Nurses’ Views of Factors Affecting Sleep for

Hospitalized Children and Their Families:

A Focus Group Study
Robyn Stremler, Sherri Adams, Karen Dryden-Palmer

Correspondence to: Robyn Stremler
E-mail: robyn.stremler@utoronto.ca
Robyn Stremler
Associate Professor
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Room 288, 155 College Street
Toronto, Ontario, Canada M5T 1P8
Adjunct Scientist
The Hospital for Sick Children
Toronto, Canada
Sherri Adams
Nurse Practitioner
Paediatric Medicine Complex Care Program
The Hospital for Sick Children
Toronto, Canada
Karen Dryden-Palmer
Clinical Nurse Specialist
Bereavement Coordinator, Critical Care
The Hospital for Sick Children
Toronto, Canada
Abstract: Light, noise, and interruptions from hospital staff lead to frequent awak-
enings and detrimental changes to sleep quantity and quality for children who are
hospitalized and their parents who stay with them overnight. An understanding of
nurses’ views on how care affects sleep for the hospitalized child and parent is
crucial to the development of strategies to decrease sleep disturbance in hospital.
The purpose of this descriptive qualitative study was to gain an understanding of
nurses’ views on their role in and influence on sleep for families; perceived barriers
and facilitators of patient and parent sleep at night; strategies nurses use to pre-
serve sleep; the distribution, between parent and nurse, of care for the child at
night; views of the parent as a recipient of nursing care at night; and the nature of
interactions between nurses and families at night. Thirty registered nurses from
general pediatric and critical care units participated in one of four semi-structured
focus groups. Four main influences on sleep were identified: child factors; environ-
mental factors; nurse–parent interaction factors; and nursing care factors. Some of
these restricted nurses’ ability to optimize sleep, but many factors were amenable
to intervention. Balancing strategies to preserve sleep with the provision of nursing
assessment and intervention was challenging and complicated by the difficult
nature of work outside of usual waking hours. Nurses highlighted the need for
formal policy and mentoring related to provision of nursing care at night in pediatric
settings. ß 2015 Wiley Periodicals, Inc.
Keywords: sleep; pediatric nursing; parent; child; hospitalization; shift work;
qualitative
Research in Nursing & Health, 2015, 38, 311–322
Accepted 14 April 2015
DOI: 10.1002/nur.21664
Published online 13 May 2015 in Wiley Online Library (wileyonlinelibrary.com).

During hospitalization, sleep is altered at a time when the
restorative benefits of sleep are needed most. Children
who are hospitalized and their parents who stay overnight
with them are attempting to sleep in a new environment
primarily focused on patient care rather than sleep. This
environment, which varies according to the acuity of the
child’s condition, is characterized by high levels of light and
noise and interruptions from hospital staff, leading to fre-
quent awakenings and detrimental changes to sleep quan-
tity and quality, for the hospitalized child (Al-Samsam &
Cullen, 2005; Corser, 1996; Cureton-Lane & Fontaine,
1997; Linder & Christian, 2012; Meltzer, Davis, & Mindell,
2012; Stremler et al., 2009) and for the parent (Franck
et al., 2014; S. Y. Lee, K. A. Lee, Rankin, Weiss, & Alkon,
2007; Meltzer et al., 2012; Stremler, Dhukai, Wong, & Par-
shuram, 2011; Stremler et al., 2014).
Sleep of inadequate quantity and quality has significant
negative effects on adults’ and children’s behavior, cognition,
and emotional and physical health, including difficulties in modu-
lating emotions, decreases in cognitive function, and difficulties
with decision-making (Bonnet, 2005; Dinges et al., 1997; Harri-
son & Horne, 1999; Stepanski, 2002). For parents who are
already challenged by their children’s health conditions, sleep is
especially important for their ability to cope with the illness
event, support their children and other family members, partici-
pate in decision-making, and maintain relationships.
In spite of knowledge that hospitalization interferes
with sleep for children and the parents who stay with them,

