Digital Repository Masters Projects Spring 2024 Nursing Education on Sleep Promotion in Neurological and Neurosurgical Intensive Care Patients Taylor D. Krahn Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Krahn, T. D. 2024. Nursing Education on Sleep Promotion in Neurological and Neurosurgical Intensive Care Patients Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Nursing Education on Sleep Promotion in Neurological and Neurosurgical Intensive Care Patients Project Title by Taylor D. Krahn Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 26, 2024 Date Taylor D. Krahn, BSN, RN, MSN Student 4/26/24 Student Name, Credentials (electronic signature) Date Chelsea Pike, DNP, RN, CNE 4/26/24 MSN Project Faculty Date (electronic signature) 4/26/24 (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Nursing Education on Sleep Promotion in Neurological and Neurosurgical Intensive Care Patients Taylor D. Krahn, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purpose/Aim: This project aims to educate intensive care nurses in the Neurosurgical Trauma Intensive Care Unit (NeST ICU) in a level II trauma center about the importance of sleep in critically ill neurological and neurosurgical patients, including techniques to promote and facilitate adequate sleep in these patient populations. Rationale/Background: Lack of sleep in the neurological/neurosurgical intensive care patient population can lead to a multitude of adverse events and outcomes, including delirium development, receiving unnecessary medical interventions, longer healing times, and increased lengths of hospital stay. Many factors contributing to the lack of sleep in this population are mitigable through nursing interventions. Methods: An educational program regarding sleep promotion techniques and rationales was prepared to be delivered to the nursing staff of the NeST ICU, which specializes in caring for critically ill neurological and neurosurgical patients. Participating nurses would complete a confidential survey prior to and immediately after receiving the education, with an additional follow-up survey completed six months later. The surveys would collect information about nurses’ knowledge and utilization of sleep promotion techniques, the effectiveness of the presentation, and barriers to implementation. The results of the surveys would be reviewed to evaluate the success of the educational implementation and guide follow-up training and policy changes. Rogers’ Diffusion of Innovation Theory will guide the implementation of this project. Results: The anticipated comparative results of the pre-and post-surveys would indicate improved confidence and understanding of sleep promotion techniques and their rationales. Anticipated results from the six-month follow-up survey would show that nurses significantly 3 increased their utilization of sleep promotion techniques in the months following the informational presentation. Conclusions: Providing education to critical care nurses on sleep promotion techniques for neurological and neurosurgical patients, along with rationales, increases nurses' understanding and application of sleep promotion techniques, facilitating improved patient outcomes. Keywords: sleep, nursing intervention, neurological, neurosurgical, critical care, intensive care 4 Nursing Education on Sleep Promotion in Neurological and Neurosurgical Intensive Care Patients Sleep is a basic human need (Gellerstedt et al., 2019). It is a vital, restorative state that aids in the body's ability to heal and regenerate (Chang et al., 2019). Critical illness notably increases the body's energy demands and sleep needs. Critically ill neurological and neurosurgical patients are chronically sleep-deprived (Grimm, 2020). Sleep deprivation in this patient population can lead to numerous complications, including unnecessary medical interventions, increased length of hospital stays, and a host of mental and physical health complications, both long and short-term (Kang et al., 2023; McLaughlin et al., 2018). Numerous epidemiologic studies have linked chronic sleep deprivation with increased morbidity (Chang et al., 2019). Elevated inflammatory markers, impaired cardiac function, and an increased risk of stroke have been found in studies on those who are chronically sleepdeprived. Psychologic and neurologic damage is also associated with sleep deprivation in ICU patients. Between 25% and 75% of individuals who survive the ICU experience neurocognitive impairments for up to a year after discharge, with some displaying symptoms up to several years post-discharge. Post-traumatic stress disorder (PTSD), anxiety, and depression are all associated with sleep impairments in ICU patients. These concerns drastically impact neurological and neurosurgical intensive care patients, as these patients are more likely to suffer from sleep disturbance as a part of routine care than other patient populations (Fowler et al., 2021). The lack of sleep these patients experience is primarily related to factors mitigable by nursing staff (Kang et al., 2023). Nurses and other healthcare providers habitually wake patients with neurological and neurosurgical diagnoses to perform care and assess the patients' neurological status (Fowler et al., 2021). Unintentional 5 sleep disturbances related to inadvertent patient exposure to visual, auditory, or tactile stimuli also contribute to a lack of restorative sleep in this patient population (Beck-Edvardsen & Hetmann, 2020). Educating Neurosurgical Trauma Intensive Care Unit (NeST ICU) nurses about the importance and techniques of sleep promotion for this patient population could improve the quantity and quality of patients’ natural sleep, thereby reducing their potential for experiencing adverse outcomes related to sleep disturbance and deprivation (Fowler et al., 2021). Statement of Problem Although it is well-known that sleep is vital to healing and recovery, patients in the intensive care unit remain concerningly sleep-deficient (Grimm, 2020). Approximately 80% of critically ill patients experience