Nursing home residents’ self-perceived resources for good sleep

Abstract

Objective. To explore the nursing home residents’ self-perceived resources for good sleep. Design. A qualitative research design. Episodic interviews were conducted, and analysis was done using thematic coding. Setting. Five German nursing homes from different providers. Subjects. Thirty nursing home residents who were at least 64 years old and oriented to place and person. Results. The nursing home residents’ self-perceived resources for good sleep can be classified into three general patterns: calmness, daily activity, and environmental factors. The residents see calmness as a psychological state and a prerequisite for good sleep. Rumination was reported as the main reason for disruption of calmness. Daily activity is also seen by residents to foster sleep, but most residents do not know how to be physically active. Environmental factors such as fresh air, silence, or the type of bed contribute individually to good sleep; however, nursing home residents usually lack strategies to foster these resources by themselves. Conclusion. The nursing home residents’ self-perceived resources for good sleep – calmness, daily activity, and environmental factors – can be starting points for non-pharmacological treatment of sleep disorders. The residents’ primary care physicians should explore these individual resources during consultation and attempt to foster them.

Key Words::

• Nursing homes
• physical activity
• psychological needs
• qualitative research
• resources
• sleep disorders

Sleep disorders among nursing home residents are a relevant problem for residents and primary care physicians and are difficult to treat. The residents’ perspective on the problem has not yet been researched.

• Most residents regard calmness as the most important resource for good sleep. Physicians should thus consider psychological factors when treating sleep problems.

• Other resources for good sleep include physical activity and environmental factors.

• Because nursing home residents typically lack strategies to foster these resources, physicians should empower residents to make use of their resources.

Introduction

Sleep problems are a relevant issue in nursing homes, for both residents and health care professionals [1,2]. At present, the prevalence of sleep disorders in nursing home patients remains unclear due to differing study results [1,3–6]. Nevertheless, actigraphy studies have clearly evidenced the often fragmented sleep of nursing home residents [7,8,9].

Because of the risk of polypharmacy, medication is not the best therapeutic option for nursing home residents suffering from sleep disturbances. Thus, non-drug treatments of sleep disorders are especially important in the nursing home setting. Various non-drug interventions have been tested in several studies, such as bright light during the day [10], physical activity [11], social activity [12], and combinations of these [13–15]. The effects of these interventions were mainly mild to moderate, and the interventions were usually based on the entire nursing home population and not adapted to the individual.

Thus far, however, little attention has been paid to the residents’ point of view; the interventions mentioned above were designed without taking the residents’ needs into account. Knowing the residents’ perspective, especially their self-perceived resources for good sleep, could help to tailor interventions to the residents’ needs and help the residents’ primary care physicians to deal with their patients in an individualized manner. To our knowledge, no study has yet addressed the nursing home residents’ perspective, though the perspective of women residing in assisted living was explored by Davis et al. [16].

Antonovsky [17] established the concept of salutogenesis and promoted a resource orientation in health care. Based on Antonovsky's salutogenesis and the patient-centred method, Hollnagel and Malterud [18] developed a model for resource orientation in daily clinical practice. One of the four cornerstones of this model is the self-assessed resources of patients. Exploring patients’ self-assessed resources raises physicians’ awareness of these resources and enables the patients to recognize their own resources [19]. This leads to the empowerment of patients and enables practitioners to encourage patients to make use of their own resources. Malterud and Hollnagel's study [20] researched general self-assessed health resources among women and among men [21] using qualitative methods. However, the self-perceived resources for good sleep among nursing home residents have not yet been researched. Hence, our study aims to explore nursing home residents’ self-perceived resources for good sleep.

Material and methods

We chose a qualitative research design to explore the nursing home residents’ subjective concepts of sleep and sleep disorders, which includes their self-perceived resources for good sleep.

The first author interviewed 30 nursing home residents in five different nursing homes. The residents had to be at least 64 years old and oriented to person and place. Sampling was conducted using a mixture of purposive sampling and gate-keeping. Purposive sampling means that we defined two categories, “gender” and “sleeping well/poorly”, dimensions which had been drawn from the literature. Our aim was to obtain a sample of interviewees with a broad range of age and morbidity within all four of the fields defined by the two dimensions “gender” and “sleeping well/poorly”. The access to the residents was established mainly with the help of head nurses or unit head nurses as gatekeepers. The sample consists of 20 women and 10 men. The women's year of birth ranges between 1909 and 1942; the men's year of birth ranges between 1918 and 1944.

