Experiences of care professionals and effects of application of sleeping protocol Night&Rest in psychogeriatric residential care: A pilot study

Abstract

Background

In long-term elderly care, sleeping problems regularly occur in nursing home residents with dementia. Three elderly care organizations in the Netherlands developed a sleeping protocol and App called ‘Night&Rest’.

Objective

To examine (1) effects of Night&Rest on the number of bedexits and moments of nocturnal restlessness and (2) experiences of professionals with Night&Rest and the value for their clients and their own work perception.

Methods

A Single-Case Experimental Design (SCED) with a pre- and post-measurement was used. Registration forms were used to gather data on residents’ characteristics, type of sleeping problem, frequency of nocturnal restlessness and bed exits. Semi-structured interviews were conducted afterwards with professionals involved.

Results

A total of 15 residents were included in the study. Results on the registration forms showed a reduction in the number restlessness and bed exits among the majority of participants. Results of the interviews indicated predominantly positive experiences with Night&Rest. Professionals appreciated the structured guidance and accompanying tools to identify sleeping problems and select interventions.

Conclusion

Mainly positive experiences and effects of Night&Rest were found on both residents with dementia and care professionals. Large-scale research into long-term effects and further implementation in psychogeriatric care is recommended.

Keywords

sleep sleeping problems dementia app protocol intervention

Introduction

A good night’s sleep is important for everyone, including nursing home residents with dementia. In this target group, the condition may lead to disrupted sleep patterns. Research showed that 60% of psychogeriatric clients suffer from at least one serious sleeping disorder, such as insomnia or sleep apnea.¹ Sleeping problems can have various consequences, like nocturnal restlessness and problem behaviour resulting in wandering, calling behaviour, or aggression at night but also during the day. Symptoms of nocturnal restlessness may include residents having a reversed day and night rhythm, not being able to fall asleep or sleep through the night, not recognizing their own bedroom, or having the urge to go to the toilet frequently. This in turn may cause even worse sleep and, as a result, sleep quality may further decline and consequently lead to fatigue, change in behaviour, decreased daytime functioning and accelerate deterioration of the disease process. These problems among residents may have repercussions on healthcare professionals since this may have impact on their perceived workload and work stress at both night and day time shifts.

Causes of disturbed sleeping patterns can vary from person to person and so may treatment to improve sleep quality. Research has shown that sleep hygiene has major impact on sleep patterns.^2–8 Sleep hygiene refers to healthy habits, behavioural and environmental factors that affect sleep and that can be adjusted to help you have a good night’s sleep. Improved sleep will not happen as soon as changes are made. To improve sleep hygiene various often low-threshold interventions can be applied. Interventions may include sleep education to stress the importance of, for example, maintenance of routines (e.g. to caregivers), lifestyle modifications (e.g. less caffeine or alcohol consumption), stimulation of exercise and/or relaxation interventions.⁹ Moreover, psychological treatments such as cognitive behavioural therapy and acceptance and commitment therapy (ACT) have been proven effective to promote healthy sleep.^10–12 In addition, innovative technological solutions, such as light therapy, sleep robots and eHealth interventions may also be considered to address sleeping problems. Studies on the effectiveness of such innovative technologies are still limited and show little evidence. For example, a study on the effect of the Somnox robot showed no significant effects on insomnia in adults with anxiety or depressive symptoms.¹³ Reviews on the effects of light therapy in people with dementia who experience anxiety or depressive symptoms shows that it may possibly have an effect on (the number of) sleep interruptions, but longer-term results are still very uncertain and unclear.¹⁴ Therefore, as a result of insufficient evidence, the Dutch guideline for the treatment of sleeping problems in long-term care does not recommend most non-pharmacological interventions and suggests more scientific research into these interventions.³

Nursing homes residents with psychogeriatric disorders regularly experience nocturnal restlessness due to poor or disturbed sleep patterns. Previous research within three of these elderly care organizations in the South of the Netherland showed that the amount and kind of nocturnal restlessness varies between residents and may be influenced by both personal factors (e.g. disorder(s), personal history, routines, preferences) and contextual factors (physical environment and factors related to the involved care professionals). The care professionals, mainly night shift workers, reported having insufficient knowledge and tools to provide their residents with person-centred care for those who have or appear to have a sleeping problem. They often ask (para)medics to deploy care to solve or prevent restlessness and associated problems which often include pharmacological interventions. Internal research has shown that it is difficult for (para)medical disciplines, including physicians, psychologists and nurses to provide concrete guidance to night shift workers, as they themselves are not present during the night and are dependent of the subjective information provided by the night shift worker.

