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RESEARCH ARTICLE

NON-PHARMACOLOGIC NURSING
INTERVENTIONS TO REDUCE DELIRIUM
RISK AND PROMOTE QUALITY SLEEP
Malissa A. Mulkey, MSN, APRN, CCNS, CCRN, CNRN1; D. Erik Everhart, PhD, ABPP1;
Cindy L. Munro PhD, RN, ANP-BC, FAAN, FAANP, FAAAS2;
Sonya R. Hardin, PhD, CCRN, ACNS-BC, NP-C3; DaiWai M. Olson, PhD, RN, CCRN, FNCS4

Abstract
The average ICU patient sleeps less than two hours/day with as many as 61% reporting sleep deprivation, placing it among the most
common ICU stressors. Sleep disturbances, lack of sleep and sleep disruption are common in older adults and a core risk factors for
delirium. Significant reductions and fragmentation of sleep lead to an absence of restorative sleep. A significant amount of invasive care
known to be a major risk contributor to the development of delirium occurs in the ICU. Nurses should be able to identify delirium risk
factors earlier and contribute greatly to their prevention by promoting good sleep hygiene interventions.

Keywords: Delirium, Sleep, Deprivation, Sedatives, Medications, Critical Illness, Geriatric, Sleep hygiene interventions \

Introduction

S pirituality is a multifaceted concept. Grounded in both

conceptual and empirical studies, spirituality refers to an
individual's feeling of connectedness to self, other persons, and a
powerful being or nature or the world; an individual's perception of
life purpose or meaning; and transcendence indicating the ability
to modify the personal perspective of life including suffering.
Spirituality is paramount in the life of an individual because it
brings about the relief of suffering; promotes a feeling of wellbeing,
adaptive capacity for life adversities, peacefulness, and strength
within. Likewise, spirituality spawns a sense of hope, motivation,
love, and happiness among others (Weathers, McCarthy, &
Coffey, 2015).
Sleep disturbances, lack of sleep and sleep disruption are core risk
factors for delirium (American Psychiatric Association, 2013).
Nursing is the leading discipline responsible for continuous direct
patient care and in a position to identify delirium risk factors earlier
and provide significant contributions toward delirium prevention.
The paradox is that while being most capable of identifying and
reducing delirium, nurses perform a significant amount of invasive
care known to be a major risk contributor to the development of
delirium. For example, noise, light and patient activity have been
found to contribute to 30% of sleep disruption (Pandharipande &
Ely, 2006), which is in turn associated with increased risk for
delirium.
Physiology of Sleep
Sleep-wake cycles and circadian rhythm are controlled by a
complex system of neurotransmitters and structural neurons that
respond to internal and external stimuli. Part of the ascending
reticular activating system includes the suprachiasmatic nucleus
(SCN) in the hypothalamus which responds to environmental
factors, primarily light exposure. The amount of light exposure
affects nighttime melatonin secretion, a neurohormone derived
from serotonin (Burry et al., 2017). The amount of light and
darkness exposure can impact secretion of melatonin from the
pineal gland and alter the circadian rhythm. When the amount of
darkness is not sufficient in a 24-hour period, the default is the
awake phase of sleep such that sleep cycles will advance a little
each night. In addition to light, environmental factors, sepsis,
systemic inflammatory response, hormone interactions,
medications (including opioids and benzodiazepines), critical
illness, burn, and mechanical ventilation have been shown to alter
melatonin excretion (Mulkey, Hardin, Olson, & Munro, 2018;
Pandharipande, Girard, & Jackson, 2013). When there is

1 Correspondence: East Carolina University, Greenville, NC; email address: mulkeym16@gmail.com

East Carolina University, Greenville, NC1; Miami University, Coral Gables, FL2; University of Louisville, Louisville, KY3; University of Texas Southwestern, Dallas, TX4