C 2015 Wiley Periodicals, Inc.
312 RESEARCH IN NURSING & HEALTH
and that such sleep restriction has negative health conse-
quences, only two small feasibility studies of activity and
relaxation interventions aimed at improving sleep for hospi-
talized children were found (Hinds et al., 2007;
Papaconstantinou, Hodnett, & Stremler, 2014), and none
were aimed at increasing sleep for parents who stay over-
night with their children. An understanding of the individual,
family, and health care system influences on sleep in hos-
pital from informants with varied perspectives is needed to
refine such interventions.
Evidence to Date on Sleep in Pediatric Acute
Care
In our prospective study of 69 children hospitalized on gen-
eral pediatric and critical care units, using objective meas-
ures of sleep, children slept 3–5 hours per night less than
recommended for their age, awoke 12–18 times per night,
and were exposed to light and sound levels well beyond
recommended levels (Stremler et al., 2009). The greatest
reductions in sleep time were experienced in the critical
care unit, and there were more minutes of excessive levels
of light and sound on the general pediatric units. Both
parents and children described noise, light, uncomfortable
sleep surfaces, anxiety, and interruptions for assessment
of the child as interfering with their sleep while in hospital
(Stremler et al., 2009, 2011). This team also studied 118
parents of children in critical care units, again using objec-
tive measurement of sleep, and found that in over a quarter
of nights, parents met criteria for acute sleep deprivation
(Stremler et al., 2014). These parents described a struggle
with deciding whether to stay overnight with their children
or to leave to sleep at home or in another location. There
was considerable variability in the amount of sleep that
individual parents achieved on different nights, and sleep
was fragmented, with a large portion of the night spent
awake.
In a third study, hospital administrators described
practices and provisions related to sleep in pediatric hospi-
tals in North America. The administrators described limits
to parents’ ability to stay overnight with their child based on
child or unit acuity, and many expected involvement of the
parent in the child’s care at night if they did stay (Stremler,
Wong, & Parshuram, 2008).
Role of Parents on Pediatric Units at Night
Designations of the recipients of care and distribution of
care between nurse and parent at night and influences on
sleep also have not been explicitly explored. Family-cen-
tered care typically denotes health care for children that
holds essential the involvement of the family. Parents may
be conceived of as co-clients or recipients of care who
need support in order to continue to be with their ill children
(American Academy of Pediatrics [AAP], Committee on
Research in Nursing & Health
Hospital Care, Institute for Patient- and Family-Centered
Care [IPFCC], 2012; Callery, 1997; Franck & Callery,
2004; Johnson, 2000). Whether parents are considered co-
clients or not, preservation of the parental role by encour-
aging their contributions to their children’s care may inter-
fere with the parents’ sleep. The extent to which overnight
care (e.g., feeding, hygiene needs) is clustered, expected,
or negotiated with families is unknown (McCann, 2008),
and the nature of personal interactions between nurses
and families in hospital during the night has not been
examined. Because decision-making capacity and the abil-
ity to monitor and modulate emotions are impaired at night
and when sleep-deprived (Dinges et al., 1997; Harrison &
Horne, 1998; Harrison & Horne, 1999), the likelihood of
interpersonal conflict may be greater at night. Families and
nurses may have divergent goals for care at night; families
may value uninterrupted periods for sleep over consistent,
regular timing of treatments or assessments (Moore & Kor-
dick, 2006). Nurses may also perceive conflicting health
care goals for the families with whom they work.
No reports were found of nurses’ views on how care
at night might affect sleep for children who are hospitalized
and their parents who stay with them overnight. Develop-
ment of effective sleep-promoting interventions in pediatric
hospitals requires an understanding of barriers and facilita-
tors of sleep, particularly from nurses’ viewpoints, given
their likely involvement in the delivery of such sleep-pro-
moting interventions and their unique insight into possible
system and environmental effects on delivery of care while
promoting sleep for families in hospital. The purpose of the
current study was to explore nurses’ perceptions of factors
affecting sleep for the hospitalized child and parents includ-
ing: nurses’ role in and influence on sleep for families; bar-
riers and facilitators of patient and parent sleep at night;
strategies used to preserve sleep; the distribution, between
parent and nurse, of care for the child at night; the parent
as a recipient of nursing care at night; and the nature of
interactions between nurses and families at night.
Methods
Design
An exploratory, cross-sectional study design utilizing in-
depth, semi-structured focus groups and qualitative
description was used (Sandelowski, 2000). Focus groups
were used to obtain qualitative data about the experiences
and opinions of nurses on factors affecting sleep for fami-
lies with a hospitalized child. Discussing the area of interest
in a permissive and nonthreatening environment allowed
the group to interact, share multiple perspectives, and stim-
ulate critical analysis of the topic at hand, providing insight
and rich data that do not usually surface with other data
collection techniques (Krueger & Casey, 2000; Morgan,
1997).
 NURSES’ VIEWS OF FACTORS AFFECTING SLEEP IN HOSPITAL/ STREMLER ET AL. 313

Sample Table 1. Characteristics of Registered Nurses in Focus

Groups (n ¼ 30)
A purposive sampling strategy was used to recruit eligible
staff nurses from a tertiary–quaternary pediatric academic Median Range
health sciences center. Posters were placed on the units to
Age (years) 28.0 23–53
advertise the study, the study was discussed at staff meet- Years of total nursing experience 4.5 0.5–32
ings, and group emails were sent to nurses explaining the Years of pediatric nursing experience 4.0 0.5–30
study. Both the critical care and the general pediatric unit Typical number of night shifts per month 7.0 3–10
were selected for recruitment to provide a sample of nurses
n (%)
familiar with working with families of children with varying
acuity of acute illness or trauma, exacerbations of chronic Type of unit
illnesses, and surgery. General pediatrics 11 36.7
The critical care unit had 21 beds and provided care Critical care 19 63.3
for children (birth to 18 years) with complex pathophysiol- Education achieved
ogy such as congenital diaphragmatic hernia, bone marrow Diploma 4 13.3
Undergraduate degree 20 66.7
and multi-organ transplantation, infectious diseases, trau-
Graduate degree 6 20.0
matic injuries, and extracorporeal support technologies.
Participant is a parent?
The general pediatric units had 53 beds, divided into four Yes 5 16.7
units on one floor, providing care to children from birth to No 24 80.0
age 18, including those with common pediatric conditions Missing 1 3.3
(e.g., asthma, bronchiolitis, pneumonia, sickle cell disease,
urinary tract infections), as well as those with complex mul-
tisystem conditions (e.g., children with genetic, develop-
participants. Participants were informed that the research-
mental, and neurological conditions), and children
ers would take every precaution to maintain confidentiality
undergoing investigations to establish diagnosis.
of data, but were reminded that because participants in
Nursing staff were all registered nurses; no nursing
focus groups would provide data in the presence of others,
assistants were employed. One hundred fifty-five nurses
confidentiality could not be guaranteed. All participants
were employed in the critical care unit, while 180 nurses
were asked to refrain from discussing the focus groups
were employed on the general pediatric units; nurses did
with those not in attendance.
not rotate across units. Eligible participants had been regis-
Four focus groups, two with critical care staff and two
tered nurses for at least 6 months and worked at least .5
with general pediatric unit staff, each lasting 1 hour, were
full-time equivalent that included regular night shifts.
conducted. The groups consisted of staff from the same
Nurses set their own schedules on both units, such that
unit as it was felt that their shared experience would best
full-time nurses completed 20 12-hour shifts in a 6-week
facilitate building upon and being stimulated by each
period. At least half of shifts are required to be daytime
other’s thoughts and ideas. Two groups were held over the
shifts, and up to half can be night shifts, with an expecta-
lunch hour, and two were held just before start of a night
tion of at least 7 night shifts of 20 shifts required for full-
shift, in order to improve accessibility. All sessions were
time employees.
held in hospital conference rooms away from the activity of
the patient care rooms and were held over a 4-day period.
Characteristics of Participants Upon arrival, participants were assigned a study
identification number and filled in a brief demographic
The sample consisted of 30 female registered nurses work-
questionnaire. Participants received refreshments and $50
ing on either the general pediatric (n ¼ 11) or pediatric criti-
in recognition of their time. The focus groups were guided
cal care unit (n ¼ 19; see Table 1). All participants were
by a master’s-prepared moderator experienced in conduct-
permanent staff members and did not rotate between units.
ing qualitative focus groups with health care professionals.
Their years of nursing experience ranged from 6 months to
Two of the three investigators attended each session. One
32 years (median 4.5 years), and most participants held a
investigator took notes at all sessions, and the other
baccalaureate degree (n ¼ 20, 67%). Given that the nurses
recorded nonverbal communication.
worked 3–10 night shifts per month (median 7), they were
A semi-structured, open-ended interview guide
able to provide their views on sleep for families in hospital
(Table 2) was used. The interview guide was developed
at night.
based on the existing literature related to children’s and
parents’ sleep in hospital and the clinical and research
experiences of the investigators. The guide also was
Data Collection
shared with several nurses from units not directly involved
Approval was obtained from the hospital research ethics in the study to ensure the questions were clear and rele-
board. Written informed consent was obtained from all vant to provision of nursing care at night. For example,