In 2022, three long-term care organizations in the south of the Netherlands exchanged their experiences on sleep and sleeping problems among their residents with dementia. They decided to cooperate and combine their expertise on identification and treatment of sleeping problems for their residents. Together with experts in the field of sleeping problems (a.o. Kempenhaege centre of expertise on Sleep Medicine), internal experts (such as psychologists, physicians) and care professionals a sleeping protocol called Night&Rest was developed. The sleeping protocol consists of a website and digital application designed in a cocreation approach. The protocol provides information about the definition of three types of sleeping problems (problems falling asleep, sleeping through the night, waking up too early) and tools to identify the type of problem. Additionally, an overview and description of (possibly suitable) interventions to be used for each type of sleeping problem is presented. The main goals of the sleeping protocol were to provide care professionals (nurses, but also involved (para)medical staff, psychologists, behavioural scientists) with: (1) information about sleep, night and day rhythm, types of sleeping problems and causes, (2) tools to identify sleeping problems among residents with dementia, and (3) information about interventions to treat different types of sleeping problems.

This pilot study examined the experiences of professionals with the implementation of the Night&Rest protocol within the three organizations on residents’ sleeping problems and on their own work perception.

Research questions

1. What are effects of application of Night&Rest by care professionals on nursing home residents with dementia suffering from sleeping problems?

2. What are the experiences with application of Night&Rest of the involved care professionals’ on the perceived value of the sleeping protocol and on their own work perception?

Methods

A Single-Case Experimental Design (SCED) pilot study was conducted to study effects on the individual level of the clients. This design meets the complexity of sleeping problems and heterogeneity of the target population. For each client registration forms were used to collect data on an individual level, before and after application of Night&Rest. After the protocol was finished, double interviews with two care professionals involved in each clients’ case were invited to participate to evaluate their experiences for the particular case.

Setting and study population

Three elderly care organizations in the South of the Netherlands providing intramural care participated in the study. The organizations provide care to elderly people with psychogeriatric (PG, especially dementia) or somatic conditions in their care and nursing homes. Organization 1 N = 620, organization 2 N = 641 and organization 3 N = 880 psychogeriatric residents at the time of the study. The study was carried out at two or three PG locations of each organization, where residents with dementia live.

Screening and selection

To select residents for participation in the study, purposive sampling was applied. Residents suspected by a physician or psychologist (depending on the method used in each organization) with sleeping problems and who met the inclusion criteria were included in the study. Informed consent was obtained from the legal representative of the resident in question. In addition, professionals involved in (night) care and dealing with sleeping problems of the selected residents were asked to participate in the study when meeting the inclusion criteria.

Inclusion and exclusion criteria

Inclusion criteria residents:

- The resident has a psychogeriatric condition (dementia)

- The resident is living at one of the PG locations where Night&Rest has recently been implemented

- The resident has an advanced stage of dementia, needs intensive care and suffers from (severe) behavioural problems

- The resident is (suspected of) having a sleeping problem

Exclusion criteria residents:

- The suspected sleeping is not diagnosed as actual sleeping problem according to the criteria of the sleeping protocol

- The sleeping problem is caused by a physical cause, like an illness or a disease (e.g. bladder infection) or through medication use

Inclusion criteria care professionals:

- The care professional works at one of the selected PG locations where Night&Rest has recently been implemented

- The care professional knows the included resident(s) personally well

- The care professional is familiar with the content and knows how to use Night&Rest

Exclusion criteria care professionals:

- The care professional is a trainee

- The care professional works on a self-employment basis or is a temporary employee (who does not know the resident(s) well)

The aim was to include and evaluate 20 cases of PG residents during the period from mid September 2023 to mid November 2023. Given differences in the number of residents per organization and their locations, the target number per organization was predetermined: 10 residents at organization 1, 6 residents at organization 2, and 4 residents at organization 3. For the interviews, the physician/psychologist and care professionals involved (e.g. behavioural scientist or occupational therapist) were invited to participate.