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insufficient melatonin, disrupted circadian rhythms, fragmented
sleep/wake cycles and nighttime awakenings result (Jaiswal et al.,
2018).
Blue light is primarily present in the morning and has a wavelength
of 460-480 nm (Estrup, Kjer, Poulsen, Gogenur, & Mathiesen,
2018). When blue light reaches the photoreceptors in the retina,
signals are sent from the SCN to the pineal gland resulting in
suppression of melatonin. In the absence of blue light, melatonin
secretion promotes sleep. In the hospital, artificial light is turned on
around-the-clock. This results in constant exposure to blue light
and melatonin suppression which may alter the natural sleep-wake
cycle. Sleep pattern disturbance is a known risk factor for
developing delirium. These disturbances of melatonin secretion
have been demonstrated in critically ill patients (Burry et al., 2017).
It is, therefore, relevant to understand the impact of circadian light
on the incidence of delirium (Estrup et al., 2018).
Assessment
Sleep is most accurately and objectively assessed using
polysomnography (PSG), simultaneous electroencephalo-
graphic (EEG) recordings and physiologic parameters. Sleep
periods are generally classified as wake, wake after sleep onset,
non-rapid eye movement (NREM) and rapid eye movement
(REM) sleep. NREM sleep is further subdivided into four stages.
Sleep onset occurs with stage 1 which is usually short-lived. The
cycle then progresses to stage 2, occupying about half of the total
sleep time, and finally to stages 3 and 4. These last two stages of
sleep, Stages 3 and 4 are characterized by delta or slow-wave
sleep (SWS); these are periods when sleep is deeper and more
restful. These phases account for as much as 15-20% of the total
sleep time in a healthy middle-aged adult. Stage 3 and 4 have
been found to be unobtainable in critical populations due to noise
and interruptions during sleep (Su & Wang, 2018). Although REM
sleep is considered more restful, the brain is quite active and, as
the name suggests, distinctive intermittent rapid eye movements
occur. Each sleep cycle is approximately 90 to 110 minutes in
duration, with REM sleep periods increasing in length with each
full cycle as the night progresses. REM sleep usually alternates
with stage 2, accounting for 20-25% of the total sleep time (Su &
Wang, 2018).
Significant reductions and fragmentation of sleep lead to an
absence of SWS and REM sleep. This is the phase during the
sleep cycle considered to be restorative sleep, and patients may
exhibit cognitive changes as a result of sleep deficits. Although not
well established, limited and sometimes absent restful or
restorative sleep is thought to be a significant contributor to the
onset of delirium may help reduce the risk for delirium (Van
Rompaey, Elseviers, Van Drom, Fromont, & Jorens, 2012).
Sleep and Delirium
Despite significant advances in knowledge regarding delirium and
sleep, the pathophysiology continues to be the least understood.
Sleep pattern disruption and delirium are thought to be related both
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to deficits and imbalances in the neurotransmitters that modulate
the control of cognitive function, behavior and mood. Sleep is not
merely a passive state but requires complex regulation by the
brainstem and diencephalic structures. While there is typically no
distinct structural defect in the brain's anatomy, the cortical and
sub-cortical areas are involved in delirium regardless of etiology.
Over time, sleep disturbances can lead to a decline in cognitive
function including psychomotor vigilance, memory and
disturbances in language and perception, characterized by
hallucinations and delusions (Mulkey et al., 2018). Evidence has
shown newly learned material and skills are consolidated during
REM sleep that is significantly disrupted thereby leading to
dysfunction in the brain's information integration capacity. This
dysfunction can lead to the hallucinations and delusions seen
during delirium and is thought to be partially responsible for post-
traumatic stress seen in patients who recover from delirium
(Bilotta, Lauretta, Borozdina, Mizikov, & Rosa, 2013; Numan et al.,
2017).
Elderly patients are more likely to develop delirium due to the
normal physiologic changes associated with aging (Mulkey,
Hardin, S.R., Olson, Munro, Everhart, 2019). This partially explains
why delirium is often present with an acute illness. During the
normal aging process, cerebral blood flow decreases by 28% and a
loss of neuronal cells occurs along with lower concentrations of
cerebral neurotransmitters, such as acetylcholine, dopamine,
gamma-aminobutyric acid (GABA), and norepinephrine
(Maldonado, 2017). These changes likely result in less physiologic
reserve to adapt to the additional neurologic stress occurring with
metabolic disturbances, infection and trauma. The inability to adapt
alters secretion of neurotransmitters that regulate the sleep/wake
cycle (Thille et al., 2018). This is thought to be the result of
modulation occurring slowly and having long-term effects over
diverse and widespread systems (Maldonado, 2017). These
effects can produce a sustained response that plays a role in
maintenance of the sleep-wake cycle (Thille et al., 2018).
Even in healthy individuals, sleep deprivation has been shown to
impair memory, attention, response time and other aspects of
neurologic function (Pisani et al., 2015). In healthy volunteers,
sleep deprivation has been shown to impair memory, attention,
response time, and other aspects of neurologic function. The
relationship between sleep deprivation and delirium in the ICU is
currently unproven. However, because sleep deprivation affects
cognitive function, a connection between delirium and sleep
deprivation in critically ill patients may exist.
Sleep disturbance is a common concern in the acute care setting,
especially the ICU (McLaughlin, Hartjes, & Freeman, 2018). The
average ICU patient sleeps less than two hours/day with as many
as 61% reporting sleep deprivation, placing it among the most
common stressors (Maldonado, 2008). The reason for these
disturbances is multifactorial. The patient's predisposing risk
factors such as age or prior cognitive impairment combined with an
acute illness or surgical procedure, the hospital environment and
medication exposure. Objective studies have indicated the noise
