Let Them Sleep: A Nurse Leader Uses Kotter's Eight Steps to Change a Hospital's Overnight Vital Signs Routine
[Student Name]
University of Phoenix
NSG/508: Leadership and Policy Development
Week 6 Assignment
[Instructor Name]
[Date]
The hospital, units and data are a composite written for a model paper.
On a composite hospital's medical units, every patient's vital signs were measured every four hours around the clock, including at 2 a.m. and 6 a.m., regardless of how stable the patient was. Patients' comments on satisfaction surveys repeatedly named the same problem: they could not sleep. A clinical nurse specialist (CNS) reviewing those comments asked the night nurses why the 2 a.m. check was done for patients whose vital signs had been normal for two days. The most common answer was "because we always have." A routine that nurses experienced as vigilance was experienced by patients as a night of interrupted sleep, and no one had asked whether it was protecting anyone. This paper describes how the CNS led a change to protect sleep for stable patients and applies Kotter's model to that change.
The Case for Change
Sleep in hospital is poor, and much of the disruption comes from care. Yoder et al. (2012), studying adult medical inpatients, found that patients slept substantially less than at home, with frequent awakenings associated with noise and with staff entering rooms, including for vital signs and medications. Sleep loss in hospital has been linked to delirium, impaired glucose control, higher blood pressure and worse patient experience.
The value of routine overnight vital signs for stable patients is uncertain. Orlov and Arora (2020), reviewing the evidence in the Things We Do for No Reason series, concluded that routine overnight vital sign checks for stable patients are often of low value, that validated early warning scores can identify patients at low risk of deterioration and that hospitals have safely reduced overnight checks for selected patients using such criteria.
Applying Kotter's Eight Steps
Kotter (1996) described eight steps for leading change: establish a sense of urgency, create a guiding coalition, develop a vision and strategy, communicate the vision, empower broad-based action, generate short-term wins, consolidate gains and produce more change, and anchor new approaches in the culture.
Establishing urgency. The CNS gathered local data: patient comments about sleep, the unit's rate of delirium among older patients and a two-night observation showing that stable patients were woken an average of four times between midnight and 6 a.m. She presented one patient's comment at a nursing leadership meeting: "I came in to rest and got less sleep than at home."
Creating a guiding coalition. She recruited a night charge nurse respected on two units, a hospitalist, a nurse manager, a pharmacist to address overnight medication timing and a nurse from the rapid response team, whose support answered safety concerns before they were raised.
Developing a vision and strategy. The coalition's vision was "protected sleep for patients who are stable, and closer watching for those who are not." The strategy was a protocol: patients with a low early warning score for 24 hours and no new clinical concerns would have vital signs at 10 p.m. and 6 a.m. only, with any nurse or physician able to continue overnight checks by clinical judgment.
Communicating the vision. The CNS presented the protocol at staff meetings on both shifts, with the rapid response nurse explaining how the early warning score works and why low-score patients rarely deteriorate between midnight and 6 a.m.
Empowering broad-based action. Informatics built an order that appeared automatically for eligible patients and a flag on the unit board, and night nurses were given explicit authority to override the protocol without a physician order.
Generating short-term wins. The pilot ran on two units for eight weeks. At four weeks the CNS shared early results: patients reported better sleep, and no rapid response calls had occurred among patients on the protocol.
Consolidating gains. The coalition used pilot results to expand the protocol to all medical units, and added adjustments to overnight medication times, moving several routine medications away from midnight.
Anchoring the change. The protocol was written into hospital policy, added to new nurse orientation and included in the unit's quality board.
Resistance and the Safety Objection
The strongest resistance came from experienced night nurses who believed the 2 a.m. check caught deterioration. Their concern was reasonable and was treated as such. The CNS did not argue that deterioration never happens; she showed that the protocol applied only to patients with low scores, that nurses retained authority to check anyone they were worried about and that rapid response and mortality data would be reviewed weekly. She also asked two of the most skeptical nurses to join the pilot evaluation, which gave them a role in deciding whether the change was safe. A second source of resistance was habit: some nurses continued overnight checks out of routine. The unit board flag and brief reminders at the night huddle addressed this.