sleep disturbance during hospital admission. Nursing interventions can mitigate many causative factors for poor sleep (Kang et al., 2023). One significant factor contributing to this problem is insufficient nursing education, leading to a lack of nurse-driven interventions to facilitate restful, restorative sleep in this patient population (Haffner & Bjorklund, 2021). This MSN project aims to educate nurses on the importance of restful sleep in their patients, increasing their awareness of, confidence in, and utilization of nursing interventions to promote sleep in neurological and neurosurgical ICU patients. Significance of the Project The implementation of this project will provide informative and applicable education to nursing staff on sleep promotion techniques and rationales, as well as a direct and accessible method to report a need for further education in a follow-up survey. Patients can benefit significantly from the implementation of this project. Preparing nursing staff to be more cognizant of the sleep needs of patients and equipping the care team with tools and education to fulfill those needs can substantially improve patient outcomes. Healing and recovery times, 6 neurological outcomes, vital signs, and overall health outcomes are all positively impacted by the attainment of adequate sleep in the neurological and neurosurgical critical care patient populations (Chang et al., 2019; Kang et al., 2023; McLaughlin et al., 2018). Instilling understanding and acceptance of the positive impact of this project will be accomplished utilizing Rogers' Diffusion of Innovation method, which has repeatedly proven to promote lasting and effective change (Frei-Landau et al., 2022). This well-established framework conceptualizes the innovation diffusion process, unlike other framework models focusing only on portions of innovation diffusion or specific factors affecting the overall process (Frei-Landau et al., 2022). This MSN project aims to outline and support the innovation diffusion process to create positive change. This aim makes Rogers' Diffusion of Innovation theory highly applicable to this project. The literature supports the application of this framework and the implementation of the proposed practice changes to promote nurse education and improved sleep in these patient populations. Review of the Literature A literature review was performed to discover the existing data on the causes and effects of sleep disturbances in ICU patients with brain injuries and nursing interventions to promote sleep in this population. A variety of studies and previous literature reviews were identified in the research. Several evidence-based frameworks and models for change were also examined. Due to its applicability in educational and healthcare settings, Rogers' Diffusion of Innovation theory was ultimately selected as the framework to build this MSN project (Haverkamp et al., 2020). Framework 7 Rogers' Diffusion of Innovation (DOI) Theory will be utilized to implement this MSN project. Frameworks such as Rogers' can aid in successfully accepting and integrating new projects and protocols by promoting a seamless transition from initial conception into routine practice (Puddester et al., 2022). Rogers' theory is particularly applicable in promoting the adoption of new ideas and practices in social systems and group organizations. The theory suggests that the spread of new ideas and information through a social environment such as a healthcare system occurs through communication among team members (Eaton et al., 2019). Rogers' framework has been used for over six decades and has proven triumphant countless times in producing desired outcomes (Puddester et al., 2022). Rogers defines 'innovation' as an idea, practice, or protocol that has never before been utilized by the group in focus (Puddester et al., 2022). This theory defines the 'adoption' phase of the process in five parts: (1) knowledge, (2) persuasion, (3) decision, (4) implantation, and (5) confirmation. The individuals who have the power to accept and implement the proposed innovations, known as adopters, must first be made aware that a problem exists. (Eaton et al., 2019). Facts and education must then be provided to persuade the adopters to commit to a change. Adopters must then decide to accept the proposed innovations. After this, the innovations are implemented and reevaluated for effectiveness, leading to confirmation (Puddester et al., 2022). The five types of adopters described by Rogers are: 1. Innovators who are risk-takers and willing to be the first to try something new. 2. Early adopters, who are open to change and comfortable following through on new ideas. 8 3. Early majority adopters, who are not necessarily change leaders but are willing to adopt new concepts, although they may require some evidence of an innovation's effectiveness before committing. 4. Late majority adopters, who are somewhat reluctant to change but are willing to adopt a change after the majority has done so. 5. Laggards, who are highly conservative and reluctant to change and require persuasion to accept change (Eaton et al., 2019). Rogers' DOI stresses that the adopters' attitudes and confidence surrounding the changes are paramount to successfully adopting and implementing the proposed innovations (Puddester et al., 2022). According to Rogers, 'innovativeness' can be described as the degree to which an individual is open to adopting new ideas into practice (Haverkamp et al., 2020). Adopters' innovativeness, their perceptions of the benefits of the innovation, and the organization's attitude surrounding innovation all contribute to the success of a proposed practice change. Strengths and Limitations Rogers' DOI framework is highly pertinent to this MSN project, as the basis of the project entails introducing new practices to a group within an organization, educating members of the group on the importance and benefits of the new practices, and promoting the application of new practices. These steps align well with those in Rogers’ model (Eaton et al., 