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generated within the hospital environment is not conducive to
sleep (Basner & McGuire, 2018; Darbyshire, Müller-Trapet, Cheer,
Fazi, & Young, 2019; Garside et al., 2018).
As previously described, these factors along with alterations in the
circadian rhythm result in a synergistic effect. Studies looking at
sleep deprivation in critically ill patients have revealed ICU patients
average approximately two hours of sleep in a 24-hour period with
<6% spent in REM sleep (Pandharipande & Ely, 2006). This
disturbance in sleep leads to detrimental effects on protein
synthesis, immunity, energy expenditure, hemodynamics and
cognitive function.
Medications
Medications that disrupt the sleep wake cycle include
antiarrhythmic agents, inotropes and vasopressors, antibiotics,
antidepressants, steroids, anticonvulsants, and bronchodilators
(Pandharipande & Ely, 2006). Beta-blockers, clonidine, ibuprofen,
naloxone, alcohol, opioids and benzodiazepines as well as high
cortisol levels decrease the amount of melatonin release
(Olofsson, Alling, Lundberg, & Malmros, 2004) Table 1. displays
information on the relationship of sleep and common medications.
Sedatives and analgesic medications are routinely administered to
patients to promote sleep. While patients appear to be sleeping,
sleep architecture is typically adversely affected. Researchers
looking at melatonin levels have discovered an abolition of
melatonin release in deeply sedated ICU patients (Maldonado,
2008). Sedatives (propofol, midazolam, lorazepam) and opioids,
administered to reduce discomfort, are known to inhibit slow wave
sleep (SWS) and REM sleep leading to the development of
delirium. Benzodiazepines and propofol prolong stage two NREM
sleep and decrease slow wave and REM sleep. Opioids on the
other hand increase stage one NREM sleep and decrease slow
wave and REM sleep (Su & Wang, 2018). Because of promoting
lighter sleep stages, there is a reduction in restorative sleep. These
findings suggest sedative agents may contribute to the
development of delirium by more than one mechanism (i.e.,
disruption of sleep patterns, central acetylcholine inhibition, and
disruption of melatonin circadian rhythm; Maldonado, 2008).
Many organizations, including American Society of
Anesthesiologists, American Geriatrics Society, American Heart
Association, Society of Critical Care Medicine recommend the use
of multimodal analgesia for acute pain management. Using more
than one analgesic agent, technique and non-pharmacological
interventions that use different mechanisms to provide better pain
relief with less opioids to address acute pain, known as multimodal
analgesia (Apfelbaum, Ashburn, & Connis, 2012; Devlin, Skrobik,
Rochwerg, et al., 2018; Shah, 2018). By combining different
analgesics, multimodal analgesia can optimize efficacy with a
lower dose of each respective agent and may also reduce the risk
for dose-related adverse events, including delirium.
Nursing Implications
Nurses play a vital role in improving a patient's sleep wake cycle
through the use of non-pharmacological nursing interventions.
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When considering interventions to promote sleep nurses need to
consider the patient's perspective of their “healing environment.”
Nursing interventions focused on optimizing the quality of sleep
can have a significant impact on the overall outcome for patients.
High quality patient centered nursing care is the only intervention
that has been shown to consistently reduce the harmful effects
associated with delirium (Siddiqi et al., 2016). Therefore,
providing good quality bedside nursing care focused on meeting
the patients basic needs should be a central focus. A recent
Cochrane review recommends the use of multi-modal nursing
interventions for the prevention and treatment of delirium, one of
which is sleep hygiene (Siddiqi et al., 2016).
Managing the Patient Factors
There are many patient factors associated with sleep
disturbances and therefore delirium. While not all of them, such as
poor overall health and chronic illnesses, are in the nurse's
control, there are several important ones that nurses can play a
key role in the management including pain, anxiety and sleep
hygiene. The Society of Critical Care Management published the
Pain, Agitation, Delirium guidelines in 2018 (Devlin, Skrobik,
Gelinas, et al., 2018). In these guidelines, they recommend
providing multi-model analgesia to address pain prior to the use of
sedatives (Barr et al., 2013). Hata and colleagues recommend
including the patient and family in evaluation of sleep quality (Hata
et al., 2014). Considering the patient's environment is also
important. It may be challenging for many nurses who may be
experiencing alarm fatigue. With the number of devices in
patient's rooms today, alarm noise can be overwhelming
(Potharajaroen et al., 2018). Staff conversations patient emotional
concerns are also frequently a source of interruption especially at
night. Promoting family and use of the patient's social network
support may help relieve anxiety, promote rest and ultimately
reduce delirium risk. Additional research is needed regarding the
impact of providing emotional support on sleep quality and healing
(Hata et al., 2014).
Daytime Routine
By promoting activity during the day with scheduled rest periods,
many units have a “quiet time” during the day. It is thought that if
patients are provided a two-hour quiet time, this will allow for a
complete sleep cycle. Studies evaluating these daytime rest
periods have had significant limitations such as pre-ICU sleep
quality, confounders related to patients themselves,
pharmacological exposure, and ICU practices that complicate
efforts. Additionally, ICU interventions that can interact and
influence the reported outcome have raised questions about the
standard, randomized controlled trial research methods that have
been used to evaluate delirium and sleep-related outcomes in the
ICU. Unfortunately, these challenges are inherent to an aspect of
ICU care such as sleep. As is the case with many ICU studies,
these confounders complicate efforts to establish causality.
Alternative research strategies that permit the integration of
multiple interventions and rapid adaptation to updated clinical
results in the research environment, such as the use of an

