to resemble what elders did in their homes.  Elders’ lives should not be so upended once they move into care communities that they have to give up what is important to them.  The succumbing to the institution does nothing more than underestimate the very existence of being human.  Now is the time to create what we would want for our families and ourselves when we need long-term care and support services.  The new model in long-term care must support normal, restful sleep and natural waking for good health and well-being.  In that, we start to change the future of elder care.

16 comments on “Good Night Good Morning Routines

  1. Rick Tabor on

    Thank you for this thoughtful dignity-in-aging suggestion. Imagine a future of Long-Term Care being shaped by it’s elders rather than structured by institutional traditions. The freedom of self-driven, person-centered, individual wishes and needs realized, with dreams set to reality in realistic achievable goals and outcomes. Perhaps this is why 95% of our Kūpuna (Elders) want to age-in-place rather than die in a nursing home. There’s a new generation of 65+, and their the fastest growing demographic in America. Baby-Boomers are about to do it their way. Hopefully a good night’s sleep can happen. There’s no reason a child’s top arguement, ‘why can’t I go to bed when I want to?’ Should be a Golden Age power struggle. Freedom of choice, never take away a person’s power. Freedom is earned through one’s ability to manage their responsibilities. This concept is a pretty simple inspiration, for people who want to feel motivated to enjoy life to it’s fullest.

    Reply
    • Sue Ellen Clark on

      Thank you for your response. It simply comes down to resident rights. Do we believe that residents have the basic right to meaningful sleep? If so, we must act in accordance with that belief in order to change the paradigm for those that cannot advocate for themselves.

      Reply
  2. donna k woodward on

    This is so important! Having routines conducive to restorative sleep and positive awakening is as important as ADLs. The tone we set by how we say goodnight at bedtime or greet a resident in the morning also contributes much to the resident’s sense of security and peace. (Or not.) If aides are too rushed to honor the resident’s habitual bedtime and rising time; too busy to learn their preferred room temperature and level of light or darkness and ensure that these are provided and that the beds are comfortable: if aides don’t have time for these things, will they ever have the time for the little extras that can make a big difference to a lonely or worried resident? Sharing a few words or a song or a prayer? Providing a warm facecloth or a drink at bedtime or upon waking ?

    Yes, we should be creating sleep and wake routines resembling what elder s did in their homes. But person-centered care gives way to the one-size-fits-all mentality of the long-term care industry. The new models of care that Sue Ellen describes will never happen unless adequate staffing ratios are mandated. An aide that has ten residents to wake and dress and groom each morning will simply not have the time for person-centered sleep and wake routines.

    Thank you for this, Sue Ellen.

    Reply
    • Sue Ellen Clark on

      Thanks, Donna, for sharing your insight. No doubt, adequate staffing is a struggle in most long term care settings. A change in sleep and morning routines can prove beneficial in spite of this fact. When residents awake naturally, there is a natural staggering over several hours (flexible, well-being, resident rights approach) versus the rush hour method to get everyone ready by the start of breakfast (inflexible, institutional strict routines & schedule approach). At night, similar practices should take precedence. Residents should have the right to choose a bed time that is meaningful for them (flexible, well-being, resident rights approach) versus the ‘get everyone into bed immediately after supper’ process (inflexible, strict institutional routines & schedule approach).

      Reply
  3. Alesia De on

    YOU ARE 100% CORRECT! IN A WAY – LACK OF QUALITY SLEEP SETS THESE ELDERS UP FOR FAILURE. THE SHEAR NATURE OF THE BUSY ENVIRONMENT IN A LONG TERM CARE SETTING IS OVERSTIMULATING TO FOLKS WITH ANY TYPE OF COGNITIVE DECLINE , IN FACT I WOULD LIKEN IT TO TORTURE WHEN YOU HAVE SLEEP DEPRIVATION. AS A NURSE I HAD LACKED SO MUCH SLEEP WORKING LONG SHIFTS DURING THE RECENT PANDEMIC THAT I ACTUALLY DROVE TO WORK FOR AN OVERNIGHT SHIFT, FELL ASLEEP IN MY CAR UPON PARKING IN THE LOT, AWOKE BY THE GRACE OF A FORCE BIGGER THAN ME, ONLY TO HAVE NO RECALL OF THE 30 MINUTE HIGHWAY DRIVE TO WORK. ALL AS A RESULT OF A LACK OF SLEEP, AND POOR SLEEP QUALITY DUE TO THE STRESS OF BEING A DON DURING SUCH AN UNPRECEDENTED TIME. THIS FOCUS IS SO NEEDED . THANK YOU FOR BRINGING AWARENESS TO THE TOPIC