The Patient's Part in the Change
Patients were part of the protocol, not only its beneficiaries. On admission, eligible patients received a short explanation that stable patients would not be woken for vital signs overnight, along with a request to use the call light if they felt unwell, short of breath or in pain. Night nurses still rounded quietly to check on patients visually, and lights and conversations in hallways were reduced after 11 p.m. as part of a broader quiet-hours effort the coalition added in the second month. Patients who preferred to be checked overnight could ask, and a few did. Involving patients in this way turned the protocol from something done to them into an agreement with them, and it gave nurses another safety net in the patient's own report of feeling unwell.
Results
Over six months across all medical units, about 40% of patient-nights met protocol criteria. Among those patients, reported sleep quality on a brief morning question improved, and the number of overnight awakenings in a repeat observation fell by about half. Neither rapid response activations nor unplanned moves to intensive care rose compared with the prior six months, and delirium rates among older patients on the pilot units declined modestly, though the change was too small and the period too short to attribute to the protocol with confidence.
Leadership Lessons
The case shows that influencing change in nursing often means changing a habit that nurses value as good care. Evidence alone did not move practice; what moved it was local data, a coalition that included respected skeptics, clear safety safeguards and early wins that nurses could see. The CNS led without line authority over any nurse, relying on credibility, evidence and the structures of Kotter's model.
Conclusion
Routine overnight vital signs for stable patients were a nursing habit with little evidence of benefit and a clear cost to patients' sleep. A clinical nurse specialist used Kotter's eight steps to lead change: building urgency with local data, forming a coalition that included safety experts and skeptical night nurses, designing a protocol with clear criteria and override authority, generating early wins and anchoring the change in policy. The result protected sleep for stable patients without evidence of harm, showing how nurse leaders can influence change in nursing practice by pairing evidence with respect for the concerns of the nurses who must change.
References
Kotter, J. P. (1996). Leading change. Harvard Business School Press.
Orlov, N. M., & Arora, V. M. (2020). Things we do for no reason: Routine overnight vital sign checks. Journal of Hospital Medicine, 15(5), 272-274. https://doi.org/10.12788/jhm.3442
Yoder, J. C., Staisiunas, P. G., Meltzer, D. O., Knutson, K. L., & Arora, V. M. (2012). Noise and sleep among adult medical inpatients: Far from a quiet night. Archives of Internal Medicine, 172(1), 68-70. https://doi.org/10.1001/archinternmed.2011.603
How this NSG 508 Week 6 example is structured
The University of Phoenix library guide for NSG/508 lists Week 6 as Leading to Influence Change in Nursing, the course's final week. The paper chooses a change that challenges a deeply held nursing habit, because influencing change in nursing is hardest when the practice feels like good care. It builds the case with evidence, applies Kotter's model step by step to what the leader actually did, treats the safety objection seriously and reports results, so the model is judged by whether the change held. Students search this week as NSG 508 Week 6, NSG508 Wk 6 or NSG/508 Wk 6; all three are the same assignment.
NSG/508 Week 6 questions, answered
What does NSG/508 Week 6 usually ask for?
The University of Phoenix library guide for NSG/508 lists Week 6 as leading to influence change in nursing. Many sections ask for a final paper applying a change model to a nursing practice or policy change the writer would lead, with evidence, stakeholders, barriers and evaluation. Check your instructions for the required model.
Which change model should I use?
Use the one your course names or the one that fits the scale of the change. Kotter's eight steps suit organization-wide changes with many stakeholders; Lewin's three stages suit smaller unit changes; Rogers's diffusion theory helps explain adoption across groups.
Is it safe to skip overnight vital signs?
For selected stable patients, evidence suggests that routine overnight checks add little and that protocols using early warning scores can identify patients who should continue them. Any change needs clear criteria, clinician override and safety monitoring, as the sample describes.
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