Research in Nursing & Health

314 RESEARCH IN NURSING & HEALTH

Table 2. Semi-Structured Focus Group Interview Guide

We are trying to get a sense of your experiences in providing care to children and families in hospital during the night shift. Nurses are the
health care professionals who spend the most time and provide the most care to children and families during the night and yet no one has
ever asked nurses to describe what it is like caring for children and families at night, how they think it influences sleep for children and
families, and their ideas about what is challenging and helpful with respect to children’s and families’ sleep at night. We are interested in your
unique experiences and hope that we will have an open discussion of your ideas. We will ask you a number of different questions to get
discussion going.

Questions Probes

1. Can you describe how children and families sleep at
night in hospital?
2. What affects the quantity and quality of sleep for children
and families in hospital?
3. Can you tell me about a situation that promoted or
hindered sleep at night for a child or family?
4. In your role as a nurse, how do you affect sleep for
children and families at night?
5. What things affect the influence you have on children’s
and families’ sleep in hospital at night?
6. What strategies do you use or what advice do you give to
children and families about sleep at night?
7. What are your expectations of the parent’s role in the
care of his or her child in hospital at night?
8. Describe your interactions with parents and children at
night.
9. Is there anything else related to sleep in hospital that you
would like to discuss?
More or less than usual, distribution across day vs. night, quality.
Provision of care by nurse or parent, environment, resources/provisions for
sleep, illness process, constraints on delivery of care, acuity of child.
How do you view sleep for children and families as part of your role? Why are
you concerned or not about sleep? How do you promote or hinder sleep?
How do you structure your delivery of care at night? How is this different than
in the day?
Are there things you wish you could do but can’t? What control do you have
over how medical orders are carried out? Tell me about the availability of
places to sleep, linen/personal care supplies. Does the acuity of child or the
unit environment make a difference?
How do you structure care at night? What recommendations do you give re:
where to sleep?
What care do you provide and what care does the parent provide? How does
this change based on the child? Based on your workload?
How are your interactions different at night compared to the day? Can you give
some examples of collaboration, examples of conflict?

participants were asked to describe situations in which
sleep for a child or parent was facilitated or compromised
at night. Participants were not given a definition of sleep,
nor were they directed to consider sleep of certain length
or depth when providing comments to the group.
Facilitators established focus group ground rules,
including confidentiality and considerate interactions, reas-
suring participants that consensus was not the goal,
encouraging participation of all members, and recording of
nonverbal interactions (Krueger & Casey, 2000). None of
the participants reported directly to any of the investigators,
so the investigators’ presence at the focus groups was not
expected to impede honesty of response. At the end of the
focus group, a brief summary was presented to the group
to verify what had been heard. Redundancy of responses
was noted across the groups.
Data Analysis
Analysis began after all groups were completed. Group
sessions were audiotaped, transcribed verbatim, and de-
identified. Qualitative analysis of the responses was con-
ducted using content analysis, consistent with qualitative
description, to comprehensively describe and summarize
phenomena in everyday terms (Sandelowski, 2000).
Analysis was facilitated by qualitative data analysis soft-
ware (N-Vivo 8, Burlington, MA). Transcripts were indepen-
dently coded by one of the co-investigators and a research
assistant with experience in qualitative data analysis. Reli-
ability was further ensured by third-party review. The
research team read and re-read all responses to become
immersed in and familiar with the data and to provide multi-
ple perspectives on the data (Berg, 1995). Notes were
made to organize initial thoughts and understandings of
nurses’ experiences and also to identify personal assump-
tions to better maintain neutrality and limit use of precon-
ceived categories.
Initial codes were created using direct quotes or stan-
dard terms to provide a description of the phenomenon
highlighted by the participants’ responses. These codes
were generated inductively, based on key issues, concepts
and recurrent ideas revealed from the data, with notations
made regarding the frequency, extensiveness, emotion,
and specificity of responses (Sandelowski, 2000). Using an
iterative process, the researchers met to review and con-
solidate codes where repetition and overlap existed and
developed consensus where differing codes were used and
as new insights to the data developed (Miles & Huberman,
1994). The raw data were revisited throughout the analysis
process so that the original context and meaning of the
interviews was not lost. After completion of coding, the