Night&Rest app

Night&Rest consists of website (https://nachtenrust.nl/welcome) and app (free downloaded in the App Store and Google Play Store). Night&Rest can be used on a mobile device (phone, tablet) based on the previously developed sleeping protocol by the three organizations. The homepage displays three sections, namely (1) sleeping protocol, (2) interventions, and (3) information about sleep. Section 1 describes the protocol and the steps to be taken sequentially. This describes who (which discipline) is responsible for what tasks, and what support tools can be used for each step (diagnostic questionnaires, sleeping diary tools etcetera). Section 2 lists interventions, existing of two main categories: (1) care and treatment interventions for each of the three types of sleeping problems, and (2) safety interventions. Each intervention describes what it entails, when and by whom it may or should be carried out. The latter has to do with applicable legislation (e.g. the Care and Compulsion Act). Different kinds of interventions are described in the app. Examples of interventions included are sleep hygiene measures (improvement of a normal day and night rhythm, sufficient exposure to daylight, sufficient physical activity during the day), but also the use of different types of beds, aggravation blankets, sensors and/or camera systems to detect, for example, bed or bedroom exits, light therapy, nutrition and movement interventions, music, sleeping robots and so on. Section 3 describes information on sleep, sleep problems in the elderly, types of sleep problems and factors that may affect sleep (such as food, medication, day and night rhythms). Care professionals of the locations selected for participation in the study received instruction and training on how to use and apply the Night&Rest App.

Procedure and data collection

Based on a signal from a caregiver or own observation, the physician/psychologist determined whether a sleeping problem was suspected in the resident. The resident was included in the study if he/she met the inclusion criteria and informed consent was obtained. Then the registration form was completed by care professionals involved in the care for the resident for five consecutive nights. They reported on the indicators: (1) frequency of nocturnal agitation (number of times per night), and (2) frequency of bed exits per night. For the five pre-intervention and post-intervention registrations an average was calculated on the indicators and this was noted by care professionals on the registration form. According to the literature, an objective picture of a sleeping pattern emerges after three to five nights.¹⁵

Relevant residents’ characteristics (e.g. age, sex, medication use) and information about the sleeping problem (such as number of moments of restlessness, kind of behaviour and number of bed exits) was also registered. Then, the care professionals started using the sleeping protocol, to identify the type of sleeping problem and selection of one or more intervention. The selected intervention(s) was applied for five to seven consecutive days and nights. Thereafter, the registration form was again completed for another five consecutive nights. After these five nights, the care professionals were asked to indicate whether the intervention(s) had or appeared to have effect on the sleeping problem. If not effective, they could stop the intervention, choose to make adjustments to the intervention, or try one of the other proposed interventions. In the latter two cases, the professionals were asked to complete the registration form again during for five consecutive nights after application of the intervention. Throughout the study, each resident was closely monitored by the attending physician or psychologist.

Afterwards, a semi-structured double interview was conducted with the involved physician/psychologist and one of the involved healthcare professionals (such as a caregiver, nurse, occupational therapist) to assess their experiences with the application of Night&Rest. The completed registration forms were used to initiate the conversation about each individual case.

Data analysis

The data from the registration forms were processed in Microsoft Excel. For each resident, the averages on the indicators of the 5 days of pre-measurement and the 5 days of post-measurement (and if applicable post-measurement 2) were entered. Characteristics of the participants and the mean scores on the registration forms were reported using descriptive statistics (by numbers, percentages and means). The audio recordings of the interviews were transcribed verbatim. Thematic analysis then took place based on the topics of the interview guide. An independent researcher began the analysis of two of the transcripts. The analysis, in the form of coding of themes and summaries of results for each theme, was submitted and discussed with the researcher who conducted the interviews. The remaining transcripts were then analyzed, compared with the results from the registration forms. Then the results were discussed by the analyst and verified with the interviewer. The results were then submitted anonymously to the project team and discussed and verified together.