We chose to conduct episodic interviews. The episodic interview [22] contains storytelling prompts and concrete questions. It thus stimulates narrations about the interviewees’ experiences and allows their opinions and assumptions to be assessed. During the interview, we asked abstract questions such as “What does good sleep mean to you?” as well as questions intended to stimulate narrations such as “Can you tell me a situation you experienced which elucidates this for me?”. An interview guideline was designed covering the topics “good sleep”, “bad sleep”, and “interventions for better sleep”. The interview guideline was not intended to be strictly followed but rather an orientation for the interviewer. All interviews were recorded and then transcribed verbatim. To complement the interviews, the interviewees were asked to fill out a structured sleep diary for one week, and we recorded diagnoses and medications from the nursing records. The first author conducted and transcribed all interviews. The interviews lasted between five minutes for an abruptly terminated interview and 88 minutes for the longest interview.

The analysis of the data was based on thematic coding [23]. In thematic coding, codes developed from the data are allocated to text segments. The codes are organized with the help of a thematic structure, which is a hierarchical thematic system of categories. In thematic coding, the data are always linked to the individual interviewees. Every interviewee constitutes a case and a case description is written for each case.

In our study, the case description was a summary of the interview complemented by data from the sleep diary and nursing records. To draft a thematic structure, we first chose three interviews, using their initial case descriptions to cover a broad spectrum of interviews. We coded these three interviews line by line [24] and developed a thematic structure out of the line-by-line codes of these three interviews. We then coded all interviews using this thematic structure and refined the thematic structure step by step. The initial case description of every interviewee was also refined. For this article, we analysed in detail all interview segments coded with the categories “positive influences on sleep” and “measures concerning sleep disturbances”. We assembled all codes and corresponding text segments belonging to these two categories and then looked for patterns in this assembled interview material. By organizing and reorganizing this interview data, we were able to arrange it into three main patterns of self-perceived resources.

The study was approved by the local ethics committee on 8 December 2008.

Results

Three patterns of resources

Twenty codes were directly related to resources for good sleep and 39 were indirectly related. During the process of coding and interpretation, three patterns of resources emerged. Most of the codes could be classified into the following three patterns:

• calmness, i.e. peace of mind;

• daily activity; mainly but not exclusively physical activity;

• environmental factors; a bundle of several different environmental resources.

Calmness. Most of the nursing home residents interviewed regard calmness as the most important resource for good sleep. Calmness is seen as a necessary condition for good sleep as it is a prerequisite for the body to calm down and sleep, as seen in the following quotation:

… Yes, calmness is one of the most important, for the whole body, as they say that the body can sleep later on, as they say. That one, because, that is the result of calmness. (R17:ll.173–175)

The interviewees usually do not state explicitly what calmness means to them; they suggest that it is a mental state or something inside themselves:

… That one is calm inside, as you say, and one can go on sleeping with calmness. That's my point of view. Concerning myself, that is my point of view. (R14:ll.224–225)

One resident describes calmness as a sort of relaxation:

… Well, that I can relax. You know? That nothing bothers me, that nothing is on my mind. You know? (R11:ll.63–64)

In this quote, the resident also mentions the opposite of calmness, i.e. that unsettling thoughts are the main impediment to achieving calmness. Rumination is the most frequently stated barrier to calmness, as stated in the following quotation:

… And I don't fall asleep. That is the problem. Then it's that one thinks about some things and ruminates about some things. However, I guess there is nothing to do about it. (R14:ll. 229–231)

As the last quote highlights, several residents do not have any strategies to calm down on their own. They know that calmness is important for them to sleep well, but they do not know how to achieve it. However, some residents do have strategies to calm down. The most important strategy for these nursing home residents is praying:

… And then I pray every evening. (I: Yes) That gives me calmness. And it, that is of course crucial. (R10:ll.28–30)

For many nursing home residents, praying in the evening is a ritualized and individualized action. Praying leads them to calm down and to sleep well. Reading a good book is another reported strategy to calm down. Many residents highlight the importance of avoiding disturbing books or films:

… And then, I want to add, one can calm down by reading or a conversation in the evening. One should try to have nothing exciting. (I: Yes) You know what I mean. Exciting or appealing books or reading material of this type or that type. One should instead take something calm or gentle. (R17:ll.42–47)

Apart from these actions, there is a general lack of strategies to achieve calmness, e.g. no resident mentioned relaxation techniques. Most of the nursing home residents interviewed stated a need for calmness, but most residents do not know how to achieve calmness on their own.

Daily activity. Many residents regard physical activity as having an important impact on their sleep. From the residents’ point of view, physical activity improves sleep through two main modes of action: physical activity makes one bodily tired, and it also exposes on to fresh air. One resident expressed this effect as such:

… One becomes tired because one walks a lot, is outside in the fresh air. (R07:ll.83–84)

The nursing home residents interviewed usually did not have strategies for how to foster their own physical activity. Instead, they try to achieve the results of physical activity without being physically active, e.g. by opening the window to get fresh air in their room.