2019). There are, however, some limitations to this framework. Rogers' theory assumes general homogeneity among the population adopting the innovation on topics such as access to information and decision-making criteria, which is not the case in all situations (Mohammed, 2023). Accounting for and incorporating individuals' differences in experience and perception is paramount in promoting widespread acceptance of a novel idea. Rogers' model also implies that change is 9 accepted linearly. Linear change is rarely the case, as accepting change is often a non-linear process, with various adopters influencing one another over time. It is vital to the success of this project that the participating nurses adopt the proposed practice changes to promote the most favorable outcomes for patients. Accounting for individual differences among the staff while implementing this project and addressing everyone's concerns and questions will facilitate the successful adoption of the proposed practice changes (Mohammed, 2023). Overall, the benefits greatly outweigh the limitations of Rogers' framework in this application, and the DOI theory will be an advantageous choice for achieving the goals of this project. Analysis of the Literature The literature review aims to discover the etiologies and sequelae of sleep disruption in neurological and neurosurgical ICU patients and how nurses can reduce the negative impact of these sleep disturbances in this patient population. It also aims to identify a successful method for educating the nurses caring for these patients and instilling the importance of practice change. The following question guides this MSN project: "Does educating nurses in the Neurosurgical Trauma Intensive Care Unit about sleep promotion techniques for critically ill neurological and neurosurgical patients improve nurses' self-reported confidence in identifying and utilizing interventions to support their patients' sleep needs?" Search Strategies A literature search for information regarding the topics of interest was conducted using Weber State University's Stewart Library OneSearch database and Google Scholar. The databases connected the researcher to multiple literature resources, including Ovid, The National Library of Medicine (PubMed), Sage Journals, Springer Links, and ScienceDirect. Numerous 10 scientific studies and literature reviews were evaluated in the search for valid evidence surrounding the subjects of focus. The search was restricted to current, valid evidence, only using sources published between 2018 and the present. Keywords entered in the literature search included intensive care, critical care, ICU, neurological, neurosurgical, patients, sleep, sleep deprivation, nurse, and nursing interventions. These keywords were combined in various patterns to obtain the most relevant, comprehensive information. Synthesis of the Literature Upon review of the existing literature regarding sleep deprivation in critically ill neurological and neurosurgical patients, four significant themes developed: 1. Contributions to sleep disturbance and deprivation in intensive care patients 2. Outcomes of sleep disturbance and deprivation in intensive care patients 3. Nursing interventions to mitigate sleep disturbance and deprivation and promote adequate sleep in this population 4. The current gaps in knowledge and practice regarding these concerns Contributions to Sleep Disturbance One central theme of the research indicates that sleep disturbances in ICU patients tend to be caused by the actions of medical professionals (McLaughlin et al., 2018). Assessments, medical care, and interventions by nurses and other healthcare professionals disturb patients multiple times per night (McLaughlin et al., 2018). Other contributory factors to sleep disruption include sensory overload due to increased stimuli in the hectic and overwhelming environment of the intensive care unit and sources such as pain and anxiety that originate from within the patient (Beck-Edvardsen & Hetmann, 2020; Grimm, 2020). 11 Assessments and Interventions. Multiple sources in the literature search identified around-the-clock assessments and interventions by medical professionals as significant contributors to sleep disturbance for neurological and neurosurgical ICU patients (Bani-Younis et al., 2019; Fowler et al., 2021; Grimm, 2020; LaBuzetta et al., 2023; McLaughlin et al., 2018). Hourly neurological exams are routinely performed twenty-four hours per day on patients in the neurological intensive care unit for days or weeks at a time (McLaughlin et al., 2018). This practice impedes patient sleep and alters thought processes and mood (Fowler et al., 2021). Hourly neurological examinations may inadvertently contribute to sleep deprivation-related secondary injuries (LaBuzetta et al., 2023). In addition to neurological assessments, nursing care activities such as overnight bathing, stocking supplies in patient rooms, and obtaining vital signs contribute to patient sleep disturbance (Grimm, 2020). Sensory Overload. Bani-Younis et al. (2019) point out that exposure to excessive light and noise harms patient sleep quality in the ICU. Several studies implicated nocturnal light exposure as a patient irritant (Grimm, 2020). Circadian rhythm function and melatonin secretion are altered by constant light exposure (Koçak & Arslan, 2021). Noise from monitor alarms and activity outside of open room doors also keeps patients awake at night (Beck-Edvardsen & Hetmann, 2020). One study found that noise was cited as the subjective reason for patients being woken 17% of the time (Al Mutair et al., 2020). The World Health Organization (WHO) recommends limiting daytime noise levels to 40 decibels (dB) and nighttime noise levels to 35 dB. Studies have assessed that noise levels in the ICU tend to range from 60 to 80 dB over 24 hours. Noises above 70 dB can lead to hearing loss from exposure over a prolonged period (Hearing Health Foundation, 2023). 