Research in Nursing & Health

 NURSES’ VIEWS OF FACTORS AFFECTING SLEEP IN HOSPITAL/ STREMLER ET AL. 315

codes were organized into broader subthemes and themes
to give an over-arching description and coherence to the
data. Finally, another reviewer evaluated the results to
ensure that the selected quotes accurately captured the
meaning in the data. Descriptive statistics were used to
characterize the sample.
Results
Nurses identified four major types of influence on sleep for
hospitalized children and their parents: (a) child factors; (b)
environmental factors; (c) nurse–parent interaction factors;
and (d) nursing care factors. Within these, recommenda-
tions for future practice and policy also emerged from the
participants’ comments (see Table 3). There were no nota-
ble differences between the types and frequency of codes
generated from participants from general pediatric versus
critical care units. Sample quotes are reported with the par-
ticipant’s study number in brackets; numbers beginning
with 1 are general pediatric nurse responses and those
beginning with 2 are critical care nurse responses.
Child Factors
Nurses described the acuity of the child’s illness and care
needs, the child’s developmental stage, and previous or
expected experience in hospital as affecting sleep for the
family.
Acuity level. Worsening condition of the child and
the need for frequent assessment and intervention was
viewed as getting in the way of sleep, while conversely,
improvements in the child’s status were seen as beneficial
to the child and parent achieving sleep.
Cognitive level. Adolescent and school-age
hospitalized children were perceived as better able than
younger children to achieve sleep and return to sleep once
woken given their greater understanding of the need for
hospitalization, assessments at night, and separation from
the comforts of home. Sleep for infants, toddlers, and pre-
school-age children was viewed as more prone to disrup-
tion due to less comprehension of their situation, along with
greater fear of health care professionals, and the possibility
of painful procedures. However, participants also sug-
gested that nurses could take on more care of infants and
toddlers at night (e.g., diaper changes, nighttime feedings)
to give parents more opportunity to sleep.
Previous or expected experience in hospi-
tal. Participants also expressed that if children had previ-
ous experience in hospital, or were admitted for a planned
respite or procedure, this was less likely to interrupt sleep
for parents and children because they knew what to expect
of sleep in hospital and could make plans for their stay.
Environmental Factors
Several aspects of the hospital environment were viewed
as detrimental to sleep for families. These included

Table 3. Influences on Sleep and Nurses’ Recommendations to Improve Sleep

Influence Subcategory Recommendations

1. Child factors Acuity level No recommendations given; these factors are nonmodifiable.
Cognitive level
Previous or expected
experience in hospital
2. Environmental Noise level Decrease use and volume of call bells, paging, equipment alarms.
factors
Plan care to anticipate and reduce noise.
Light exposure Increase use of lights on dimmers, flashlights, soft lighting from equipment to
decrease use of overhead lighting.
Continuous and formal efforts to make staff aware of their contribution to noise and
light levels.
Interruptions Cluster assessments and interventions to minimize interruptions.
Parents’ sleep space Provide enough sleep spaces for all parents who wish to stay overnight.
3. Nurse–parent Level of trust No related recommendations given.
interaction factors Communication Communicate with parents re: child’s status and care plan.
Expectations of the parents’ No related recommendations given.
role
Negotiation of child’s care Discuss distribution of child’s care between parent and nurse at beginning of shift.
4. Nursing care Prioritizing sleep for the Convey to the family the value of sleep to child and parent health.
factors child and parent
Nighttime monitoring Use clinical judgment to determine frequency of nighttime monitoring.
Delivery of care Advocate for, and plan, timing of assessments and interventions to preserve sleep.
Mentor new nurses in strategies to preserve sleep.
Develop evidence-based guidelines around provision of nursing care at night
related to preserving sleep for the child and parent.