Data management

The registration forms were completed by professionals of the organizations. The local researchers linked a unique code to each resident. They kept this key document in a secure place at their own location. The anonymized forms were then analyzed by researchers from Zuyd University of Applied Sciences. Audio recordings of the interviews were stored by the researchers on the specially equipped and secured research disk of Zuyd. After the interviews were transcribed, audio recordings were deleted. All data will be kept for 15 years from the termination of the research project on the secure disk in a folder only the lead researchers have access to. Before the start of the study, medical ethical approval was obtained by the Medical Ethics Review Committee METC-Z (METCZ20230086).

Results

Description and characteristics of participants

A total of 15 residents were included in the study. These included 4 residents from organization 1, 4 residents from organization 2 and 7 from organization 3 (see Table 1). A total of 14 double interviews took place with 17 care professionals to evaluate the cases. Some professionals were involved in multiple cases.

Table 1.

Description of residents per organization and number of interviews with professionals.

Organization	Residents with dementia (n)	Double interviews with professionals (n)
Organization 1	4 residents at 3 locations	5 interviews with 8 caregivers (3 nurses, 3 behaviour counsellors, 1 psychologist, 1 geriatric physician)
Organization 2	4 residents at 1 location	1 interview with 2 caregivers (1 nurse, 1 psychologist)
Organization 3	7 residents at 3 locations	8 interviews with 7 caregivers (1 nurse, 1 therapist expressive arts, 1 occupational therapist, 4 psychologists)

Results registration forms

Residents were included across a total of seven sites of the three organizations. For each of the 15 residents included in the study a registration form was completed (see results in Table 2). The average age of the residents was 86 years, ranging from 73 to 100 years. Two residents with suspected sleeping problems were identified with a falling asleep problem, six residents with a sleeping through problem, three with both a falling asleep and sleeping through problem, and the remaining four were to have a combination of falling asleep, sleeping through and/or waking up too early problem. Most residents used medication, but only one participant used sleeping medication.

Table 2.

Results of the registration forms.

Client	Age (in years)	Type of sleeping problem	Symptoms	Frequency restlessness (pre-intervention) (n)	Bed exits (pre-intervention) (n)	Intervention(s)	Frequency restlessness (post-intervention) (n)	Bed exits (post-intervention) (n)	Effect of intervention(s) (yes/no)
1	88	Sleeping through	Walking, wandering	2–3×	2	Aggravating blanket	3	3	No
2	88	Falling asleep	Tiredness during daytime, not wanting to go to bed, wandering	-	0	Suspension of going to bedtime, more activities, spreading medication throughout the day	-	0	-
3	80	Sleeping through	Sitting upright in bed, falling asleep during the day, fall incidents	-	1	No afternoon nap	-		Yes
4	84	Sleeping through	Variable sleeping pattern, tiredness during the time	Variable	0	Different type of bed	Variable	0	No
5	85	Falling asleep, sleeping through	Being awake at night, sleeping a lot in wheelchair	8	8	Micro Cosmos (bed cover)	0	0	Yes
6	100	Sleeping through, waking up too early	Being awake at night, sitting on the edge of the bed, searching and calling behaviour	8	6	Use of night lamp for better orientation, suspension of morning medication, adjustment of personal approach	2	2	Yes
7	93	Sleeping through, waking up too early	Being awake at night, wandering, searching behaviour (looking for toilet)	3 or more	6	Micro Cosmos, use of night lamp, adaptations in physical environment (e.g. leaving doors open)	1 or 2	2	Yes
8	91	Falling asleep, sleeping through	Reversed day and night rhythm, being stressed when lying in bed (discomfort)	10	0	Relaxing music, projections on wall, use of lying orthosis	5	0	Yes
9	85	Falling asleep, sleeping through and waking up too early	Wandering at night, searching behaviour (toilet), barricading room door	4	4	Aggravating blanket, night lamp, fixed positions of clothes, furniture in the room	1 or 2	2	Yes
10	86	Falling asleep, sleeping through	Wandering and restlessness at night, searching behaviour, reversed day/night rhythm	4	4	Night light, different position in bed, adjustment of personal approach	2	2	Yes
11	87	Sleeping through	Sitting on the edge of the bed, getting up at night	3–5	0	Somnox (sleeping robot)	Variable	4	No
12	81	Sleeping through	Wandering, searching behaviour	5	5	Aggravating blanket	2	3	Yes
13	90	Falling asleep	Mulling at night	6	1	Somnox (sleeping robot)	0	3	Yes
14	73	Sleeping through	Rummaging in the room	2	9	Music pillow	4	2	Yes
15	83	Sleeping through, waking up too early	Watching television before going to sleep, wandering	3	2	Double blanket, heating in bedroom	1	1	Yes

Sleeping problems manifested itself in a variety of factors, including nocturnal awakening and/or wandering, frequently getting up to go to the toilet, walking urges, daytime fatigue, searching behaviour (for belongings, toilet, people, etcetera), moaning or making noise.