12 Innate Patient Concerns. Pre-existing sleep disorders are another contributor to sleep alterations in this patient population (Grimm, 2020). Pain and fear also decrease ICU patients' ability to sleep. A study concluded that pain was the causative factor for sleeplessness in nearly 50% of ICU patients (Al Mutair et al., 2020). Anxiety about the inability to sleep also negatively impacts sleep in 70.6% of these patients. Critical illness is associated with catecholamine production, another factor in poor sleep quality. The age and sex of patients can contribute to alterations in their sleep patterns, as well (Koçak & Arslan, 2021). Subjective patient studies reveal significantly more detailed information regarding intrinsic reasoning for patient sleep disturbance than nursing interviews (Al Mutair, 2019). While patients and nurses agree that sleep quality is deficient, nurses often underestimate the perceived sleep deprivation of patients (Grimm, 2020). This inconsistency indicates that nursing staff may not be fully aware of the individual sleep needs of their patients unless they make it a priority in practice to inquire about them (Al Mutair et al., 2020). Outcomes of Sleep Disturbance Various detrimental patient outcomes have been associated with inadequate sleep in critically ill neurological patients, affecting both physical and mental health outcomes (Grimm, 2020). Inadequate sleep negatively impacts every system within the body (Liew & Aung, 2021). Ailments affecting the function of the cardiovascular, respiratory, neurological, musculoskeletal, immune, endocrine, and integumentary systems are all associated with sleep deprivation through numerous scientific studies (Liew & Aung, 2021). Adverse alterations in memory, cognition, and behavior are also found in those who do not get enough sleep. Physical Health Concerns. In addition to baseline neurological and neurosurgical complications, sleep deprivation in neurological ICU patients can introduce compounded 13 physical complications. Compromised cardiac and immune system function, increased inflammation and wound healing times, musculoskeletal complications, and respiratory dysfunction are all associated with sleep deprivation in the critically ill (Al Mutair et al., 2020; Grimm, 2020; Haffner & Bjorklund, 2021). Dependence on mechanical ventilation is prolonged in ICU patients who do not get adequate sleep (Beck-Edvardsen & Hetmann, 2020). Increased cardiovascular morbidity is another severe complication attributed to chronic sleep deficiency (Haffner & Bjorklund, 2021). Cardiovascular morbidity could be related in some cases to malfunction of the suprachiasmatic nucleus (Liew & Aung, 2021). This brain structure regulates the autonomic nervous system and cardiac functions and cannot perform appropriately with inadequate sleep (Liew & Aung, 2021). A lack of sleep also affects the hormones regulating energy metabolism and satiety; glucose intolerance, insulin insensitivity, and the development of obesity and diabetes can ensue. Mental Health Concerns. Mental health concerns such as developing emotional distress, anxiety, depression, delirium, and Post-Traumatic Stress Disorder (PTSD) are all associated with sleep disturbance in ICU patients (Al Mutair et al., 2020; Grimm, 2020). Results of a cohort study following patients after ICU discharge indicated that sleep deprivation persisted for up to six months after hospital discharge, which showed adverse effects on psychological health outcomes (Al Mutair et al., 2020). Memory, attention span, agitation levels, and reaction times are also negatively impacted by inadequate sleep (Al Mutair et al., 2020; Haffner & Bjorklund, 2021). Sleep deprivation is correlated with a reduction in intracellular cyclic adenosine monophosphate (cAMP) and protein kinase A (PKA) (Liew & Aung, 2021). A lack of these chemical signaling compounds in the brain leads to altered neuronal plasticity in the hippocampus, causing impaired memory function. Other neurotransmitters such as 14 synaptophysin, synapsin, melatonin, and neuropeptides are also dysregulated by a lack of sleep. Cognitive decline and psychiatric illnesses can occur secondary to the dysregulation of these brain system communicators and receptors. Nursing Interventions Nurse-driven interventions have successfully facilitated sleep among patients in the neurological ICU. Non-pharmacologic sleep promotion techniques result in a significant improvement in subjective sleep quality in patients (standardized mean difference = 0.30, 95% confidence interval [CI] = 0.05 to 0.56) (Kang et al., 2023). Nursing interventions for sleep promotion can take various forms, including patient advocacy, care clustering, and optimizing patients' sleeping environments. Patient Advocacy. McLaughlin et al. (2018) advise nurse advocacy for patients receiving frequent neurological exams. Their research indicates that the risks of hourly neurological exams may outweigh the benefits after the first forty-eight hours of admission. Study results suggest implementing sleep protocols to optimize sleep in intensive care patients (Al Mutair et al., 2020). Individualized routines encouraging daytime activity and interaction and creating a calming, restful environment at night have also proven beneficial in promoting patient sleep (Grimm, 2020). Family involvement can maximize daytime interactivity, leading to more restful sleep at night (Kang et al., 2023). Educating patients on the importance of sleep and the techniques to maximize sleep in the ICU is another beneficial form of patient advocacy. Initiating daily sedation vacations and minimizing overall sedation dosages while ensuring maintenance of patient safety should also be performed to minimize circadian disruption in this patient population. 