Research in Nursing & Health

316 RESEARCH IN NURSING & HEALTH
excessive noise and light, interruptions from staff, parents
and other visitors, and lack of space and provisions for
sleep. Participants described their use of strategies to
reduce light and noise and had many recommendations for
improvements to the physical environment.
Noise level. Noise from equipment (e.g., IV
pumps, overhead paging systems), proximity to public
areas where noise levels were higher (e.g., nursing station,
high traffic corridors, public washrooms), and sound from
other patients or visitors was noted to prevent children and
families from achieving adequate sleep. Participants
described their use of strategies to reduce noise, including
anticipating or responding quickly to beeping of infusion
pumps, moving carefully through rooms, and with equip-
ment. They had many recommendations for changes to the
physical environment (e.g., quieter call bell/pager system,
more control over monitor alarms and volume) that could
reduce noise.
The participants also noted that hospital staff contrib-
uted to noise at night which increased sleep disruption for
families:
We’ve all been in the middle of a night shift
and we’re laughing at the desk and realize
the kid over here is asleep. So we’ve all
done that too, where you’ve had to be quiet,
or ask someone to keep it down. We’re kind
of mixed up too, right, this is our daytime
because we’re here in the middle of the
night. (2-09)
Light exposure. Participants described tension
between having adequate lighting for assessment and mini-
mizing disruption to the family:
Sometimes we really try to avoid that light
coming into the room, and we’re doing it at a
cost to how well we can see and how well
we assess the kid. For me, I just did it yes-
terday, I said “yes, we have the lights off
now, but if need be, I’m going to turn on the
light, and I might need to do it every hour.”
And I just set up rules, not rules, but just
adjusting to how I might do things. I carry
around a flashlight with me, but there’s only
so much you can do with that, and just to
facilitate sleep we sometimes are blind in
there. And I’ve gotten very good at looking at
things without any light. Even if it’s pitch
black, you can see things. Or trying different
things with your IV monitor. (1-04)
Participants outlined the ways they reduced patients’
exposure to light at night (e.g., use of flashlights, avoidance
of overhead lighting) and suggested changes to the
Research in Nursing & Health
equipment used and available in the hospital (e.g., lights
with dimmers) that could decrease light exposure. Nurses
called for more continuous efforts and formal programs to
make staff aware of their contribution to excess noise and
light in the environment.
Interruptions. Participants recognized that inter-
ruptions for care by hospital staff were a significant source
of disruption to sleep for the child and family. Parents or
other family members and visitors sometimes were viewed
as wanting to engage with the child at the expense of the
child’s sleep time:
And then when they’re awake (the parents),
or visitors come, they want to come in and
see the child and wake up the child, they
want to talk to the child. In the morning they’ll
come in and start talking to the child, mean-
while we’ve been working with an agitated
child. . . You just get them comfortable sleep-
ing, maybe with a little bit of sedation or
whatever, and then their sleep gets broken
more often [laughs]. (2-02)
Parents’ sleep space. Nurses’ views varied on
the relative benefits of the sleep locations available to fami-
lies. On the general wards, one twin-sized cot was typically
available in the patient’s room, but usually no sleep surface
was available for parents in the critical care unit. Other pos-
sible sleep spaces included a few designated parent rooms
in the hospital (assigned based on a number of factors,
such as distance of the family from their home, acuity of
the child, need for breastfeeding, etc.), waiting room
couches, space at an off-site Ronald McDonald house, a
local hotel, or home. Some nurses were certain that sleep
in a location designed for sleep was more restorative, lead-
ing to more refreshed parents who could better cope with
their children’s illnesses. In contrast, other participants rec-
ognized that if a child was not doing well, a parent might
choose to sacrifice sleep to stay nearby, or that sleep at
home might not be restful due to worry about the child or
care demands for other children at home.
All nurses agreed that sleeping on waiting room
couches, chairs at the bedside, or cars in the hospital park-
ing lot was not ideal. Many viewed the lack of availability of
spaces in which to sleep, and few provisions (e.g., pillows,
blankets) given to facilitate sleep, as hindering sleep for
parents:
So sometimes you find two parents squished
together on the cot, or one parent sleeps on
the floor, or one parent sleeps on two chairs.
. . . But parents want to be there for their
kids, and both parents want to be there, and
they support each other and that’s
important. . .I see parents sleeping in cars, in
 NURSES’ VIEWS OF FACTORS AFFECTING SLEEP IN HOSPITAL/ STREMLER ET AL.
the cars in the parking lot at night. So space
is a major limitation. (1-09)
Several nurses noted that parents attempted to nor-
malize the physical environment by incorporating comfort
items from home and approximating the family’s usual bed-
time routine as much as possible.
Nurse–Parent Interaction Factors
Aspects of interactions between parents and the child’s
nurse including trust, communication, role expectations,
and negotiation of care were viewed as having an influence
on families’ sleep during a child’s hospitalization.
Level of trust. Parents’ comfort in surrendering to
sleep was viewed as related to their level of confidence in
a particular nurse’s care, as shaped by past interactions.
As one nurse related:
Definitely if there’s an instance where they
don’t get along with a staff member, or have
had a past bad experience with our staff
members, they’ll definitely linger closer to
the bed or not sleep at all during the night.
Relationships affect it [sleep] as well. (2-08)
Communication. Many nurses spoke of the
importance of communicating with the parents and child to
facilitate care, and thus sleep, at night. Communication
related to the child’s status and expected assessments and
interventions was viewed as a way of promoting sleep,
while missing out on this opportunity to connect with
parents was thought to interfere with sleep:
Everything seriously goes back to communi-
cation. If you meet with the parents, and tell
them what you’re doing, and why you’re
doing it, and why it’s important, and why it’s
good for their kid, and why it’s good for
everybody and that kind of stuff, then I find
that it’s a lot more cooperative. (1-01)
However, there also was recognition that communi-
cation at night was different than that during the day.
Nurses noted that working the night shift disrupted their
Muito importante sleep-wake rhythms, as it did for the hospitalized child and
parents, and yet nurses were expected to function as they
did during the day shift. The challenge of working as a
nurse outside of usual wake time was thought to affect
interactions with parents:
You have to remember, we’re also up all
night. So we don’t get in the best conversa-
tions at 4:00 in the morning with parents.
You’re not at your finest professionalism at
Research in Nursing & Health
317
4:00 in the morning [laughs]. Parents are all
upset. (1-02)
In contrast, nighttime interactions with families were