Data of the registration forms was not all completed by the care professionals (missing data represented by ‘-’, see Table 2). These values could not be included in the results below. The average frequency of restlessness measured over five nights at the start varied between residents, also per resident per night. On average, there were five moments of restlessness per night per resident (ranging from 2 to 10) which led to duration of care taking per client between 5 and 20 min (excluding three outliers of 40, 50 or 75 min). There were on average three bed exits per resident per night.

After application of the selected intervention(s), 10 residents showed a decrease in the number of moments of restlessness at night (the average decrease of all residents was 2). The number of bed exits decreased in 8 of the 15 residents with sleeping problems, the average number decreased from 3.2 to 1.7. The number of minutes of care per moment remained between 5 and 20 min in most cases, but showed a decrease in about half of the residents (from 20 to 13 min). In 11 of the 15 residents the care professionals indicated that the intervention was effective. Only in two of the residents a follow-up intervention was deployed, with indications for a (more) positive effect of the second than the first intervention (less restlessness, care time spent and bed exits; values not included in Table 2).

Results of the interviews

Use of the Night&Rest app

Overall, all users reported the app to be very user-friendly. It is easy to use and the structure of the app was rated as good. The information on sleep and interventions is very clear and the steps are helpful.

“You can go through the sleep protocol step by step and if you notice we are not there yet, you can also go back again. It’s a guide that works well and is clear for care.” The care professionals used the app on their own tablets. The step-by-step approach was used to first identify whether there was a sleeping problem or an underlying somatic cause, which could have induced the sleeping problem. Subsequently, they identified the type of problem (falling asleep, sleeping through, or waking too early) and, often in consultation with team members, selected in one or more interventions represented in the app and applied it on them, simultaneously or consecutively. Interventions used were mainly measures in the field of sleep hygiene (not going to bed too early, no more caffeine in the evening, winding down the day (dimming the lights in the evening), adjustments in room design (different position of the bed, for example, in relation to the door), furniture (different type of bed), bedding (weighting blanket), clothing (cotton pajamas), or lighting (night light). Additionally, musical interventions (soothing music) or several types of technology, such as daylight lamps, sleep robots (like Somnox), bed covers (like Micro Cosmos) were also frequently used interventions.

Value of the sleeping protocol for residents and professionals

The main added value of Night&Rest for the residents according to the care professionals was that the use of the app led to better understanding of and connection with the residents’ individual needs. Care professionals who were directly involved in the care for participating residents mentioned the app to be of great added value to their work. Interviewees praised the step-by-step and structured approach used in the app. This perceived added value was similar across the three organizations.

Participants mentioned that the app gave them more insight into the concept of sleep and helped them to map sleep rhythms and sleeping problems, and to identify possible causes. Tools available in the app, such as questionnaires or forms were very helpful, such as the ‘24-hour circle’.¹⁶ Also frequently mentioned was both the importance of having insight into the background, habits and rituals of their residents when they were still living at home, and the involvement of family, for better understanding of the current sleeping patterns and behaviour in the nursing home situation. Night shift workers indicated, that the setup of the bedroom, such as the position of the bed in relation to the door, or the amount of light could be of great importance for restlessness at night (due to disorientation when residents wake up).

“I realize much better now that the structure of the nursing home sometimes or often does not fit well with residents’ rhythms.”

In general, the sleeping protocol created more awareness on the topic of sleep among care professionals, about what a ‘normal’ day and night rhythm is, and what really happens at night. Targeted observations and objective reports of findings often showed different outcomes from what was assumed beforehand.

“The more I go through the sleep protocol and delve into it, the more I find out that residents do miss things in their standard bed or room in the nursing home compared to their prior home situation.”