15 Care Clustering. Nighttime nursing activities pose a marked disturbance to patients. One study revealed that patients' sleep was interrupted 86% of the time that nursing interventions were performed during sleeping hours (Al Mutair et al., 2020). Another study found that patients in a control group were disturbed by nursing staff more than 60 times per night. Grouping or retiming routine nocturnal care and interventions such as bathing, bed changes, radiography, and blood draws reduce sleep interruptions in ICU patients (Bani-Younis et al., 2019; Grimm, 2020). Patients should be allowed to sleep without disturbance through an entire sleep cycle of REM sleep, which lasts from 90-120 minutes, as many times per night as possible (Beck-Edvardsen & Hetmann, 2020). Optimizing Stimulation. Applying noise and light-blocking devices during sleeping hours is advisable to promote sleep in neurological ICU patients. Melatonin secretion and rapid eye movement (REM) sleep are increased in critical care patients who wear eye masks and earplugs while sleeping (Bani-Younis et al., 2019). Patients subjectively reported improved sleep quality when using eye masks and ear plugs for sleep in nonrandomized intensive care unit control trials (Koçak & Arslan, 2021; Beck-Edvardsen & Hetmann, 2020). Closing the doors to patient rooms when appropriate decreases the volume of bedside alarms and telephones for patients, thereby encouraging sleep (Bani-Younis et al., 2019). A study found that minimizing auditory disturbances at night in the ICU increased patient sleep quantity by 7-18%. In addition to minimizing stimulation at night, increasing stimulation and maximizing patients’ interactivity during the day have been shown to positively impact their sleep. Grimm (2020) emphasizes that increasing daytime exposure to light can dramatically benefit patients by promoting appropriate circadian rhythm function. Knowledge and Practice Gaps 16 Education and research on patient sleep concerns are not commonly prioritized in nursing (Watach et al., 2022). The nature of the ICU environment and patient population create numerous difficulties in accurately assessing sleep (Grimm, 2020). Few studies have addressed the specific concern of sleep disturbance in ICU patients, and even fewer have specified studying sleep disturbance among particular ICU patient populations. Research Limitations. Most sources in the literature search indicated that further research is needed on sleep deprivation in the neurological critical care setting to form conclusive data. A lack of large-scale studies exists regarding sleep concerns in critically ill patients, and there is an even smaller subset focusing specifically on neurological critical patients and nursing interventions to promote sleep in this population (Kang et al., 2023). Almost all of the research sources reported limited sample sizes. A large portion of study results were based on subjective data, which is historically unreliable (Kang et al., 2023). There are also prohibitive cost barriers associated with the ability to obtain in-depth sleep data on ICU patients (Grimm, 2020). The limited methods of obtaining this critical data need further testing to prove their validity and reliability (Grimm, 2020). Nursing Education Gaps. Sleep education is not a routine focus of the nursing curriculum (Gellerstedt et al., 2019). Bachelor's level nursing programs and even graduate programs that provide training to first-line providers who often treat patients with sleep-related disorders tend to disregard the importance of sleep education for students (Gellerstedt et al., 2019; Watach et al., 2022). One study that focused on the syllabus content of nursing programs at three major universities found that the word 'sleep' was not listed in any of the schools' programs or course syllabi (Gellerstedt et al., 2019). Another study concluded that educating medical staff on patients' needs provided the resources for nurses to successfully meet their 17 patients' needs (Haffner& Bjorklund, 2021). The study showed that a one-day training program improved nurses' confidence in practice changes to provide appropriate care to a sleep-deprived patient population (Haffner& Bjorklund, 2021). Summary of Literature Review Findings and Application to the Project A review of the existing literature reveals that inadequate patient sleep is a profoundly troublesome phenomenon in critically ill neurological and neurosurgical patients. The lack of sleep in this patient population has the potential to lead to a deluge of physical and mental health ailments. The literature proposes numerous factors contributing to this grave concern, many of which can be mitigated through nursing intervention and practice changes. Nursing practices such as implementing individualized sleep hygiene routines, weighing the risks and benefits of overnight nursing assessments and vital signs, encouraging daytime wakefulness and interaction, reducing stimuli during sleeping hours and limiting nighttime sleep interruptions all have the potential to greatly benefit patients' sleep patterns. This MSN project aims to provide knowledge on these sleep promotion practices to nurses who provide direct care to the patients most severely afflicted by sleep disturbance. The information gained through the literature review will be utilized to create an evidence-based educational presentation for the nursing staff of the NeST ICU to incorporate recommended nursing actions into routine practice to maximize sleep potential in the patients under their care. The critically ill neurological and neurosurgical patient population can benefit significantly from improved sleep due to this educational intervention. The evidence reviewed indicates that the mental, emotional, and physical health outcomes of these individuals are closely linked with the attainment of adequate sleep during the crucial ICU period. ICU nurses 18 have a key position in the facilitation of this sleep. Educating these nurses will better equip them to facilitate optimal outcomes for those in their care. Project Plan and Implementation A primary component of successful change implementation includes creating a detailed plan to introduce the proposed changes to stakeholders (Wijk et al., 2021). The plan for this proposed change will include several comprehensive steps to ensure all nursing staff receive the necessary education to provide optimal care to address the sleep needs