also described as happening more readily, given less activ-
ity and fewer staff on the units, and had greater openness
and depth:
Some of the most powerful therapeutic con-
versations I’ve ever had, I’ve had them on
the night shift. . . It’s a quiet moment when
you’re by the bedside, and the mom is there-
. . .and it turns to “do you think my baby’s
going to die?” That’s a pretty powerful ques-
tion for whatever time it is in the morning.
Because that’s when your fears come up,
and your vulnerabilities come up. And that is
when your true bedside manner can come
through. I just listened to this poor mom talk
about her fears. And it was really powerful,
and she turned to me and said “I feel like I
can go to sleep now, I’m going to say a
prayer for my baby.” And that was an amaz-
ing experience. So nights isn’t always a hor-
rible thing, sometimes it does give us a
window, because that mom may have been
able to be a bit stronger for their child. (2-13)
Expectations of the parents’ role. Parents’
presence and expected role in their children’s care at night
were viewed as both impeding and facilitating sleep for the
family. One nurse related:
When parents don’t stay, we have more time
to focus on the child as opposed to answer-
ing questions that the parents have of what
you’re doing. A lot of parents are anxious,
and they ask questions; “why are you doing
blood sugar, why are you doing blood pres-
sure?” instead of doing your essential care.
You’re calming their anxiety, but. . .I know
that it’s good to have them involved in the
care but it gives you more time to focus on
the child. (1-11)
Other nurses reported that parental presence in the
hospital at night improved the nurse’s ability to promote
sleep for the hospitalized child:
I love when the parents are there, it’s so
much more easier for me because I feel like
they have the answers to a lot of questions
that I would have to find out. I can just ask
them, and they would know; when do they
fall asleep, how do they like to sleep, what is
318 RESEARCH IN NURSING & HEALTH
their favourite toy to sleep with, things like
that. (1-08)
Negotiation of child’s care. Negotiating the dis-
tribution of care between nurse and parent was viewed as
essential to facilitating sleep for parents:
If the child is feeding every 3 to 4 hours, at
the beginning of my shift I might negotiate
with parents in terms of what feeds they’ll
do, and what feeds I might do for them so
that they can get a continuous few hours of
sleep. (1-05)
There was also recognition that workload at night
could be unpredictable, and parents needed to be made
aware that despite the nurse’s commitment to preserving
sleep by providing as much care as possible, her workload
might interfere:
You can’t say “you just go to sleep and I'm
going to do everything.” When you make a
new rotation, I always say something like
“look, there are times when I may not be
here right when it (IV pump) beeps, or may
not be able to come at the time when you
want me to, but I’ll try my best to accommo-
date it. I have other patients and families to
help out too.” (1-03)
Nursing Care Factors
Much of the focus group discussion centered on issues
related to nursing care that affected sleep in hospital at
night. The degree to which sleep was prioritized in the
nurse’s practice, the amount of monitoring of patients that
occurred, and the way care was delivered were seen as
crucial to the amount and quality of sleep attained by
families.
Prioritizing sleep for the child and family.
Prioritization of sleep manifested as valuing sleep for
patients and encouraging the family to sleep. Nurses
described a tension between care priorities and protecting
sleep, and the need to make a concerted effort to place
importance on sleep:
I mean everyone has a different interpreta-
tion of the value of sleep, right? So a lot of
people would say “well, you’re in an ICU,
you’re this sick, I’m more concerned about
saving your life than how much sleep you’re
getting.” And in certain patients, maybe that
is the case for that one night, but it can’t be
something that we, just because it happened
Research in Nursing & Health
one night, we need to encourage it through-
out the entire ICU stay. (2-19)
Nurses also described taking steps to encourage all
family members to get as much sleep as they could, partic-
ularly so they would be able to face the challenges of the
following day:
I always say that the child may be my patient
but so are the parents as well. . . And I say
my intention is to make sure this child gets
some sleep, and I hope that they (the
parents) will as well. . .Have them understand
that tonight is going to be quiet hopefully,
and tomorrow’s going to be a busy day so
you need to get your sleep in order to be up
and ready. . . for a busy day tomorrow. (2-05)
Some participants suggested that it was useful if
parents or other relatives could spell each other off on
Intercalar
alternate nights to maximize the amount of sleep among
permanências
family members. noturnas com a
Nighttime monitoring. Monitoring of patients’ criança
health status was believed to affect families’ sleep in sev-
eral ways. Hospital equipment and nursing assessments
were viewed as a source of anxiety and frequent awaken-
ings for children and their parents, and some nurses
described a comfort in using their own discretion regarding
monitoring frequency, regardless of the medical orders writ-
ten for that child. This comfort grew with the nurse’s experi-
ence, and was guided by the individual patient’s context:
So you know that between 7:30 or 8:30 I
have to get vitals done because that’s what
you’re supposed to do every four hours. But
then as you get more experienced, and more
comfortable in your care and your judgment,
then you start the negotiation period where
okay, the next time the kid wakes up, I’ll do
vitals. If it’s six hours from the last time, it’s
fine. You just have a better assessment and
better judgment on what the acuity is of a
child and what they need during the night.
Within what’s ordered, but with mild varia-
tions so that you do optimize their sleep in
the nighttime, and you get the parents to feel
more comfortable, stuff like that. But I know
in the beginning I was like oh, I have to do
my vital signs. And you didn’t even think
about it, “oh why am I doing it every four
hours if the kid’s going home tomorrow?”
. . .As I’ve gotten more experienced, I’m
much better at negotiating and optimizing
care, and going to the doctor and saying . . .
change it to every six or every eight. . .But
 NURSES’ VIEWS OF FACTORS AFFECTING SLEEP IN HOSPITAL/ STREMLER ET AL.
when you’re new, you’re just like “I have to
get my tasks done, I have to get through the
night or the day shift,” you don’t think about
the total care. (1-03)
At odds with some nurses’ comfort in reducing moni-
toring to spare sleep were other nurses who expressed
concerns for patient safety and liability if monitoring was
reduced and described a culture of expectation of monitor-
ing, or at least hourly observations.
Delivery of care. Workload shaped nurses’ ability
to deliver overnight care in a way that preserved sleep for
the family. For example, numerous admissions could get in
the way of organizing assessments and interventions in a
way that maximized time between care episodes. There
was much discussion among the nurses on timing of care
or tests (e.g., bloodwork, x-rays) as convenient to staff
needs or schedules without taking into account the family’s
need for sleep. Family distress at procedures scheduled in
the early morning hours was viewed as understandable.
Nurses described considerable nursing work to plan