Another added value of the app was that it enabled care professionals to get started themselves without necessarily calling in other disciplines or sleeping experts. They could use the app and try out low-threshold interventions themselves together with their team. The app displays for each step in the protocol which disciplines may be involved or consulted. On a team level, the app resulted in improved multidisciplinary cooperation and coordination of sleep care for residents.

Experienced added value of Night&Rest

The effects of Night&Rest on residents, according to the professionals, were a decrease in both number of bed exits and moments of nocturnal restlessness. The also experienced residents to return to bed quicker after getting out of bed, or resulted in less restlessness during the day was also seen as a gain.

“Because residents sleep better at night, they seem more relaxed and calmer during the day than before.”

Care professionals indicated positive effects of Night&Rest during the interviews. The app increased their awareness about the needs of their residents, and made them think more and more consciously about sleep and sleeping problems.

“The caregivers gained more insights into various sleep problems and started to recognize that there is a problem with sleep rather than a resident with dementia just being restless.”

By using the app, they could deploy faster and better solutions for their residents. This resulted in fewer bed exits or calls by residents during the night, and consequently to more rest and peace on the ward. Night shift workers did not have to visit residents so often and fewer residents wandered around disturbing fellow residents in their sleep. Some night shift workers indicated that the positive effects on residents resulted in less workload for themselves. Others mentioned that care for some residents decreased, but not the overall workload.

“You may have to go and check on a resident with a sleeping problem less because they get out of bed less, but that doesn’t mean that there is then less work, there are always enough care tasks to do.”

An important factor for success interviewees reported was that selected interventions should be used consistently by all professionals involved, and therefore mutual coordination between team members was important. Besides positive effects, also some negative effects passed by. A few night shift workers, in particular, experienced the use Night&Rest as an extra burden as I t felt as they were given assignments. Going through the app, but especially completing and maintaining reports on paper, took them extra time (e.g. completing the 24-hour circle). Others indicated that sometimes the information from the forms did not match the report in the resident’s file or was not described correctly (e.g. due to lack of specific knowledge about sleep). This did not apply for all sites and seemed to be related to the extent to which care professionals were involved and included in the implementation of the sleeping protocol.

“I actually hear some negativity from night care workers involved: why do we have to complete this again, we already know this anyway. They get irritated and mostly complain about it.”

Suggestions for improvement and future implementation

Some suggestions for improvement of the app were pointed out such as the findability of some of the tools in the app. In addition, in the current version it was not possible to complete forms and questionnaires digitally. Professionals indicated that it would be quite an improvement in terms of ease of use and efficiency if they could be completed, saved digitally immediately and ideally be linked to the electronic client file. Furthermore, several interviewees (especially treatment staff) noticed insufficient knowledge in the field of sleeping (problems) among care professionals, which led to (unconsciously) doing the wrong things or creating routines not contributing to a good sleeping pattern. The importance of trying to involve residents’ family members more actively in mapping problems and to identification of relevant background or contextual factors was also stressed. Furthermore, based on the mainly positive experiences and effects, most interviewees indicated the wish to continue use of Night&Rest. They also recommended further implementation among colleagues, other locations and organizations to increase competencies of care professionals about sleep in order to improve sleeping quality of their residents with dementia.

Discussion

The results of this study showed indications for positive effects of the Night&Rest protocol on both residents with dementia and the involved professionals. In particular, Night&Rest provided professionals with knowledge and insight into sleep, sleeping problems and (ab)normal day-night rhythms. The tools in the app were considered to be very helpful to map information and to identify (type of) sleeping problems. Additionally, the clear display of possible interventions helped professionals to select one or more possible solutions. Results of the registration forms showed a decrease in moments of restlessness at night and number of bed exits in the majority of residents, and it contributed to more rest during the day. Main effects mentioned by professionals were that they could take action themselves more quickly without having to call in external parties and that it improved multidisciplinary cooperation on sleep. Improved clients’ rest also resulted in more time to spend on other clients or other care tasks. However, no workload reduction was experienced (yet).