of their patients. Another crucial portion of implementing change entails the involvement of superiors and colleagues to work collaboratively as part of an interdisciplinary team in accomplishing change goals (Wijk et al., 2021). Interdisciplinary collaboration within the healthcare setting promotes favorable outcomes not only for patients but for overall systems as well (Hulen et al., 2019). Plan and Implementation Process The first step in implementing change is to create an awareness of the need for change (Eaton et al., 2019). Data and findings regarding sleep deprivation in neurological and neurosurgical intensive care patients will be presented to the NeST ICU leadership team, including members of nursing management, nursing education, and the medical director. This information will bring leadership awareness to the necessity of altering nursing practice to maximize patient benefits. Once the information has been delivered to leadership, an educational presentation will be created to present to the nursing staff. This presentation will be created with feedback and guidance from the medical director of the unit. Once finished, the proposed educational presentation will be delivered to the leadership team for approval to present to the nursing staff. Adjustments and additions to the presentation can be made as necessary at the discretion of the leadership team. 19 Before introducing the proposed practice changes to nursing staff, an anonymous survey will be individually delivered via e-mail to be completed and submitted electronically by each nursing staff member. This survey will assess the current level of nursing awareness and implementation processes of appropriate sleep promotion techniques within critically ill neurological and neurosurgical patients on the unit. Once this benchmark assessment is complete, an introduction to the proposed innovative solutions can be made to stakeholders (Eaton et al., 2019). This integral element of the change process will be completed by presenting the approved educational program to the nursing staff. The educational presentation, which will be approximately ten minutes long, will provide nursing staff with information regarding the causes and detrimental effects of sleep deprivation on the patient populations served by the unit and how nursing staff members can lessen the burden of this phenomenon on their patients. Immediately after presenting the information, an anonymous post-survey will be e-mailed to all nursing staff members. This survey will assess nursing confidence levels in implementing the proposed practice changes after viewing the presentation. A copy of the presentation will also be given to staff members so they may refer to its contents as needed. A follow-up survey will be delivered to staff members six months after the initial presentation. This survey will assess nursing staff utilization of the sleep promotion techniques included in the presentation and assess the overall effectiveness of the educational program in creating lasting improvements in the unit. Positive post-survey results will confirm and reinforce that the change implementation was successful (Eaton et al., 2019). Negative results will indicate that reassessment and alterations are needed to create the desired culture and practice changes within the unit. 20 Interdisciplinary Team Each member of an interdisciplinary team brings a unique perspective to creating a solution for an identified concern. Interdisciplinary-based approaches promote comprehensive and effective patient care (Hulen et al., 2019). When combined, a variety of viewpoints creates a strong foundation on which to construct successful change. Practical communication skills, shared vision, and mutual trust are vital elements in creating a cohesive interdisciplinary team that will, in turn, produce the desired results (Hulen et al., 2019). Members from various disciplines will have a role in creating, promoting, and embracing the practice changes surrounding sleep promotion for patients in the NeST ICU. The nursing management team members are all necessary to the success of the proposed practices. These team members include the nurse manager and the unit supervisors, the unit nursing educator, and the unit's medical director, Dr. Craven, who is a board-certified Neurologist that completed fellowship training in neurological critical care. Each team member occupies an individualized space of importance in the proposed action plan. Dr. Craven will serve as a source of relevant information regarding the specific patient concerns in focus. His neurological critical care experience and expertise have provided him with a wealth of germane knowledge regarding the sleep needs and disparities of neurological critical care patients. His predominant positions in this plan are to share his insights with the nursing staff and to promote a unit culture shift toward sleeping excellence for patients. Members of the nursing management team will serve as a sounding board for the probability of the successful execution of the plan. These team members know the likelihood of staff receptivity and the chances of viability of a new practice in the current state of the unit. They will be able to provide insight on how to tailor the information to maximize acceptance. 