the timing of medications, anticipate when machines might
signal the end of infusions, and arrange the physical envi-
ronment to preserve sleep for families. Modifying care to
protect the family’s time for sleep at night was also viewed
as within the nurse’s role:
I think that we need to remember that we
can advocate for our patients. Sometimes
they’re [physicians] just not thinking about
what they’re ordering, they just are thinking
about what they want to come out of it. To
say, “just a second, can we wait until morn-
ing?” If you’re ordering a chest x-ray in the
middle of the night it’s likely for a reason, like
de-compensation, or something is happening
with your patient. Obviously that would take
priority over sleep at that moment. But the
things that can be put on a more routine
schedule, we need to be able to recognize
what’s appropriate to do so, and when you
should ask to have that. (2-16)
They called for mentoring of new nurses on strate-
gies to preserve sleep for families. As one nurse noted:
I think that there definitely can be some men-
toring for new nurses. And I was certainly
doubtful of this too, because [when you are
newly graduated] you go into a room and
you’re like “okay, I have 10 things to do.”
You don’t have that fluidity or that routine
that “okay, I'm going to seal the IV,” and you
don't have the grace of the way you move
around the room. And I was like that,
Research in Nursing & Health
319
haphazard, and I’d forget to turn the monitor
off [laughs]. And I know often that’s one of
the things I work with new staff on, is turning
the monitor off, shutting the door, turning the
lights off even because you’re so focused on
those other things as a new nurse that it’s
hard to consider the environment. (1-09)
Finally, the importance of developing evidence-based
guidelines on sleep in hospital was mentioned in one
group:
We have guidelines now for pain and seda-
tion. We have all these little protocols, but
just sitting here I’m beginning to realize we
have no best practice guideline about
sleep. . . To be honest, what is a good
approach to get them to sleep? What kind of
sleep hygiene do our patients need? Per-
haps that’s where the inadequacy is coming
through. (2-13)
Discussion
Nurses described many factors that affected sleep for hos-
pitalized children and their parents. Factors related to the
child’s circumstances were largely portrayed as nonmodifi-
able. Some factors related to the hospital environment,
relationship with parents, and nursing practice were ame-
nable to intervention by nurses, but others restricted the
nurses’ ability to optimize sleep.
The nurses perceived that noise was a barrier to
sleep for families and, in fact, the contribution of noise in
pediatric acute care settings to patients’ sleep disruption,
Consequências do
increased distress, and greater need for sedation has been barulho
documented repeatedly (Carno & Connolly, 2005; Cureton-
Lane & Fontaine, 1997; Trapanotto et al., 2004). Nurses
expressed frustration with their limited ability to decrease
noise generated by monitors, overhead paging, and the
built environment.
While hospital administrators in pediatric settings
could facilitate sleep by changing design elements, equip-
ment and materials, participants also acknowledged the
role of the nurse in creating noise at night. This finding is
supported by a study in a PICU setting in which health care
professionals were the largest contributor of noise in the
environment (Milette & Carnevale, 2003). Nurses’ contribu-
tions to noise were viewed as related to lack of awareness
of noise levels and the need for socialization and interac-
tions related to performance of work duties. Nurses recom-
mended space and opportunity for nurses to communicate
quietly for work and social engagement away from the bed-
side, acknowledging the importance of interaction with
 320 RESEARCH IN NURSING & HEALTH
co-workers to staying alert on night shift, and sustaining
change over time with intervention champions.
Nurses acknowledged that light in the hospital envi-
ronment was interfering with sleep at night but described a
tension between ensuring adequate lighting for safe
assessment of patients and striving to limit light to preserve
sleep. Similar conflict between provision of care and pres-
ervation of sleep was reported related to monitoring of
patient status. Families focused on achieving sleep, hospi-
tal administrators focused on patient safety, and physicians
focused on orders for monitoring may not appreciate the
degree of nurses’ awareness of and distress at these com-
peting demands or their impact on nurses’ practice deci-
sions at night.
Increased attention to these issues is evidenced by
the Choosing Wisely campaign of the American Academy
of Nursing, which includes waking patients for routine care
as one of ten “Things Providers and Patients Should Ques-
tion” (American Academy of Nursing, 2015). The Choosing
Wisely campaign aims to promote conversation between
nurses and patients to help make decisions about the most
appropriate care based on evidence and a patient’s individ-
ual condition or care requirements. These efforts should be
built upon through open dialog among health care pro-
viders, administrators, children and their families, to
develop formal policies to guide safe and effective practice
during night shifts while taking patient acuity into account.
Issues raised by the nurses highlight significant dif-
ferences between nurses’ and families’ experiences in the
hospital environment and bring into question whose needs
define the nature of the setting. Ethnographers have
As dificuldades
identificadas por revealed the tension between pediatric hospital spaces as
investigadores a site for delivery of professional medical care and as a
como a falta de bedroom for the child (Macdonald, Liben, Carnevale, &
condições
estruturais dos Cohen, 2012), and our findings support this disconnection.
hospitais Nurses described the hospital space as belonging to
pediátricos
nurses, as reflected in their reluctance for parents and fam-
ily members to interact with the child and nurse at night
and their suggestions that parents leave the hospital at
night, either due to lack of sleep space or based on the
presumption that parents will sleep better elsewhere. Fur-
thermore, as in our previous survey of pediatric hospital
administrators (Stremler et al., 2008), nurses revealed that
families often are separated at night, particularly in higher-
acuity settings, calling into question whether family-cen-
tered care can truly exist in such a context.
We found previously that parents were significantly
sleep-deprived and faced multiple, often competing,
demands that affected their ability to achieve sleep,
whether they slept near their children or not (Stremler
et al., 2011, 2014). Parents struggled to decide whether to
stay at the bedside and had difficult thoughts and feelings
such as anxiety and worry that affected their sleep. Inform-
ing nurses of parents’ mixed experiences of sleep in the
hospital is an important adjunct to other strategies identified
by nurses as helpful to family sleep, such as building trust,
Research in Nursing & Health
communicating a plan of care for the night, and partnering
with parents in care of their children.
Clustering assessments and interventions to maxi- O agrupamento de
mize sleep is clearly within nurses’ scope of practice but cuidados/procedimen
tos é descrito com
also is limited by conditions beyond the nurse’s control, importante, mas
such as patient acuity, orders from other team members, difícil de realizar,
nomeadamente à
