Redesigning the Hospital Environment to Improve Restfulness

Hospital wards are often not conducive to patient sleep, negatively affecting patient health and experience.

To assess determinants of in-hospital restfulness and to design and test rest-promoting interventions on the wards in partnership with clinicians, staff, and patients.

This rapid-sequential mixed-methods quality improvement study was performed at a large urban academic hospital in St Louis, Missouri, from May 1, 2021, to December 31, 2022, with follow-up through hospitalization. Mixed-methods activities involved purposively selected hospitalized adults on the wards, nurses, hospitalists, and hospital staff. Interventions included all adult hospitalizations on the study wards.

Sequential stacked bundles of multimodal rest-promoting interventions (general education, focused education on light or noise, safely reducing overnight monitoring or testing, and environmental personalization).

Pre-post comparisons of perceived nighttime quietness (via surveys) and sleep opportunity (coprimary outcomes) as well as clinical interruptions overnight, environmental noise, and adoption and satisfaction.

Nine patients (4 female) and 14 staff members (10 female; 3 nurse managers or administrators, 10 nurses, and 1 physician) were interviewed, 38 surveys were collected, and more than 100 hours of observation were performed. Interventions were evaluated for 671 patients (mean [SD] age, 60 [16] years; 336 [50%] female). Determinants of in-hospital rest included infrastructure, staff attitudes, priorities, culture, and patient experiences of anxiety, uncertainty, and loss of control. Informed by these determinants, codesign workshops yielded 39 potential interventions, from which 9 were selected for testing. Related interventions were organized into bundles, which were tested in sequential 2-week sprints. Perceived nighttime quietness improved nonsignificantly during the project (wards "always" quiet at night: 51% preintervention vs 86% postintervention; P = .09), with excessive noise events decreasing from 0.65 (95% CI, 0.53-0.77) to 0 per 100 patient-nights before the intervention (P = .02). Sleep opportunity improved significantly (mean, 4.94 [95% CI, 4.82-5.06] hours per patient-night before the intervention vs 5.10 [95% CI, 5.00-5.20] hours per patient-night after the intervention; P = .01).

In this quality improvement study, a set of feasible, acceptable, and beneficial rest-promoting interventions were developed. After implementation of these interventions on the wards, a significant improvement in nighttime quietness and sleep opportunity was observed. These results demonstrate how human-centered design methods can generate practical and effective strategies for improving an important patient-related outcome and a core element of patient experience.