21 The unit educator will ensure that the information provided to staff aligns with hospital policies. The educator can also facilitate the creation of new hospital policies if needed, given the validity and importance of the presented data and the potential patient benefits that practice change could provide. The unit staff arguably plays the most crucial interdisciplinary role in change implementation. The decision of primary stakeholders to adopt an innovation is paramount to its success; rejection could ultimately lead to overall failure (Eaton et al., 2019). A practice change can only be successfully executed if those who will perform the practice are willing to participate. Just as a shared vision is required in a successful interdisciplinary team, a shared vision is necessary among members of the same discipline to bring desired change to fruition (Doten-Snitker et al., 2021). The role of nursing staff is to be open and amenable to new ideas to promote the providence of optimum quality care to those admitted to the unit. The end goal of the collaborative efforts of this interdisciplinary team has the potential to enhance patient outcomes during hospitalization and afterward. Each healthcare professional involved in the change process contributes to the well-being of patients through their unique perspectives and actions that contribute to the overall success of the proposed action plan. Description and Development of Project Deliverables Project deliverables will be utilized to implement this project. Project deliverables include pre-and post-surveys, a presentation, and a follow-up survey. The primary goal in the development of these project deliverables was to achieve accessibility, engagement, and brevity in the presentation materials. The ultimate objective of these project components is to assess the long-term success of the application. 22 Pre-Survey. Before delivering educational content, a pre-presentation survey will be conducted via a SurveyMonkey questionnaire (see Appendix A). The survey will be individually emailed to each member of the NeST nursing staff for completion. The survey will allow staff members to answer questions regarding their understanding and utilization of sleep promotion techniques before participating in the planned education. The pre-survey allows for establishing a knowledge and utilization baseline to determine post-education progress more efficiently; baseline assessments illuminate areas where potential knowledge gaps may exist (Pienaar et al., 2021). Presentation. The educational presentation will be delivered to NeST nursing staff via a brief, in-person PowerPoint presentation, which will be given during an upcoming staff meeting (see Appendix B). Brevity, accessibility, and convenience are primary considerations of the developed presentation materials. Adult learners, such as NeST nursing staff, place a high value on convenience regarding their learning (Yao, 2019). The presentation will provide an abbreviated version of the information contained within this project paper. The presentation is expected to last approximately 10 minutes and will allow for questions at the end. Post-Survey. Immediately after the delivery of the presentation, a post-survey will be sent via email to members of the NeST nursing staff (see Appendix C). This survey will provide a means of comparing the confidence and understanding of sleep promotion techniques in nursing staff before and after being provided with educational content. This survey will also allow staff members to provide feedback on the presentation's effectiveness and indicate whether they feel they require further training to solidify their understanding of the concepts discussed. End-user feedback is valuable in improving the performance and effectiveness of educational materials and presentations (Yilmaz et al., 2022). 23 Follow-up Survey. Six months after the sleep promotion presentation, a follow-up survey will be emailed to NeST staff members (see Appendix D). This survey will compare the implementation of sleep promotion techniques before and after delivery of the presentation. This data will provide an overarching picture of the effectiveness of the education provided on sleep promotion practice changes. The follow-up survey will also allow staff members to comment on how the change implementations have impacted the unit and the patients therein, highlighting the patient benefits of the practice changes. Timeline The initial implementation phase of this project is projected to take place over six months, with continued follow-up education to take place periodically for the foreseeable future. The plan is for NeST nursing staff members to implement the sleep promotion techniques discussed in the presentation immediately afterward and maintain the practices throughout their time working on the NeST. A visual representation of the proposed timeline for the implementation is included in the Appendix section of this paper (see Appendix E). The overall goal of this project is that its implementation will provide the neurological and neurosurgical patients in the NeST with benefits and improvements to their health and well-being for years to come. Project Evaluation Evaluating outcomes is essential to determine if the project goals have successfully been met. Completion of the previously discussed pre-, post-, and follow-up surveys by NeST nursing staff will allow for accurate measurement of this project's effectiveness. Similar questions will be asked among the surveys so that direct comparisons can be made between them. Comparisons between the levels of understanding and implementation of sleep promotion techniques among 24 staff members before engaging in the education session and afterward will demonstrate this project's overall success level. The results of the surveys will reveal the potential need for further staff education on sleep promotion techniques. It is important to note that there will be no punitive action for staff members' lack of understanding or implementation of the techniques. The survey evaluations were created as tools to understand progress points and barriers to success in this project's application. Ethical Considerations All staff members who participate in this project will do so voluntarily. An integral component of this project is for NeST staff members to receive educational training on the various tools and methods that can be implemented to facilitate sleep improvement in their patients. While staff members are highly encouraged to incorporate this information into their daily nursing practice, they are not necessarily required to do so. The survey results will remain confidential and kept under password protection via the SurveyMonkey platform. No personally identifiable data will be collected during the surveys. There