    Reply
    • Sue Ellen Clark on

      Thank you, Alesia, for your dedicated commitment to long term care over the course of the last few years. Every one needs meaningful and restful sleep including the Director of Nursing!

      Reply
    • Sue Ellen Clark on

      Thank you for sharing. Unfortunately this is a common practice in most long term care communities across the United States.

      Reply
  4. Theresa Bocchino on

    Heightening awareness is essential. Your mission is noble. It is no secret that recruitment of CNAs is a challenge due to the working conditions that exist in these facilities. I experienced this with my Mom who I had to place in one that was originally reputable, as it was run by the county government which was well-funded. That changed when a private group took over and drastically lowered salaries, forcing the departure of many of the quality staff.
    I believe that many of us can afford to underwrite costs; but choose to direct our income elsewhere.

    Reply
    • Sue Ellen Clark on

      I am sorry to hear of the change in experience with your mom. I worked in a highly regarded county nursing home which placed a high value on the residents much to what you described. Over the years, that nursing home has been slated to be sold many times with much protest from the local community. They feared a change in staff as well as quality care among many other concerns under new ownership. To date, they remain a county run nursing home dating back more than 175 years to when it was originally a poor farm. Thank you for your reply.

      Reply
  5. Kelly Ording on

    So True!!! As a traveling regional I frequently stay in our communities overnight and have experienced some of the same things Sue Ellen describes. The difference for me is that I have an opportunity for coaching the next morning. It is remarkable the difference the next night after we have talked through my previous stay. Everyone is much more respectful of conversations in the hallway and my particular pet peeve, walkie volume on 10! If you manage memory care (or assisted living), this is not a once and done, frequent checks on the quality of life experience of our residents is essential to ensuring that our high standards are met and our residents are living the life they want and we should want for them as well.

    Reply
    • Sue Ellen Clark on

      Thank you for your reflective post, Kelly! Your coaching approach with staff is commendable. I can all to well identify with the walkie talkie volume on 10. The constant chatter over the ‘cb’ makes me feel like I am in a big rig driving down the highway versus in a resident’s home.

      Reply
  6. Leslie Fuller on

    When I traveled for work with Brookdale, I tried to stay in community guest suites when possible. I stayed in an AL for a week one time. Overall it was a good experience, but the unfamiliar noises and the thought that anyone could walk in the door at any moment were both challenging. When residents move in, we try to make the daytime engagement welcoming, but we don’t think about those 8-10 hours of their day much beyond “here’s your bed”. I like the focus of night time sleep hygiene being a focus – thank you!

    Reply
  7. Deanna Vigliotta on

    Excellent article Susan Ellen Clark and so encouraging to see in print that others too “get it” regarding the importance of restorative sleep. As a young kid, and about 40 years ago, (no typo), I worked in nursing homes for several years on the 11am-7pm shift. At that time, you were called a “nurses aide” with no certification needed. Interestingly enough, today we require the “Certification” part and yet nothing has changed in 40 years regarding “rounding” and waking people up every two hours. It sounds so silly actually even just writing that or maybe “disturbing” is a better word. I hope to meet you at The Pioneer Network conference. Looking forward to it as PN truly provides hope for a better tomorrow.

    Reply
    • Sue Ellen Clark on

      Thank you for your reply and sharing your past experiences. I am speaking in depth on this topic on Friday, July 29 at 9:15 AM in Governor’s Square 16. I hope our paths cross at the conference!

      Reply

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