adaptive platform trial design, may better serve the exploration of
complex clinical questions such as the link between delirium and
sleep in critical illness (Skrobik & Devlin, 2018; Skrobik, Duprey,
Hill, & Devlin, 2018; Thille et al., 2018; Yu et al., 2013).
While there remains uncertainty regarding the relationship between
sleep and delirium, this association is one of many “accepted” by the
critical-care community (Skrobik & Devlin, 2018; Y. Skrobik et al.,
2018; Thille et al., 2018; Yu et al., 2013). Having a daytime rest
period has been found to be beneficial for the patient while also
providing an opportunity for nurses to complete tasks and chart
patient care. During these quiet times some patients may like having
the door closed or earplugs to limit noise, blinds or curtains closed
and eyes masks to limit light distractions (Van Rompaey et al., 2012).
For this to be successful, it may be necessary to have standardized
orders or implement these practices in standard patient care
routines.
Night-time Routines
To obtain quality sleep one complete 90-minute cycle is needed.
Care providers are the primary barrier to patients obtaining quality
sleep (FitzGerald et al., 2017). Implementing strategies that are
thought to be natural “sleep cues” such as reducing the lights and
decreasing the noise level, whether truly effective, improve the
individual's perception of the quality of the sleep obtained (FitzGerald
et al., 2017). When there is frequent deprivation of N3 and REM
phase of the sleep cycle, sleep is not restorative and therefore
strategies minimizing the number and frequency of sleep disruption
should be considered (Su & Wang, 2018). Strategies that promote
sleep hygiene such as implemented earplugs and eye masks need
to be included in the patient plan of care (Su & Wang, 2018).
Limiting Interruptions
As a result of the need for care related to the patient's medical
condition, many patients are not provided with enough time to meet
optimal sleep needs. Routine nighttime awakenings often occur to
complete tasks needed for clinicians during the day, such as vital
signs, blood draws, and daily weights. It is important to consider both
sleep quality and efficiency (Ghaeli, Shahhatami, Mojtahed Zade,
Mohammadi, & Arbabi, 2018). Data from observation studies of
hospitalized patients have shown that patients rarely obtain 2-3
hours of uninterrupted sleep (Barr et al., 2013; Ghaeli et al., 2018;
Hata et al., 2014).
When nurses are planning to implement “quiet time” or any sleep
program, recruiting all the disciplines who interact directly with
patients is needed. For example, if the laboratory technicians come
to the unit at 0300 to draw morning labs or respiratory therapy
changes oxygenation tubing during the proposed “quiet times” it will
be necessary to work with those departments to change their
workflow to meet these expectations. Nurses will need to give up
some of the “sacred cows” such as nighttime bathing (Ghaeli et al.,
2018).
Environmental Disruptions
The Environmental Protection Agency recommends noise levels
less than 45 decibels during the day and lower than 35 decibels
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during the night. The noise level in most hospitals is between 50-
70 decibels with night time levels closer to the 70-decibel range
(Ghaeli et al., 2018; Stewart & Arora, 2018). As a result of these
findings Medicare now includes noise level at night as part of the
publicly reported HCAHPS surveys patients receive after
discharge. Medicare uses this data as part of their determination
for the amount reimbursement or payment hospitals receive.
This metric continues to be the most challenging. Even with
“quiet at night” impacting reimbursement, this is the patients
report that as many as 42% of hospitals are not quiet at night.
Additional studies have shown that more than half of the noise is
unnecessary (Darbyshire & Young, 2013). For example, staff
conversations and television volumes have been reported as
the most irritating cause of sleep disruption (Stewart & Arora,
2018). Electroencephalogram studies have shown these noise
levels do interfere with sleep. When considering the limited
diurnal light-dark cycles and sleep disruption, the hospital
environment interferes with circadian rhythm that guides the
patients sleep structure,
Elevated noise levels during hospitalization are more than just
annoyance. When clinicians do not provide quiet environments,
patient's clinical outcomes may be impacted through several
mechanisms, sleep disruption, an increase in medical errors,
and by increasing the body's response to stress.
Therefore, nurses should promote the delivery of high quality
and compassionate care by making a concerted effort to
reduce the noise levels in the patient care environment as the
minimum standard of care (Stewart & Arora, 2018).
Alternative Therapy
Over the years a variety of complementary and alternative
therapy have been utilized to promote sleep(FitzGerald et al.,
2017; Ghaeli et al., 2018; Stewart & Arora, 2018). Some
therapies than can be implemented by nurses include
aromatherapy, massage and relaxation strategies(FitzGerald et
al., 2017; Stewart & Arora, 2018). Music therapy, phototherapy
and acupressure will likely require collaboration from integrative
medicine. A few small studies and one meta-analysis have
evaluated the use of bright light therapy. The data from these
studies suggest that day time bright level therapy is a protective
factor against delirium onset (FitzGerald et al., 2017; Ghaeli et
al., 2018; Moyce, Rodseth, & Biccard, 2014; Stewart & Arora,
2018). The use of phototherapy has been evaluated in case
reports with suppression of delirium symptoms when resistant
to haloperidol with mixed results (FitzGerald et al., 2017; Ghaeli
et al., 2018; Luther & McLeod, 2018; Potharajaroen et al., 2018;
Stewart & Arora, 2018).
Conclusions
Sleep disorders are extremely frequent among all patient
population. Sleep deprivation and disturbances in quality are
known to have significant consequences for patient outcomes.
However, more severe disturbances in sleep fragmentation and
the sleep-wake cycle have been associated with delirium.
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Therefore, careful consideration is warranted when providing care
to older patients, especially those with dementia (Huson, Stolee,
Pearce, Bradfield, & Heckman, 2016). Nurses have the capacity to
integrate non-pharmacological interventions for sleep promotion
that can have a significant impact on patient outcomes. By
removing barriers to quality uninterrupted sleep, nurses are
therefore able to improve the healing process.
Providing multi-modal analgesia to reduce opioid use, decreasing
nursing care activities at night to provide periods of uninterrupted
sleep, and promoting family and social support are interventions
that may improve sleep and are unlikely to have unintended
effects. Sleep hygiene interventions that have been effective in
healthy populations might also be helpful in promoting sleep in the
ICU, such as maintaining a quiet dim nighttime environment,
reducing blue light at night, and use of white and pink noise.
Scheduling “quiet time” or rest periods during the day has
repeatedly been shown to improve sleep, but is limited to only a
few hours (Dennis, Lee, Woodard, Szalaj, & Walker, 2010; Olson,
Borel, Laskowitz, Moore, & McConnell, 2001). Moreover, daytime
napping runs counter to well establish advice for patients with
sleep problems to avoid sleeping during the day. Likewise, it is
unclear whether ear plugs and eye masks will improve sleep in the
ICU, or whether blocking appropriate environmental stimuli might
increase risk of delirium. Melatonin use in the ICU also requires
additional research (Jaiswal et al., 2018).
Sleep disturbances are common in the acute care setting. A review
of the literature raised the question of how important it is to monitor
the quality of sleep to avoid clinical consequences including
delirium. Delirium is independently associated with worse
outcomes including increased length of stay and increased
mortality risk at a rate of 10% each day delirium is present. Nursing
is the primary discipline capable of impacting modifiable delirium
risk factors. Both non-pharmacologic and pharmacologic
measures such as those previously mentioned can reduce the
incidence and duration of delirium. Nurses can provide
interventions which impact the environment through limiting
interruptions in sleep and by providing an environment that
promotes sleep.
.....................................
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deprivation in neurointensive care unit patients from serial neurological
checks: How much Is too much? Journal of Neuroscience Nursing.
doi:10.1097/jnn.0000000000000378
Moyce, Z., Rodseth, R. N., & Biccard, B. M. (2014). The efficacy of peri-