and the available physical environment. Care planning to
noite dependo de
preserve sleep and communicating with families about vários fatores
care at night were seen by nurses as time- and energy-
intensive but are essential to family-centered care, exempli-
fiying the invisible work of nursing. The nurses recom-
mended mentoring of new graduates to formalize and
increase use of such interventions.
While nurses discussed significant nursing work
related to planning care to preserve sleep, there was no
mention of routine assessment of sleep. Although they
were not asked specifically about the assessment of sleep,
nurses did not volunteer the topic. When health care pro-
fessionals in an adult acute care setting were asked specif-
ically about efforts to assess sleep, they described them as
minimal (Ye, Keane, Hutton Johnson, & Dykes, 2013).
Given the dearth of evidence for interventions that effec-
tively promote sleep in the hospital setting, the lack of sys-
tematic assessment of sleep in hospital is not surprising.
When strategies to improve sleep in hospital are developed
and shown to be effective, assessment of their effects on
sleep are more likely to occur.
Nurses acknowledged that their work on the night
shift occurred at a time when their ability to respond to fam- Dificuldade de dar
ilies’ needs was suboptimal. It is essential to recognize that respostas eficazes e
prontas durante o período
nurses are being asked to perform psychologically and da noite por parte das
physically challenging work at a time in their circadian enfermeiras - ritmo
circadiano
rhythm when they should be asleep. Interventions aimed at
improving patient and family sleep would likely gain buy-in
from nurses if the interventions also addressed the chal-
lenges of performing the highly skilled work of nursing at
night and included strategies for nurses to feel alert and
effective at work at night and to sleep well during the day.
Although later bedtimes and earlier rise times have
been documented in the literature as restricting the amount
of sleep children achieve in hospital (Linder & Christian,
2012; Meltzer et al., 2012; Stremler et al., 2009), the
nurses in the focus groups viewed sleep disturbance as
resulting primarily from frequent awakenings rather than
shortened opportunity to sleep. These views may explain
the participants’ focus on strategies to reduce nighttime
interruptions due to noise, light and care activities. No men-
tion was made of pain relief, comfort, or relaxation strate-
gies for parents or children that might aid in initiation or
maintenance of sleep, such as music, massage, or pain
medication. This finding is in contrast to two studies of
health care professionals’ practices around sleep in adult
acute care settings, in which pharmacological and non-
pharmacological comfort strategies were used for sleep
promotion (Eliassen & Hopstock, 2011; Ye et al., 2013).
Some interventions to promote sleep may be limited by the
 NURSES’ VIEWS OF FACTORS AFFECTING SLEEP IN HOSPITAL/ STREMLER ET AL.
acuity of the child’s condition or hospital unit, given that as
acuity increases, so does the need for interventions and
the frequency of assessments. Given that many of our par-
ticipants worked in a critical care environment, this also
may explain their focus on sleep disturbance due to more
wake time at night.
Limitations
In all focus groups, there is a risk that participants’
responses might be inhibited by the focus group setting or
other participants (Krueger & Casey, 2000). These issues
were addressed by holding multiple focus group interviews
and engaging a facilitator with extensive experience who
maximized participants’ comfort and openness in expres-
sion. We did not conduct analysis before completing all
focus groups, which may have better allowed us to build on
each group’s key messages as we moved to the next ses-
sion. Findings reflect the experiences of a limited number of
nurses from one pediatric hospital and may not be transfer-
able to other pediatric settings that might have different prac-
tices, systems, and policies related to sleep in hospital.
However, common themes were found across focus groups
and between nurses working in general pediatric units and
critical care units, which increases the likelihood that the
results are relevant to pediatric nurses with varying years of
experience and practice specialties (Mays & Pope, 2000).
Research Recommendations
Future researchers should leverage what we have learned
from previous studies in children and their parents in hospi-
tal (Stremler et al., 2009, 2011, 2014), and in hospital
administrators (Stremler et al., 2008) and nurses to develop
interventions. While it may be simpler to test single
approaches to improving sleep, such as noise reduction
strategies, they have limited power to effect change, given
the multiple and conflicting influences on sleep in hospital.
We suggest an integrated, multi-pronged knowledge trans-
lation intervention wherein all stakeholders are involved in
the development, implementation, and evaluation.
Key strategies are education for all stakeholders
regarding other groups’ views on challenges to sleep in
hospital; environmental, staffing, and policy changes to
decrease light and noise for families while ensuring safe
practice conditions for nurses; systematic assessment of
sleep for children and their parents; sleep-promoting inter-
ventions that have shown promise in adults and children in
hospital (e.g., eye masks, ear plugs, music, relaxation tech-
niques); education for nurses regarding challenges of sleep
and shift work and its intersection with provision of care;
and improvements in space for families to be together at
night in hospital. All these strategies need to be balanced
with safe practice and family-centered care principles. Eval-
uation should include sleep quantity and quality for children
Research in Nursing & Health
321
and parents, nurses’ alertness on night shift and ability to
sleep on days off, family satisfaction with care, noise, and
light levels, staff awareness of sleep assessment and inter-
vention strategies, and nurses’ perceived ability to influ-
ence sleep for patients.
Conclusion
This study was the first to explore nurses’ views on factors
affecting sleep for the hospitalized child and parent and the
provision of nursing care at night. Balancing strategies to
preserve sleep with the provision of nursing assessment
and intervention was challenging and complicated by the
difficult nature of work outside of usual waking hours. The
struggle between provision of care and promotion of sleep
was also seen in conflicting views between family and
nurses related to prioritization of sleep and the physical
space for care. Nurses highlighted the need for policy
change and mentoring related to provision of nursing care
at night in pediatric settings.
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Acknowledgments
Dr. Stremler received funding for this project through the Rosenstadt Health Research Fund, Lawrence S. Bloomberg Faculty of Nursing, Univer-
sity of Toronto. Dr. Stremler is a recipient of a Canadian Institutes of Health Research New Investigator Award and an Early Researcher Award
from the Ontario Ministry of Research and Innovation. Study sponsors had no involvement in any aspects of study design, data collection, analysis
or interpretation of data, writing or submission of the paper. We wish to thank Radha McCulloch for guiding the focus groups, Stanley Ing for
assisting with data analysis, Julie Weston for study coordination, and the participating nurses for sharing their time and experiences.

Research in Nursing & Health