Diana Kerr is Research Fellow at the Centre for Research on Families and Relationships, University of Edinburgh, and has worked for many years as practitioner, educator, trainer and researcher in the field of older age, dementia and learning disability and dementia.

Here, she answers some questions about her latest JKP title, Providing Good Care at Night for Older People: Practical Approaches for Use in Nursing and Care Homes.

How did this book come about?

Care homes are charged with providing 24-hour care for their residents and yet there is almost no research about what goes on at night, about the needs of residents at night and on how to support staff at night. Additionally, homes are not inspected at night with the same rigour as they are in the day time.

We were lucky to get funding from the Joseph Rowntree Foundation to carry out an action research study. This involved us working at night in 3 different care homes, finding things that could be improved, working with staff to put things in place and seeing if things improved. We found that even some quite small changes could make a positive difference.

This made us even more determined to spread the word about what happens at night and how to better meet the needs of residents.

How do the needs of care home residents change at night?

Night time and day time are different – ‘as different as day and night!’

Night time, the hours between 10pm and 6am, is the time when the dark descends, when the world is shut away, and when ‘our nightly appointment with death’ becomes the time when fears and worries take hold. The night hours seem longer than the day hours. The night time, which can hold us in slumber and peace can also be the time of fear and turmoil as we endure the dark watches of the night. How often do we wake in the morning to find the fears of the night to be gone or at least diminished?

In the still of the night, time changes, it dislocates, it fools and extends. The anchors and cues of the day time are gone.

Many care home residents now have dementia, and for these people this stillness and emptiness can be particularly frightening and disorientating. Dementia takes people back in time. They need cues and help to orientate. Alone, at night, these cues can be missing. The person with dementia is trapped in the past, unable to understand the present. The damage to the circadian rhythm, the mechanism that regulates our body clock, telling us the difference between day time and night time, means that people with dementia will often misinterpret or mistrust such night time cues as do exist. People will often assume that if they wake it is morning and time for the tasks of the new day rather than the task of the night time, to sleep.

It is also often the case that the views of day staff about particular residents vary greatly from those of night staff. Residents, for example who are quiet during the day may be very agitated and noisy at night. People who are not seen to be troubled by incontinence may be incontinent at night or people who are mildly incontinent in the day may need very strong pads at night.

What is the core function of night staff in care homes?

Night staff have to provide the same level of person centred, individualised care as day staff. Their primary task is seen as the promotion of sleep. This can often mean that they feel compelled to get people back to bed as quickly as possible. Often, however, residents need, time, food, activity, and TLC as well as an opportunity to talk and discuss, particularly their fears and worries.

Why is night time care overlooked?

The night is overlooked because it is not a time that people generally think about and it is generally invisible in policy, training and management support.

The reasons why inspections don’t take place at night are varied. Some inspectors are concerned about disturbing residents if they visit (this does not need to be the case; where inspectors do visit they are not disturbing). There is also a general practice that inspections are only carried out at night if there is a complaint or cause for concern. With small staff groups and few visitors at night the likelihood of complaint is significantly reduced.

How does working at night affect night staff?

Working at night can be a significant health risk for staff. There is lots of evidence that too much night work can lead people to be vulnerable to a series of quite serious illnesses and conditions such as breast cancer, prostate cancer, irritable bowel syndrome, sleep disturbance, weight gain, infertility and miscarriage.

These are alarming facts but there is a lot than can and should be done to alleviate this. Employers have a duty to give night staff health checks before and during their employment. There are also optimum shift patterns that can reduce risk. The book contains lots of advice and easy things that can be out in place to help staff.

Copyright © Jessica Kingsley Publishers 2010.

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