operative interventions to decrease postoperative delirium in non-
cardiac surgery: A systematic review and meta-analysis. Anaesthesia,
69(3), 259-269. doi:10.1111/anae.12539
Mulkey, M. A., Hardin, S. R., Olson, D. M., & Munro, C. L. (2018).
Pathophysiology review: Seven neurotransmitters associated with
delirium. Clinical Nurse Specialist, 32(4), 195-211.
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Mulkey, M. A., Hardin, S.R., Olson, D.M., Munro, C.L., Everhart, D.E.
(2019). Considering causes for hypoactive delirium. Australasian
Journal of Neuroscience, 29(1). doi:10.21307/ajon-2017-015
Numan, T., Slooter, A., van der Kooi, A. W., Hoekman, A. M. L., Suyker, W. J.
L., Stam, C. J., & van Dellen, E. (2017). Functional connectivity and
network analysis during hypoactive delirium and recovery from
anesthesia. Clinical Neurophysiology, 128(6), 914-924.
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Olofsson, K., Alling, C., Lundberg, D., & Malmros, C. (2004). Abolished
circadian rhythm of melatonin secretion in sedated and artificially
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Scandinavica, 48(6), 679-684. doi:10.1111/j.0001-5172.2004.00401.x
Olson, D. M., Borel, C. O., Laskowitz, D. T., Moore, D. T., & McConnell, E. S.
(2001). Quiet time: A nursing intervention to promote sleep in
neurocritical care units. Am J Crit Care, 10(2), 74-78.
Pandharipande, P., & Ely, E. W. (2006). Sedative and analgesic
medications: Risk factors for delirium and sleep disturbances in the
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doi:10.1016/j.ccc.2006.02.010
Pandharipande, P. P., Girard, T. D., & Jackson, J. C. (2013). Long-term
cognitive impairment after critical illness. New England Journal of
Medicine, 369. doi:10.1056/NEJMoa1301372
Pisani, M. A., Friese, R. S., Gehlbach, B. K., Schwab, R. J., Weinhouse, G.
L., & Jones, S. F. (2015). Sleep in the intensive care unit. American
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doi:10.1164/rccm.201411-2099CI
Potharajaroen, S., Tangwongchai, S., Tayjasanant, T., Thawitsri, T.,
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do? Current Opinion in Anaesthesiology, 31(1), 83-88.
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Thille, A. W., Reynaud, F., Marie, D., Barrau, S., Rousseau, L., Rault, C., &
Drouot, X. (2018). Are sleep alterations the cause of ICU-delirium?
American Journal of Respiratory and Critical Care Medicine.
doi:10.1164/rccm.201804-0609LE
Van Rompaey, B., Elseviers, M. M., Van Drom, W., Fromont, V., & Jorens, P.
G. (2012). The effect of earplugs during the night on the onset of
delirium and sleep perception: A randomized controlled trial in
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Yu, A., Teitelbaum, J., Scott, J., Gesin, G., Russell, B., Huynh, T., & Skrobik,
Y. (2013). Evaluating pain, sedation, and delirium in the neurologically
critically ill-feasibility and reliability of standardized tools: A multi-
institutional study. Critical Care Medicine, 41(8), 2002-2007.
doi:10.1097/CCM.0b013e31828e96c0
ABOUT THE AUTHORS
Malissa A. Mulkey has been a nurse for 24
years and is currently a Neuroscience Clinical
Nurse Specialist and PHD candidate. Her
program of research involves early detection
of delirium in critically ill older adults.
Dr. D. Erik Everhart, PhD, ABPP is a board-
certified clinical neuropsychologist with
expertise in assessment and diagnosis of
neurodegenerative disease and sleep
disorders. His research interests include sleep
disorders, emotion regulation, and
electrophysiology.
Dr. Cindy Munro is Dean of the School of
Nursing at University of Miami. Her research
program focuses on high-impact research in
critical care. She is currently conducting an NIH
funded delirium research study regarding a
reorientation intervention for delirium in the
ICU.
Dr. Sonya R. Hardin, Dean of the School of
Nursing at the University of Louisville is a
Professor and adult nurse practitioner. She has
over 35 years of experience in the acute care
setting of critical care. Her research interest
include symptom management and care of older
adults.
Dr. DaiWai M. Olson is a Professor of
Neurology at the University of Texas
Southwestern with a research focus on care of
patients with neurological or neurosurgical
injury who require intensive or critical care.
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NURSES’ VOICE FROM THE FIELD
NURSING RESEARCH:
EVIDENCE TO DEVELOP HEALTH POLICY
Reiner Lorenzo J. Tamayo, RN1
n urses are at the forefront of delivering health care services.
This gives nurses a unique position to view health problems
at both micro and meso levels. Experiences at the bedside or in
the community often create a culture of inquiry whereby nurses
are led to question and evaluate their practices, and engage in
solving identified problems and challenges through research.
Research at the bedside produces valuable impact on patients and
nurses. It provides evidence to support nursing practice (Bridges,
2015). However, evidences generated by nurses through research
are often not utilized in the development of health policies. This
understanding of the current state of policy research in the country
warrants us to broaden our focus from research on bedside
interventions to research that addresses care across the health
continuum at the system level.
Nursing research has a huge potential to develop health policies
with the goal of improving health outcomes. Nurses, however,
should have a good understanding of the political process and how
research actually advances health policy. The policy process
framework provides a simple structure for understanding the
connection between research and policy.
The framework breaks down the policy process into a series of
stages: (1) problem identification and issue recognition, (2) policy
formulation, (3) policy implementation, and (4) policy evaluation
(Buse, Mays &Walt, 2012). In the real world, policy development
does not occur in a linear fashion. Nevertheless, it is helpful to
imagine policy making occurring in these stages and placing
nursing research in the context of a specific stage (Buse, Mays &
Walt, 2012; Ellenbecker & Edward, 2016).
Nurses can envision their research in this policy process
framework. Nursing research may contribute evidence to one
stage of the policy process. Others may not fall into one specific
stage but contribute evidence at various stages of the process.
Increased understanding of the policy process and how research
contributes to each stage of the process prepares nurses to be
more effective in contributing to health policies that can potentially
affect the nursing profession as well as the population it caters
(Ellenbecker & Edward, 2016)
1 Correspondence: Philippine General Hospital, Taft Avenue, Manila, Philippines 1000; email address: rjtamayo@up.edu.ph
PJN VOL. 89 | NO. 1
Problem Identification and Issue Recognition
The first stage of the policy process explores how issues get on
the policy agenda. Policy issues surface when they are identified,
described, and acknowledged as problems requiring attention
(Buse, Mays & Walt, 2012; Ellenbecker& Edward, 2016). Nursing
research, in the early stages of the policy cycle, can help define
the nature and severity of the problem. It deepens the
understanding of why a problem exists or why it continues to exist.
Various research designs can be utilized to advance problem
identification. These include case studies, phenomenological
studies, descriptive and correlation studies.
One example of research contributing at the problem
identification stage is a study on nurse-to-patient ratio in
government- and private-owned hospitals in the Philippines. The
study found that the number of nurses in relation to the number of
government hospital beds is not adequate. Identifying this
problem, the researchers stressed the importance of addressing
a policy issue (i.e. internal nursing shortage) by improving
recruitment and retention policies for government hospital nurses
(Corral, Montoya-Del Rosario & Manalo, n.d.).
Policy Formulation
Not all policy issues are given adequate attention by policy
makers. But when they do, policy solutions and alternatives are
considered by policy makers at the policy formulation stage of the
policy process. Nursing research can feed into policy formulation
by providing evidence on policy interventions based on defined
criteria such as quality, cost-effectiveness, and feasibility. Most
commonly used research designs at this stage are those that test
interventions using experimental or quasi-experimental methods.
Meta-analysis and cost-effectiveness analysis can also
contribute substantial information on effective interventions.
A study determining the required skill mix to deliver primary
health care services across various rural and urban communities
is a good example of a research providing evidence for policy
alternatives. The study determined the current structure of health