Another important effect of daily activity is meaningfulness. Many nursing home residents mention the importance of the job they once had. One resident describes this feeling with regard to sleep:

… One does not have the feeling of having accomplished work and deserving sleep. (R30:ll.37–38)

However, only a few nursing home residents accomplish meaningful work in the nursing home; for instance some are members of the nursing home's advisory board. Another resident reports helping with daily routine work:

… or we sort all the daily tickets for the whole day for each room, and then the meals for lunch and dinner for each table. That is nice, then we have something to do, and one must concentrate not to do anything wrong. I like all of that here. (R27:ll.120–124)

Despite those few exceptions, the interviewed nursing home residents usually did not report accomplishing meaningful work or participating in the nursing home. This seems to be mainly due to a lack of opportunities to do so.

Environmental factors. Calmness and daily activity are primarily self-related resources for good sleep. The third pattern consists of external resources. Environmental factors cover a broad range of positive influences on sleep. They are often individual and nursing home specific, but there are also several general factors, such as silence, fresh air, and bed facilities.

Most residents interviewed do not regard themselves as having any influence on these environmental factors. Others do, however, negotiate with the nursing staff about open/closed windows or complain about noise or their bed. The preferences concerning environmental factors are individual: some residents prefer to sleep in a warm room, others in a cool room. Some prefer to have a roommate while others prefer to have their own room.

Discussion

Our results show that the nursing home residents’ self-perceived resources can be classified into three patterns: calmness, daily activity, and environmental factors. The first two patterns describe internal resources and the final pattern covers external resources. Most of the nursing home residents interviewed lack strategies to foster these resources. For example, despite the importance of calmness, nursing home residents’ strategies to calm down and find peace of mind are limited: a few pray or read a good book, and several residents try to avoid disturbing situations.

One main limitation of our study is that severely cognitively impaired nursing home residents were not able to take part in such an interview study. Thus, our results cannot be immediately generalized to severely demented nursing home residents. Additionally, the structure of our results reflects our methods. Different methodological approaches and methods such as participant observation might have revealed differently structured results, e.g. highlighting the construction of the nursing home residents’ concepts in the interaction with nurses and other actors in the nursing home environment. With qualitative interviews we were able to explore what the residents themselves perceive as resources for good sleep; there might, however, be further resources the residents are not aware of.

There are parallels to the results of Malterud and Hollnagel [20] and Hollnagel et al. [21], who explored general resources for the health of middle-aged women and men. The patients they interviewed also emphasized physical activity and meaningful activities as non-specific resources for good health. Davis et al. [16] did not explore the resources of the assisted living residents who were interviewed.

The nursing home residents’ lack of strategies to calm down stand in opposition to the vast body of professional and scientific knowledge concerning measures to calm down. Many nursing home residents seem to be psychologically stressed. From their point of view this stress leads to sleep disturbances. This perception fits with prior studies, which have proved a high prevalence of depression in nursing home residents [25], a condition which is known to be highly associated with sleep disturbances [6]. However, to our knowledge, no interventions aimed at the sleep of nursing home residents target the residents’ mental state. There is critical lack of attention in this area, and there is a need to research calmness and mental influences on the sleep of nursing home residents and older adults in general. The psychological needs of nursing home residents are often neglected; indeed, there seems to be no other group as under-treated with psychotherapy as nursing home residents [27].

The same lack of strategies can be seen concerning the categories of daily activity and environmental factors. This indicates a general lack of self-efficacy [28] of nursing home residents, at least concerning sleep-related behaviour. The residents are usually not aware of their own capabilities to improve their sleep. The nursing home residents’ perceived behavioural control [29] seems to be low.

This highlights a need for primary care physicians to empower nursing home residents who encounter sleep problems. Empowering nursing home residents to make use of their own resources might help to avoid pharmacological treatment of sleep disorders, which is ineffective [30] and often has adverse effects on nursing home residents.

These three patterns of resources indicate that primary care physicians should pay more attention to the psychological and social factors that contribute to sleep disorders among nursing home residents, as well as to a potential lack of physical activity. Physicians can use these three patterns as a basis for exploring an individual's self-perceived resources during consultation. Once an individual's specific resources are known, physicians might be able to empower the residents to foster these resources.

Conflict of interest and funding

The authors declare no conflict of interest. The first author received a stipend from the Robert Bosch Foundation. The study was associated with the research project INSOMNIA, which was financed by the German Federal Ministry of Education and Research (BMBF).