The sleeping protocol connects well with the recently published guideline for long-term care ‘Healthy sleep and sleeping problems’ in the Netherlands¹⁷ that aims to implement knowledge about and treatment of sleeping problems broadly in long-term care, specifically care for the mentally disabled and elderly. This also applies for residents with dementia living in long-term care facilities such as nursing homes, for whom specific dementia-related factors should be taken into account. Contextual factors such as routines or habits residents had when they were still living at home may be important for their functioning at the care facility, such as the position of the bed in the room, the use of lighting during the night, bedtime, or wearing pajamas.

Strengths of the study were the joint development of Night&Rest by three elderly care organisations and the close collaboration with experts in the field of sleep. The development was based on the sustainable innovation process model.¹⁸ The process consisted of iterative phases, in which various end-users, such as practitioners, care workers and innovation professionals were closely involved in the development of the protocol and the subsequent usability and feasibility testing phase of the app. A weakness of the study was the recruitment of residents. The main reason for the lower number of participants than determined in advance was the short period in which the research had to take place due to grant regulations. In this short period the number of residents suspected with sleeping problems was also lower than observed earlier within the organizations. For the purpose of the study, to study the potential of Night&Rest, the number of participants seems fair. For more robust effect measurements in the future, the number of participants should be based on power calculation and the intervention period as well as the period for outcome measurement may be extended to assess long-term outcomes. The intervention period was now set to 5–7 days and outcomes on registration forms were assessed afterwards. Based on the results, professionals had the opportunity to stop or change the intervention or to extend the intervention period with a second period of 5–7 days. It was expected that for most interventions, like sleep hygiene measures (including interventions as maintaining a consistent schedule or bedtime routine, avoiding alcohol and nicotine, limiting use of screens before bedtime),⁹ at least some (indications for) effects would occur within a week. However, interventions such as sleep robots may take a longer intervention period to demonstrate actual effects on sleep.¹³

However, based on the promising results of this study, Night&Rest may contribute to the improvement of sleeping care for people with dementia. Despite the fact that there are few effect studies on the effects of non-pharmacological interventions in elderly care available yet,¹⁷ the results of the current study are very promising.

How to implement and upscale Night&Rest among other locations and organisations is a point of attention. Results of the interviews showed differences between the organizations in the strategies and actions used for implementation of Night&Rest at the participating locations. Differences occurred in what disciplines were involved, such as an occupational therapist at one organization, a behavioural scientist at another organization, and the number of nursing assistants and nurses. This led to differences in starting point on knowledge about (normal) sleep and treatment of sleeping problems. In one organisation night shift workers received instruction from colleagues who received instruction and training by the project leader during a daytime session, while in another organisation night shift workers were introduced into the sleeping protocol personally by the project leader. This may have had impact on the results, for example, on the experiences of the professionals about the added value of the protocol or preferences for certain interventions, like technological solutions. Therefore, attention should be paid to determination of responsibilities and to the required competencies of professionals to use the sleeping protocol correctly. A multidisciplinary approach may facilitate successful implementation, as well as appropriate instruction and training at the start and (technical) support during the process.

Besides further implementation within psychogeriatric care, Night&Rest may also be promising for residents with (mainly) somatic complaints or elderly people living at home who receiving home care. Further research is warranted to examine the implications for the app in terms of applicability of (diagnostic) tools as well as interventions. For long-term care, application of Night&Rest in different sectors, such as care for the mentally disabled or psychiatry may be further explored.

Conclusion

This study showed positive results on the perceived added value and indications for positive effects of the Night&Rest app on both residents with dementia and care professionals. These results are promising for further implementation and upscaling within elderly care. Further research on the (long-term) effects of Night&Rest on both residents with dementia and professionals is recommended.

Footnotes

Acknowledgements

The authors would like to thank all care professionals of Cicero Zorggroep, Sevagram and Zuyderland for participating and for their valuable contribution.

Author contributions

Conception: RD, ML, MB, MS, HR, BM.

Performance of work: ML, MB, MS, HR, BM.

Interpretation or analysis of data: ML, MB, MS, HR, BM.

Preparation of the manuscript: ML, MB, MS, BM, HR, RD.

Revision for important intellectual content: ML, RD.

Supervision: ML, RD.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The project was financially supported by CZ Zorgkantoor.

Ethical approval

The research protocol was approved by the accredited Medical Research Ethics Committee METC Z (number METCZ20230086).

ORCID iD

Monique Lexis

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