workforce in rural and urban communities, and factors
influencing the determination of appropriate skill mix and health
worker ratios in these settings (Abad, Dones, Medina, & Cordero,
2016). This evidence can provide a concrete rationale for a policy
on the appropriate skill mix in primary care in various
communities in the country.
Policy Implementation
Policy implementation is arguably the most important stage of the
policy process. Enacting a law does not guarantee that it will be
implemented the way policy makers intended. Many policies do
not achieve their goals due to an implementation gap between
what was planned and what occurred as a result of the policy
(Buse, Mays & Walt, 2012). Research at this stage examines how
a policy has been implemented by government agencies and
how the objectives of a policy have been translated into actual
practice (Ellenbecker & Edward, 2016). Qualitative, quantitative
and mixed method study designs are often used to examine
variables related to implementation.
One example of a research contributing to the implementation
stage is a study evaluating the factors influencing the
implementation of local policies to promote physical activity. The
study's findings suggest that intergovernmental coordination,
knowledge and awareness, commitment and capacity, conflict,
and the presence of an advocate influence the implementation of
a physical activity policy at the local level. Future policies seeking
to increase physical activity through policy should focus on the
aforementioned implementation features to make policy
implementation more successful (Salvesen et al., 2008).
Policy Evaluation
The final stage of the policy process examines what happens
after a policy was put into effect. It describes how a policy has
achieved its objectives and whether it has unintended
consequences (Buse, Mays & Walt, 2012). Research at this
stage looks at the outcomes of the law after it has been
implemented. Evaluation studies can actually determine the fate
of a policy - whether to improve or repeal the policy. Experimental
and mixed method designs can be used to comprehensively
evaluate both the short- and long-term outcomes of a law.
Philippine laws, if at all, are seldom evaluated. This presents an
opportunity where nurses and other stakeholders can take
advantage of. Next to devolution, the passage of the Universal
Health Care (UHC) law promises a system wide health reform
that ensures access to a comprehensive set of health services
without suffering from financial catastrophe. The potential impact
of this law will not be palpable in the next five years. However,
future evaluation of the UHC law will determine how this policy
reform affected overall health care delivery and population-
based outcomes.
73
JANUARY - JUNE 2019
End Note
As frontline workers, nurses offer a unique perspective on
various aspects of the health care delivery system. More
importantly, nurses possess a collective voice that can influence
policy development. Using the policy process framework as
guide, nurse researchers can refocus their research on
addressing problems that are on the health agenda. Thus,
allowing nurses to fully engage in health policy research that will
inform and advance relevant health policies seeking to improve
patient outcomes.
.....................................
References
Abad, P., Dones, L., Medina, V., & Cordero, A. (2016). Determining the
Required Skill Mix to Deliver Primary Health Care Services Across
Various Rural and Urban Communities. Department of Health:
Manila, Philippines
Bridges, E. J. (2015). Research at the bedside: It makes a difference.
American Journal of Critical Care, 24(4), 283-289.
Buse, K., Mays, N., & Walt, G. (2012). Making health policy. McGraw-Hill
Education (UK).
Corral, R., Montoya-Del Rosario, M., & Manalo, J. (n.d). Study on Ratio
of Physicians and Nurses to the Existing Number of Patient's Bed in
Government and Private Owned Hospitals in the Philippines.
Department of Health: Manila, Philippines
Ellenbecker, C. H., & Edward, J. (2016). Conducting nursing research to
advance and inform health policy. Policy, Politics, & Nursing
Practice, 17(4), 208-217.
Salvesen, D., Evenson, K. R., Rodriguez, D. A., & Brown, A. (2008).
Factors influencing implementation of local policies to promote
physical activity: a case study of Montgomery County, Maryland.
Journal of Public Health Management and Practice, 14(3), 280-
288.
ABOUT THE AUTHOR
Reiner Lorenzo J. Tamayo is a
neuroscience nurse at the Philippine
General Hospital. He earned his bachelor's
degree in nursing from the University of the
Philippines Manila in 2015. Reiner is
currently pursuing a graduate degree in Health Policy Studies
at the UP College of Public Health. He writes opinion pieces
and regularly publishes them at mrtamayo.com.
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PHILIPPINE NURSES ASSOCIATION, INC.