will be no penalties based on survey results. The results will be used solely for comparison purposes to guide future education and unit policy changes. The nature of this project presents a minimal risk of creating an ethical dilemma. There is no risk of harm to the intended population of NeST staff members. This project does not involve direct patient involvement, so patients’ risk is not addressed herein. Any ethical concerns that may arise due to these practice changes can be discussed among NeST nursing staff, nursing leadership, and physicians to reach a resolution. Staff are encouraged to share their thoughts, ideas, or concerns regarding the project at any time, assured that they will be heard. Discussion 25 The expected results of implementing this MSN project have the potential to positively impact the recovery and lives of countless hospitalized neurological and neurosurgical patients recovering in the Neurosurgical Trauma intensive care unit. Promoting and supporting adequate sleep in this patient population can help reduce the negative impacts associated with sleep deprivation, including adverse physical health outcomes, mental health concerns, unnecessary medical interventions, and prolonged hospital stays. Utilizing nurse-driven interventions, the NeST nursing staff can be empowered to facilitate better sleep-related outcomes for those in their care without relying on medical intervention. Evidence-based Solutions for Dissemination To provide the most significant benefit to patients, it is crucial to expedite the process of sharing research findings with stakeholders and involved parties. Rapid translation from research into practice optimizes results (McNeal et al., 2021). In addition to the initial in-person presentation of the information, this project's significant findings will be disseminated to stakeholders through infographics placed throughout the unit. Then, to facilitate sustainability and remind NeST staff members about the importance of the presented information, these deliverable items will be posted on the unit quickly after the initial presentation. Significance to Advance Nursing Practice Understanding the information this MSN project shares can empower nursing staff to maximize their potential for beneficence and non-maleficence through sleep promotion practices. Beneficence and non-maleficence are two of the foundational pillars of nursing practice (Cheraghi et al., 2023). Nurses equipped with the knowledge provided by this project can be capacitated to work within their scope of practice to facilitate favorable patient outcomes while minimizing the need for medical provider intervention to achieve desirable results. Nurse 26 autonomy promotes favorable patient outcomes in the intensive care setting (Zampieri et al., 2019). Nursing possession of these strengths and abilities will fortify the culture of critical thinking and best practices among the nursing staff in the NeST ICU. Implications Barriers to the success of this project include a lack of willingness by the patients or members of the nursing staff to participate in the proposed practice changes. Carrying out this project will require effort and an openness to change. Ideally, providing education on the immense value of these practice changes will create a culture of openness within the NeST unit that can contribute to the project's success. Strengths of this project application include the intuitiveness of the suggested implementations and the strong evidence supporting the recommended nursing interventions. There is significant evidence across the literature to support the specific sleep-supporting nursing practices that are outlined in this project. Interventions such as reducing stimuli, clustering cares, and controlling pain have repeatedly shown to improve patients’ sleep. These suggested interventions are low-cost or no-cost, and are not difficult to incorporate into daily nursing practice. Recommendations Continuous reassessment and reevaluation are paramount to the long-term success of this project. Patients’ needs and best nursing practices are constantly evolving. The most effective way to stay abreast of the latest information is to continuously gather new data to adjust practices to fit current standards. It is recommended to carry out periodic follow-up research, reassessment, and re-education for staff on the topics discussed in this MSN project to propagate the data most accurately and effectively. Differing patient populations within various hospital 27 settings could also benefit from the information gathered in this project. Future dissemination of the data to nursing staff members in these other settings could expand the benefits it provides. Conclusions Most of the factors that contribute to poor sleep for patients in the ICU setting can be mitigated by the actions of nursing staff. The simple actions performed by nursing staff to promote sleep in these patient populations can reduce the time the patients must stay in the hospital, improve their immune function, reduce their long-term physical and mental health sequelae, and provide countless other benefits. Nurses are influential healthcare team members with significant sway over their patients' outcomes. This project aims to improve overall outcomes for neurological and neurosurgical ICU patients through sleep promotion practices and demonstrate that implementing nursing interventions can help achieve those outcomes. 28 References Al Mutair, A., Shamsan, A., Salih, S., & Al-Omari, A. (2020). 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Intensive Care Medicine, 45(11), 1599. https://link.gale.com/apps/doc/A724266028/ITOF?u=ogde72764&sid=summon&xid=e1c a48dd 33 Appendix A Pre-Survey 34 35 Appendix B PowerPoint Presentation 36 37 38 39 40 41 Appendix C Post-Survey 42 43 Appendix D Follow-Up Survey 44 45 Appendix E Timeline Pre-Survey Administration (Day 1) Powerpoint Presentation (Day 1) Post-Survey Administration (Day 1) Follow-Up Survey Administration (Day 180) Periodic reassessment and re-education (Ongoing)