PNA’s Position on the Contractualization

of Nurses in the Philippines

What makes nurses distinct from any other healthcare professions is that they provide hands-on
care to patients. The focus of the nurse is providing patients a safe care, thus, they spend a great
deal of time caring for the patients, both well and unwell. They provide other health care
professionals and even physicians the needed information to make decisions on managing the
care and treatment of patients. On top of it, nurses are primarily responsible for the execution of
care plan formulated for their patients reference.

Despite their significance, nurses feel that they are not being valued. For years, they have been
clamoring as victims of unfair labor practices and deprivation of unjust compensation, undignified
treatment at work, and poor working environment. Yet, reported incidents of exploitation and
unfair labor practices among nurses persist and are increasing. There are documented cases
that nurses went on duty beyond their health capacity as humans, forcing them to work for a
straight 48 hours. This is already considered as unsafe healthcare practice. PNA also
documented some reported cases wherein nurses are still being paid below the prescribed
minimum wage. Just last month, despite the very meager salary thatnurses are receiving, PNA
received requests for help from four (4) nurses who did not receive their salaries for straight four
(4) months, yet were still forced to render clinical duty of up to 36 hours.

Why do you think these abuses continue among nurses if refusing to do so can be an option? It is
the code of ethics of the nursing profession---patient safety is more important than anything else.
Nurses are trained not only in adhering to these ideals but also to own it as their life’s purpose of
what it means to be a nurse. Sadly, it is the very same code of ethics that
non-compliant health care facility employees make use of, thus, exploitation among nurses
continues to exist. Nurses are held hostage to the very purpose and nature of their profession, the
very reason that when hospitals are understaffed, and nobody receives the next shift
endorsement, poor nurses had no choice but to attend to their patients safety.

This month, there were reported incidents in Cebu, wherein out of 89 nurses under cost of service
contract, 64 were no longer renewed. This is very alarming, and is detrimental not only to patients
who are at the hospital during the time these nurses were dismissed, but also to public safety. In
the Philippines, the ideal nurse to patient ratio is 1:12 according to the Department of Health
(DOH). But in reality, the average ratio based on actual data in one public hospital today, is1:60.
Imagine the impact of massive and outright removal of these nurses from the health care facility?
In place of these nurses who were removed, who will carry out the doctors order? Who will
prepare the treatment plan and document what had been done to patients? Who administers the
medications and monitor the patients response and progress?

This mirrors the worsening scenario of our health care system today. Current laws and labor
practices and even hospital policies are insufficient to protect not just the rights of our nurses, but
also that of the ordinary citizens whose right to quality health and even to safety were deprived.
According to the World Health Organization (WHO), nurses are the keys to the successful

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JANUARY - JUNE 2019

implementation of the Universal health Care System (UHC), The UHC even requires hiring more
nurses to improve the access to care and services among patients. With the current
practiceshowever, coupled with the negative experiences of nurses, how can we encourage
nurses to support this plan.

Since 2016, contractualization had been at the forefront when President Rodrigo Duterte
promised to end it. Nurses are one of the hopefuls, thus hold their reigns and endured staying
where they are, refusing the lucrative offers abroad in exchange of an improved living condition
for their family. As of the moment, we have around 17,000 nurses in the government who are
under cost of service contract. Although House Bill 5707 states that the LGU may exclude allied
and health professionals through right-sizing, still these group of professionals including nurses
are at the discretion of the Local Chief Executive (LCE) and has therefore no security of tenure.
Now, even the President himself vetoed the passage of law against contractualization and this
was confirmed last July 26, 2019. With this, what reasons beyond human comprehension can we
give our nurses as an encouragement to stay and choose to serve our countrymen, over foreign
nationals who can provide them a just compensation, a better living condition, and above all,
make them feel that they are highly valued as a professionals?

There was a remedial measure proposed by Sen. Christopher Bong Go by amending RA 6758,
with an SSL 5 adjustment. Senator Richard Gordon authored a separate Resolution and Senate
Bill. Senate Bill 562 is the closest we have, but it aims to revise Republic Act 9173. It recognizes
that nurses provide safe, humane, quality and holistic care to individuals of varying age, gender
and health status, population groups and communities, and that they render professional
services in various health facilities and institutions, including hospitals, in shifts and irregular
hours for so long as their services are needed. A provision is found reiterating that nurses will have
a Salary Grade 15, entry level. It guarantees a decent and living wage. Yet, even with a higher
salary grade as a provision, it has no other proposal that prefers regularization over
contractualization.

Still, these are not sufficient to keep our nurses from going abroad. The current law provides for
nurses an SG 11 rate, equivalent to P 20,754. Should government nurses be included in the
proposition of Sen. Go and if it gets an approval, the maximum increase that the nurses can get is
only around P4,000 which is still way far from what PNA is pushing since 2002, for nurses to be
given at least an SG15 rate equivalent to P30,531. That of Senator Gordon is more promising.

PNA further stands against cost of service, job orders, project-based, consultancy service and
any forms of contractualization particularly among nurses. Health care is a basic necessity, the
demand for quality health care is growing, and the health care system is becoming more complex
thus requiring a more efficient coordination among health care professionals with nurses primarily
responsible for implementing the health care management plans. With the UHC implementation,
we need to bring back our nurses to where they should be - here, taking care of every Filipino,
providing safe and quality health care, and as primary partners in promoting primary health care.
We can only do that if we will show them how valuable they are through giving them a competitive
pay with a well-deserved security of tenure, providing better working condition primarily by
treating them with respect, and by upholding their dignity as valued professionals. These should
be translated into laws, policies, and implementing guidelines that health care institutions adhere
to. Otherwise, it is but inhuman to compel them to stay in workplaces that do not uphold their
dignity as professionals and deprive them of their rights to a just compensation and fair treatment,
free from exploitation and intimidation.

(SGD) PNA Board of Governors 2019

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The PJN is indexed in the Western Pacific Region Index Medicus (WPRIMP, a project of the World Health Organization Western Pacific Regional
Office in collaboration with several institutions in its Member States. All journals must be approved by the Regional Journal Selection Committee
before inclusion of any articles or abstracts in the WPRIM database. The PJN was officially accepted for inclusion on August 15, 2014, in a meeting
held in Ulaan Bataar, Mongolia.

PJN VOL. 89 | NO. 1

 BOARD OF GOVERNORS 2019
• Mr. George Michael P. Lim EDITORIAL BOARD
Chairperson
Governor, PNA Region X Erlinda Castro-Palaganas, PhD, RN
• Mr. Angelo C. Cawasa
Editor-in-Chief
Corporate Secretary
Governor, PNA Region IX
• Dr. Erlinda C. Palaganas Members
National President Cora A. Añonuevo, PhD, RN
Governor, PNA CAR Cecilia M. Laurente, PhD, RN
• Mr. Melbert B. Reyes
VP for Programs & Development Editorial Assistant
Governor, PNA Region IV
Hazel Vera D. Tan, RN
• Dr. Annabelle R. Borromeo
Vice President for Finance
Cover Design and Layout
Governor, PNA NCR Zone 3
• Dr. Yolanda T. Canaria Raul DC. Quetua
Treasurer
Governor, PNA NCR Zone 6
• Dr. Rosie S. De Leon
Governor, PNA NCR Zone 1
PEER REVIEWERS
• Mr. Neil G. Cabbo
Governor, PNA NCR Zone 2 CARMENCITA M. ABAQUIN, PhD, RN
• Dr. Maria Geraldine Q. Dimalibot FARHAN ALSHAMMARI, PhD, RN
Governor, PNA NCR Zones 4 & 5 ARACELI O. BALABAGNO, PhD, RN
• Ms. Miriam I. Ramones TERESITA I. BARCELO, PhD, RN
Governor, PNA Region I ALAN BARNARD, RN, BA, MA, PhD
• Mr. Jan Nicanor B. Tugadi SHEILA R. BONITO, PhD, RN
Governor, PNA Region II ANNABELLE R. BORROMEO, , PhD, RN
• Dr. Victor C. Quimen, Jr. HELEN M. BRADLEY, PhD, RM, RN
Governor, PNA Region III IRMA C. BUSTAMANTE, PhD, RN
• Ms. Alilie G. Gaduena EDWARD VENZON CRUZ, RN, BN, MEM, MScN
Governor, PNA Region V CARMELITA C. DIVINAGRACIA, PhD, RN
• Dr. Lea P. Alayon SUSAN FOWLER-KERRY, PhD, RN
Governor, PNA Region VI CAPRICE A. KNAPP, PhD
• Dr. Marylou B. Ong LETTY G. KUAN, EdD, RN
Governor, PNA Region VII THOMAS S. HARDING, PhD, RN
• Mr. Nino Archie S. Labordo MILABEL E. HO, EdD, RN
Governor, PNA Region VIII LETICIA S. LANTICAN, PhD, RN
• Ms. Jessica Mae D. Alaban MARIA CYNTHIA LEIGH, PhD, RN
Governor, PNA Region XI MILA DELIA M. LLANES, PhD, RN
• Mr. Ser Rosenkranz G. Espartero ROZZANO C. LOCSIN, PhD, RN
Governor, PNA Region XII FELY MARILYN E. LORENZO, DrPH, RN
• Ms. Ella June C. Delos Reyes ARACELI S. MAGLAYA, PhD, RN
Governor, PNA CARAGA CELSO PAGATPATAN, DrPH, RN
• Mr. Fahd S. Schuck JOSEFINA A. TUAZON, DrPH, RN
Governor, PNA ARMM PATRAPORN TUMPUNGKON, PhD, RN
BETHEL BUENA VILLARTA, PhD, RN
Maria Liza Peraren, MAN, RN PHOEBE D. WILLIAMS, PhD, RN
Executive Director

CALL FOR PAPERS

PHILIPPINE NURSES ASSOCIATION, INC. PJN July-December 2019 Issue:
1663 F.T. Benitez Street, Malate, Manila 1004
Telephone Nos: 8521-0937, 8400-4430 / Telefax: 8525-1596 Theme: “Caring and Nursing Research: What Nurses Do Best”
Website: www.pna-ph.org | Email: philippinenursesassociation@yahoo.com.ph

PJN VOL. 89 | NO. 1